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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 anaesthesia.co.in@gmail.com.

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ANAESTHETIC MANAGEMENT OF A PATIENT WITH A PACEMAKER

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  1. 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 anaesthesia.co.in@gmail.com

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

  3. COMPONENTS OF PACING SYSTEM

  4. Pacing lead Pulse generator Electrodes (heart muscles)

  5. PULSE GENERATOR

  6. Power source (thin metal box) • Lithium iodine battery • 4-10 years • Low rate of self discharge • Electrical circuits • Pacing circuit • Sensing circuit • Implanted / External

  7. PACING LEAD

  8. 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

  9. THRESHOLD R-WAVE SENSITIVITY

  10. 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

  11. R-wave sensitivity • Voltage (mv) required to activate the generator’s sensing circuit to inhibit / trigger the pacing circuit • Permanent non-programmable PM – 2mv

  12. INDICATIONS FOR PERMANENT PACING (ACC/AHA)

  13. 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

  14. 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

  15. PACEMAKER CODE (NASPE / BPEG)

  16. First position : chamber being paced Second position : chamber being sensed A : Atrium V : Ventricle D : Dual O : Neither, PM switched off / asynchronous mode

  17. Third position : mode of sensing I : Inhibition T : Triggering D : Dual O : Neither

  18. Inhibition • Most common • Sensed event will inhibit the PM • If no sensed event  impulse • Eliminates competition • Energy sparing • Diathermy  inhibition

  19. 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

  20. TYPES OF PACEMAKERS

  21. SINGLE CHAMBER VENTRICULAR PACING – VVI

  22. 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

  23. DUAL CHAMBER PACING - DDD

  24. AV block • Sinus node disease • Carotid sinus syncope • 2 pacing leads • RA appendage • RV apex • Atrial event will inhibit or trigger a ventricular response

  25. Advantages • Maintains AV synchrony • Preserves atrial contribution to preload (áCO – 34%) • Disadvantages • Pacemaker mediated reentrant tachycardia

  26. ASYNCHRONOUS / SYNCHRONOUS MODE

  27. 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

  28. Synchronous / sensing mode • Demand pacing • No competition • 2 circuits • Impulse formation • Sensing circuit • Inhibited / triggered • Diathermy interpreted as cardiac activity

  29. TEMPORARY CARDIAC PACING

  30. Temporary bradyarrhythmia (MI, cardiac surgery) • Before permanent pacing for a life threatening bradyarrythmia • Elective replacement of permanent PM • During surgical procedures

  31. TRANSVENOUS / ENDOCARDIAL PACING

  32. Leads introduced subclavian / jugular / femoral • RA / RV under fluoroscopy • Bipolar • Pacing leads are more rigid (J shaped)

  33. TRANSCUTANEOUS (EXTERNAL PACING)

  34. Rapid, safe, easy to initiate • Large self adhesive surface patch electrodes (8cm) • Advantages • Before transvenous / permanent • Disadvantages • High threshold • Severe chest pain

  35. PREOPERATIVE EVALUATION

  36. History • CAD – 50% • HT – 20% • DM – 10% • Drug history (digoxin, antiarrythmics) • Indication for PM implantation • Return of pre PM symptoms (vertigo, syncope)

  37. PACEMAKER EVALUATION

  38. 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

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