Anaesthetic management of a patient with a pacemaker
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ANAESTHETIC MANAGEMENT OF A PATIENT WITH A PACEMAKER. Dr. Vandana Talwar Senior Specialist & Associate Professor VMMC and Safdarjang Hospital, New Delhi. www.anaesthesia.co.in [email protected]

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ANAESTHETIC MANAGEMENT OF A PATIENT WITH A PACEMAKER

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Anaesthetic management of a patient with a pacemaker

ANAESTHETIC MANAGEMENT OF A PATIENT WITH A PACEMAKER

Dr. Vandana Talwar

Senior Specialist & Associate Professor

VMMC and Safdarjang Hospital,

New Delhi

www.anaesthesia.co.in

[email protected]


Anaesthetic management of a patient with a pacemaker

Artificial pacemakers are electronic devices that stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


Anaesthetic management of a patient with a pacemaker

COMPONENTS OF PACING SYSTEM


Anaesthetic management of a patient with a pacemaker

Pacing lead

Pulse generator Electrodes

(heart muscles)


Anaesthetic management of a patient with a pacemaker

PULSE GENERATOR


Anaesthetic management of a patient with a pacemaker

  • Power source (thin metal box)

    • Lithium iodine battery

      • 4-10 years

      • Low rate of self discharge

  • Electrical circuits

    • Pacing circuit

    • Sensing circuit

  • Implanted / External


Anaesthetic management of a patient with a pacemaker

PACING LEAD


Anaesthetic management of a patient with a pacemaker

  • Flexible insulated metal wire or lead

  • Ni, Co, Cr, Mb, Fe

  • Unipolar

    • Negative electrode (cathode) – RA / RV

    • Positive electrode (anode) – pulse generator

    • Works if anode is in contact with the body

  • Bipolar

    • ‘pos’ and ‘neg’ are in the paced chamber

    • Coaxial


Anaesthetic management of a patient with a pacemaker

THRESHOLD

R-WAVE SENSITIVITY


Anaesthetic management of a patient with a pacemaker

THRESHOLD

  • Lowest amount of energy that will stimulate the heart and produce a paced impulse

    • Acute threshold

    • Chronic threshold

  • Lower the threshold – longer the life


Anaesthetic management of a patient with a pacemaker

R-wave sensitivity

  • Voltage (mv) required to activate the generator’s sensing circuit to inhibit / trigger the pacing circuit

  • Permanent non-programmable PM – 2mv


Anaesthetic management of a patient with a pacemaker

INDICATIONS FOR PERMANENT PACING (ACC/AHA)


Anaesthetic management of a patient with a pacemaker

Acquired AV block

  • Third degree and advanced second degree block

    Symptomatic bradycardia

    Drugs  sympt bradycardia

    Asystole > 3 sec or escape rate < 40 beats / min

    Acute MI

    Postoperative AV block

    After catheter ablation of AV junction


Anaesthetic management of a patient with a pacemaker

  • Chronic bifascicular and trifascicular block

    Intermittent 3° AV block

    Type II 2° AV block

  • Sinus node dysfunction

    Symptomatic bradycardia

    Symptomatic chronotropic incompetence

  • Hypersensitive carotid sinus syndrome and neurocardiogenic syncope


Anaesthetic management of a patient with a pacemaker

PACEMAKER CODE (NASPE / BPEG)


Anaesthetic management of a patient with a pacemaker

First position : chamber being paced

Second position : chamber being sensed

A : Atrium

V: Ventricle

D: Dual

O: Neither, PM switched off / asynchronous mode


Anaesthetic management of a patient with a pacemaker

Third position : mode of sensing

I : Inhibition

T : Triggering

D : Dual

O : Neither


Anaesthetic management of a patient with a pacemaker

Inhibition

  • Most common

  • Sensed event will inhibit the PM

  • If no sensed event  impulse

  • Eliminates competition

  • Energy sparing

  • Diathermy  inhibition


Anaesthetic management of a patient with a pacemaker

Fourth position

Programmable

Rate adaptive function – designed to raise or lower the pacing rate to help meet the body’s need during physical activity or rest

Fifth position

Antitachycardia function


Anaesthetic management of a patient with a pacemaker

TYPES OF PACEMAKERS


Anaesthetic management of a patient with a pacemaker

SINGLE CHAMBER VENTRICULAR PACING – VVI


Anaesthetic management of a patient with a pacemaker

  • Most widely used

  • At flutter/AF and heart block or long ventricular pauses

  • Not recommended

    • Sinus node disease (chronic AF)

    • AV block

  • Pacemaker syndrome

    • Loss of AV synchrony


Anaesthetic management of a patient with a pacemaker

DUAL CHAMBER PACING - DDD


Anaesthetic management of a patient with a pacemaker

  • AV block

  • Sinus node disease

  • Carotid sinus syncope

    • 2 pacing leads

      • RA appendage

      • RV apex

    • Atrial event will inhibit or trigger a ventricular response


Anaesthetic management of a patient with a pacemaker

  • Advantages

    • Maintains AV synchrony

    • Preserves atrial contribution to preload (áCO – 34%)

  • Disadvantages

    • Pacemaker mediated reentrant tachycardia


Anaesthetic management of a patient with a pacemaker

ASYNCHRONOUS / SYNCHRONOUS MODE


Anaesthetic management of a patient with a pacemaker

Asynchronous / non-sensing mode (AOO, VOO, DOO)

  • Fixed rate pacing

  • Rarely used

    Advantages

  • Not inhibited by diathermy

  • Useful to cover surgery

    Disadvantages

  • Competition – R on T vent arrhythmias

  • Wastes energy


Anaesthetic management of a patient with a pacemaker

Synchronous / sensing mode

  • Demand pacing

  • No competition

  • 2 circuits

    • Impulse formation

    • Sensing circuit

  • Inhibited / triggered

  • Diathermy interpreted as cardiac activity


Anaesthetic management of a patient with a pacemaker

TEMPORARY CARDIAC PACING


Anaesthetic management of a patient with a pacemaker

  • Temporary bradyarrhythmia (MI, cardiac surgery)

  • Before permanent pacing for a life threatening bradyarrythmia

  • Elective replacement of permanent PM

  • During surgical procedures


Anaesthetic management of a patient with a pacemaker

TRANSVENOUS / ENDOCARDIAL PACING


Anaesthetic management of a patient with a pacemaker

  • Leads introduced subclavian / jugular / femoral

  • RA / RV under fluoroscopy

  • Bipolar

  • Pacing leads are more rigid (J shaped)


Anaesthetic management of a patient with a pacemaker

TRANSCUTANEOUS

(EXTERNAL PACING)


Anaesthetic management of a patient with a pacemaker

  • Rapid, safe, easy to initiate

  • Large self adhesive surface patch electrodes (8cm)

  • Advantages

    • Before transvenous / permanent

  • Disadvantages

    • High threshold

    • Severe chest pain


Anaesthetic management of a patient with a pacemaker

PREOPERATIVE EVALUATION


Anaesthetic management of a patient with a pacemaker

History

  • CAD – 50%

  • HT – 20%

  • DM – 10%

  • Drug history (digoxin, antiarrythmics)

  • Indication for PM implantation

  • Return of pre PM symptoms (vertigo, syncope)


Anaesthetic management of a patient with a pacemaker

PACEMAKER EVALUATION


Anaesthetic management of a patient with a pacemaker

  • When was it implanted and last checked

  • Factory preset rate

  • Battery status (10% reduction in rate)

  • What type of generator (I-Card)

    Pacing mode, stimulation threshold, sensing function

  • S/S cerebral hypoperfusion when exercising muscles around generator


Anaesthetic management of a patient with a pacemaker

EXAMINATION


Anaesthetic management of a patient with a pacemaker

  • Pulse

    Regular (70-72/min)

    Irregular (competition)

  • BP

  • Bruits

  • Signs of CCF

  • Location of generator

  • Consciousness level


Anaesthetic management of a patient with a pacemaker

INVESTIGATIONS


Anaesthetic management of a patient with a pacemaker

  • CBC, coagulation screening, uninalysis

  • Well penetrated X-ray chest

    • Radio opaque marker : model of PM

    • Integrity and position of leads

  • 12-lead baseline ECG (one to one capture)

  • S.electrolytes

    • K+ - 3.5 – 5meq/L

    • K+ imbalance : loss of pacing / V. Tach


Anaesthetic management of a patient with a pacemaker

INTERPRETATION OF ECG


Anaesthetic management of a patient with a pacemaker

No / intermittent pacing spikes : own rhythm

Check PM function

  • Asynchronous mode

  • Carotid massage / valsalva

  • Magnet / programmer

    Pacing spikes before every beat : PM dependent

  • Inhibit device to check innate rythm


Anaesthetic management of a patient with a pacemaker

PREOPERATIVE PROPHYLACTIC

PM INSERTION


Anaesthetic management of a patient with a pacemaker

  • Third degree AV block

  • Second degree AV block

    • Symptomatic

    • Ventricular escape rate < 40 beats /min

  • Asymptomatic second degree / first degree AV block

    • S/S of SSS

    • Relief of symptoms with temporary pacing

  • Any type of BBB with

    • Second / third degree heart block

    • Syncope


Anaesthetic management of a patient with a pacemaker

GA / REGIONAL


Anaesthetic management of a patient with a pacemaker

  • Based on underlying disease

  • Regional – more reasonable choice

  • GA

    • Not contraindicated

    • Inhalational anesth do not alter threshold


Anaesthetic management of a patient with a pacemaker

MONITORING


Anaesthetic management of a patient with a pacemaker

  • Dictated by the surgery

  • Pulse and BP

  • Pulse oximeter

  • Oesophageal stethoscope

  • ECG-V5 and II (interference)

  • PAC - caution (could dislodge if endocardial lead is < 4wks old

  • CVP - caution


Anaesthetic management of a patient with a pacemaker

Electromagnetic Interference


Anaesthetic management of a patient with a pacemaker

Sources

  • Conducted (direct contact)

    • Electrocautery, diathermy

    • Defibrillation

    • TENS

  • Radiated

    • MRI, PET

    • Radiation therapy

      Increased EMI

      Unipolar leads ( sensing)

      Dual chamber PM


Anaesthetic management of a patient with a pacemaker

HOW DOES EMI AFFECT PACING

(RF 300-500 KHZ)


Anaesthetic management of a patient with a pacemaker

  • Inhibition

    • Interpreted as cardiac activity

  • Asynchronous pacing

    • EMI recognized

  • VF / AF

  • Increased pacing threshold

  • Irreversible loss of battery output

  • Reprogramming(DDD VVI / VOO)  haemodynamic compromise


Anaesthetic management of a patient with a pacemaker

PRECAUTIONS for EMI


Anaesthetic management of a patient with a pacemaker

  • Bipolar cautery – preferable

  • Use minimum current

  • Do not use within 15cm of pulse generator

  • Limit to 1 sec bursts every 10secs

  • Ground plate

    • Close to operative site

    • Good skin contact (thigh)

    • Away from pulse generator


Anaesthetic management of a patient with a pacemaker

OTHER FACTORS AFFECTING PACING THRESHOLD


Anaesthetic management of a patient with a pacemaker

  • K+ balance

    • Acute   V.Tachycardia

    • Acute   loss of pacing (hyperventilation, diuresis)

  • MI

    • Loss of PM capture

  • Myopotential inhibition (unipolar pacing)

    • Exercise

    • Shivering

    • Muscle fasciculations (Scoline)

  • Hypoxia / Hypercapnia


Anaesthetic management of a patient with a pacemaker

Precautions and Preparation in OT


Anaesthetic management of a patient with a pacemaker

  • Temporary reprogramming to asynchronous/ triggered (avoid if prone to VT and VF)

  • Programmer / External converter magnet

    Magnet : VT

    Reprogramming of PM

  • Emergency drugs (atropine, isoproterenol)

  • Temporary pacing

  • Defibrillator


Anaesthetic management of a patient with a pacemaker

PM INHIBITED


Anaesthetic management of a patient with a pacemaker

  • No intrinsic and no PM rhythm

  • Cease cautery

  • High powered magnet over generator

  • Atropine / Isoproterenol / Inotropes

  • Temporary pacing

  • Repeated precordial thumps

  • CPR


Anaesthetic management of a patient with a pacemaker

EXTERNAL DEFIBRILLATION


Anaesthetic management of a patient with a pacemaker

  • High energy current  thermal burns

  • Use lowest defibrillator current

  • Ant-post paddles

    • Ant - far away from pulse generator

  • If Ant paddles must be used

    • Place perpendicular to leads

    • Atleast 10-15 cm from the generator


Anaesthetic management of a patient with a pacemaker

POSTOPERATIVE EVALUATION


Anaesthetic management of a patient with a pacemaker

  • Evaluation of PM function

    • Early postop period

    • 24h-48h later

  • Demand / magnet rates vary from preop

  •  capture threshold

    • Permanent damage

    • Reprogramming


Anaesthetic management of a patient with a pacemaker

Thank You

www.anaesthesia.co.in

[email protected]


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