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Artificial pacemaker and anesthesia

Artificial pacemaker and anesthesia. Presenter: Abraham sonny Bala chandran Moderator:Rashmi Ramachandran. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Preop assessment . Device assessment Patient evaluation and preparation. Preop assessment-Device.

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Artificial pacemaker and anesthesia

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  1. Artificial pacemaker and anesthesia Presenter: Abraham sonny Bala chandran Moderator:Rashmi Ramachandran www.anaesthesia.co.in anaesthesia.co.in@gmail.com

  2. Preop assessment • Device assessment • Patient evaluation and preparation

  3. Preop assessment-Device • Device assessment: • Type of device • Indication of device • Pacemaker mode with its special function • Device functioning status

  4. Preop assessment-Device • Clinical history and physical examination • Manufacturers ID card / CXR to identify type of device • 12 lead ECG with and without magnet • Assessment of device functioning

  5. Preop assessment-Patient • Patient level of dependency to device • Intraop factors interfering the device function • Consideration of reprogramming • Investigations

  6. Preop assessment-Patient • History and evaluation of disease that mandated pacemaker • Continue antiarrythmic drug and other cardiac drugs as mandated • Consider Electromagnetic and Mechanical Interference (EMI)

  7. Conditions warrant pacemaker reprogramming • Pacemaker dependent patients • Major procedure in abdomen and chest • Rate adaptive feature of pacemakers • Suspension of antitachycardia function • Surgical procedures with high chances of EMI

  8. Electromagnetic and mechanical interference and pacemaker • Radio wave frequency between 0 -10 9 Hz and microwaves frequency 109 – 10 11 Hz cause EMI • Shielding of pulse generator, bipolar leads, and filtering of incoming signals offers some protection against EMI • Frequencies 5 -100 Hz overlap with intracardiac signals

  9. Electromagnetic and mechanical interference and pacemaker • High probability of EMI • Electrocautery use • Lithotripsy • ECT • Radiation therapy • MRI • Orthopaedic procedures

  10. Electromagnetic and mechanical interference and pacemaker • EMI effects on pacemaker: • Asynchronous pacing • Pacemaker inhibition or triggering • Resetting or reprogramming pacemaker • Damage to electronic circuits • Burn injury to myocardium • Inappropriate activation of rate adaptive feature and anti tachycardia therapy

  11. Intraoperative management • Monitoring • Anesthetic technique • Measures to prevent device malfunctioning • Pacemaker failure trouble shooting • Preparation for temporary pacemaker and defibrillation

  12. Monitoring • Continuous ECG • Signs of peripheral perfusion • Invasive monitoring Cardiac status Type of surgery Pacemaker failure

  13. Anesthetic technique • Tailored to cardiovascular disease status • Anesthetics and pacing threshold • Succinylcholine and pacemaker

  14. Electrocautery and pacemaker Uses radiofrequency of 300- 500 kHz • May affect pacemaker related to distance and orientation with the device

  15. Electrocautery and pacemaker • Unipolar vs Bipolar vs Ultrasonic scalpel • Distance to pulse generator • Unipolar return pad • Lowest energy possible in short bursts

  16. Magnet and pacemaker • Activates magnetic reed switch • Model dependent behaviour with magnet

  17. Pacemaker magnet behaviour • Asynchronous pacing – most common • No apparent rate or rhythm change • Brief asynchronous pacing and then return to programmed value • Continuous or transient loss of pacing

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  19. Pacemaker failure • Recognise • Assess haemodynamic status • Identify the cause • Manage

  20. Pace maker failure • Failure to pace • Failure to capture • Undersensing / failure to sense • Oversensing

  21. Failure to pace • Loss of pacing artifact in ECG in the absence of spontaneous QRS wave

  22. Failure to capture • Absence of ‘P’or ‘QRS’ wave following atrial or ventricular artifact in ECG

  23. Under sensing • Pacing artifact in the middle of spontaneous ‘P’ or ‘QRS’ wave -no change in automatic interval

  24. Factors increasing pacemaker threshold • Myocardial ischaemia/infarct • Electrolyte disturbance • Acidosis or alkalosis • Hypoxia or hypercapnia • Abnormal antiarrythmic drug level especially Class I and beta blockers

  25. Defibrillation • Defibrillation • Discontinue any obvious source of EMI • Restore antitachycardia function if available in device and BP stable • Pad or paddle position • Defibrillation and cardioversion dose • Post shock interrogation/ reprogramming

  26. MRI and pacemaker • Torque effect on pulse generator • Magnetic field gradient closes magnetic reed switch • MRI produces radiofrequency waves of 30- 3000Hz

  27. MRI and pacemaker • Latest models has less chance of torque effect • RF waves cause inappropriate pacing • Heat energy through leads- burn injury • MRI generally considered contraindicated in patients with pacemakers

  28. MRI and pacemaker • Sommer et al in a prospective study assessed effects of MRI on pacemaker 82 patients undergoing extrathoracic site MRI.In this study they found no pacemaker inhibiition or arrythmia induction or any other serious injury during or after procedure. Hence they concluded MRI is safe and can be performed under due precautions - Circulation 2006; 114(2): 1285

  29. MRI and pacemaker • Nazarian et al studied 55 patients (31 with pacemakers and 24 with AICD) undergoing cardiac and non cardiac MRI and found no significant adverse effects. They also concluded MRI can be safely performed in these patients considering the benefits in these patients - Circulation 2006; 114 (12):1277

  30. MRI and pacemaker • Both these above studies were done under ECG and pulse oximetry monitoring and after appropriate reprogramming of the cardiac rhythm management device. Hence recommended these precautions to be followed during the procedure and MRI can be safely done in patients with CRMD.

  31. Lithotripsy and pacemaker • Pacemaker circuitry damage • Focal point of beam directed away from generator • Atrial pacing and rate adaptive function need to be disabled • Contraindicated in patients with piezoelectric circuit implanted in abdominal wall

  32. Lithotripsy and pacemaker • Albers DD et al found that lithotripsy can be performed safely done after appropriate reprogramming of the CRMD provided focus of beam is 5 cms away from the device. This study was done on 20 patients - J Endourol 1995; 9(4): 3011

  33. Lithotripsy and pacemaker • Asroff et al described a case report of 75 yr male with pacemaker safely undergoing lithotripsy after inactivating rate adaptive function of device. They also suggested pacemaker generator not be located in the abdominal wall - J Endourol 1997; 157(3) : 189

  34. Electroconvulsive therapy & pacemaker • Little current pass through heart • Seizures may cause inappropriate activation of AICD and rate adaptive feature of pacemaker • Other features may left intact • In patients with inactivated AICD be prepared for external defibrillation if VT/VF occurs

  35. Automatic Implanted Cardioverter Defibrillator and anesthesia • Pacing and shocking function • Precautions similar to pacemaker • Deactivate cardioversion and defibrillation function of AICD

  36. Automatic Implanted Cardioverter Defibrillator and anesthesia • Magnet and ICD: • Pacemaker function is rarely altered • Suspends anti tachyarrythmia therapy • Some ICD have no magnet response • Most are permanently disabled • Hence recommended not to be used in patients with ICD

  37. Automatic Implanted Cardioverter Defibrillator and anesthesia • External defibrillation in patients with AICD • Apply external defibrillator pad before surgery • Remove EMI source • Reenable antitachycardia function • If above measures fails provide external defibrillation with precaution as for pacemakers

  38. Postoperative care • Monitoring • Device interrogation • Reprogramming

  39. Summary • Pacemaker and AICD implanted patients undergoing elective surgery: • Contact pacemaker or AICD clinic or manufacturer • Reprogram the device function in selective group of patients

  40. Summary • Pacemaker and AICD implanted patients undergoing elective surgery: • Monitoring and anesthesia technique with due considerations to patients CVS status • Avoid electrocautery use. If necessary consider use of bipolar or harmonic scalpel • Be ready for alternate mode of pacemaker and defibrillator if necessity arises

  41. Summary • Pacemaker and AICD implanted patients undergoing emergency surgery: • Try get information regarding pacemaker or AICD at earliest possible or if time permits • Initiate invasive arterial pressure monitoring in addition to standard monitoring

  42. Summary • Pacemaker and AICD implanted patients undergoing emergency surgery: • If pacemaker failure is associated with haemodynamic instability consider magnet application • Consider magnet application with AICD only when EMI source cannot stopped and it is associated with haemodyanamically destabilising inappropriate shocks • Interrogate device following either elective or emergency surgery at the earliest possible and consider appropriate resetting if required

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  44. Thank you www.anaesthesia.co.in anaesthesia.co.in@gmail.com

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