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Cardiac Electrophysiology, Perioperative Implications, Pacemakers/AICD. Todd Akins, MD April 28 th , 2009. Intraoperative ECG. No Contraindications

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cardiac electrophysiology perioperative implications pacemakers aicd

Cardiac Electrophysiology, Perioperative Implications, Pacemakers/AICD

Todd Akins, MD

April 28th, 2009

intraoperative ecg
Intraoperative ECG
  • No Contraindications
  • ASA Standards “Every patient receiving anesthesia shall have the electrocardiogram continuously displayed from the beginning of anesthesia until preparing to leave the anesthetizing location.”
detects
Detects
  • Dysrhythmias, myocardial ischemia, conduction abnormalities, pacemaker malfunction, and electrolyte disturbances
3 lead vs 5 lead
3-Lead vs 5-Lead
  • 3-Lead: lead II axis parallels atria thus greatest p-wave voltage (rate determination)
  • Provides enhanced diagnosis of arrhythmias and inferior wall ischemia
3 lead vs 5 lead1
3-Lead vs 5-Lead
  • 5-Lead: only way to get a “true” V5
  • Lead V5 placed at 5th ICS, anterior axillary line
  • Detects anterior and lateral wall ischemia
  • “Modified V5” with a 3-Lead by placing LA at the V5 position (5th ICS, AAL) and selecting lead I for display
ideally
Ideally
  • Lead II and Lead V5 monitored simultaneously with a 5-Lead
  • Use a 5-Lead in obese patients
  • If monitoring only a single lead, then choose lead to monitor based on patient’s history of prior ischemia or infarct (i.e. II if inferior MI, V5 if anterior or lateral)
artifact
Artifact
  • Caused by patient or lead wire movement, electrocautery, 60 cycle interference, faulty electrodes
  • Monitoring filters help but can distort ST segments
  • Monitor confuses large t-waves or artifact as QRS complexes
  • Better conductance by cleaning skin with alcohol or degreaser, or exfoliating area
intraoperative mi
Intraoperative MI
  • Commonly accepted criteria:
  • 1. flat or down sloping ST > 2mV, particularly with t-wave inversion
  • 2. ST segment elevation and peaked t-waves
  • *** Make sure volume is loud enough to hear while attention is elsewhere***
pacemakers
Pacemakers
  • Classification:
  • 5-letter code (usually omit last 2 letters)
  • Chamber Paced ( O, A, V, D)
  • Chamber Sensed (O, A, V, D) senses p or r
  • Response to Sensing (O, T, I, D)
  • Programmability (O, P, M, C, R)
  • Antitachyarrhythmia Function (O, P, S, D)
  • Most common: VVI, DDD, or on tests DVI
functioning
Functioning
  • If intrinsic HR < program (typically 72) then see spike then QRS and palpable pulse (100% capture)
  • If intrinsic HR > program, NO spike
  • When low battery, sensing lost before pacing output
  • Magnet defaults to VOO mode
interference
Interference
  • Electrocautery Interferes
  • Interpreted as intrinsic function and can suppress pacemaker
  • Solution is to place grounding pad as far from pacemaker as possible
  • ***mandatory continuous monitoring of arterial pulse during cautery by palpation or pulse oximetry
pearl
PEARL
  • ***accentuated myospasticity from succinylcholine induced fasciculation or post-operative shivering can also suppress pacemaker
operative implications
Operative Implications
  • NO MRI------EVER
  • ECT is fine, but have magnet available
  • ESWL:
  • 1. risk of developing arrhythmias
  • 2. shock waves can damage components
  • Contact manufacturer for best method of managing device, i.e. Reprogram vs. magnet
  • Time ESWL shock wave to 20msec after r-wave to decrease incidence of arrhythmias
slide14
AICD
  • Turn Off
references
References
  • 1. Morgan GE, Mikhail MS, Murray MJ, Clinical Anesthesiology, 3rd ed., New York, McGraw-Hill, 2002, pp. 97-100, 124-125, 431-432
  • 2. Chu, LF, clinical Anesthesiology Board Review, A Test Simulation and Self-Assessment Tool, McGraw-Hill, 2005, pp. 231-232
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