1. Anaesthetic considerations in patients with permanent pacemaker
Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu),
Dip. Diab.DCA, Dip. Software statistics
PhD (physio)
Mahatma gandhi medical college and research institute, puducherry, India
Dr.S.Parthasarathy MD DNB PhD

2. Dr.S.Parthasarathy MD DNB PhD
Nomenclature
cardiac implantable electronic device (CIED)
Dr.S.Parthasarathy MD DNB PhD

3. Dr.S.Parthasarathy MD DNB PhD
Indications
Artificial pacing is generally indicated for the treatment of symptomatic bradycardia of any origin.
Innumerable !!
two major indications
1. failure of impulse formation and 2.failure of cardiac conduction.
Clinically , sick sinus syndrome and complete heart block
Dr.S.Parthasarathy MD DNB PhD

4. Dr.S.Parthasarathy MD DNB PhD
Pacemaker
What is the normal physiological pacemaker ?
Sinus node
If it fails
AV node
If it also …
Dr.S.Parthasarathy MD DNB PhD

5. Dr.S.Parthasarathy MD DNB PhD
Conduction – normal
Dr.S.Parthasarathy MD DNB PhD

6. Three basic techniques
Application of external pacing pads,
insertion of a transvenous pacing lead via central venous access,
implantation of permanent intracardiac leads along with a pulse generator
Dr.S.Parthasarathy MD DNB PhD

7. Dr.S.Parthasarathy MD DNB PhD
Terms
Pulse Generator
Leads
Electrode
Pacing threshold
Endocardial pacing
Epicardial pacing
Dr.S.Parthasarathy MD DNB PhD

8. Dr.S.Parthasarathy MD DNB PhD
Pacing code
North American Society of Pacing and Electrophysiology (NASPE)
British Pacing and Electrophysiology Group (BPEG)
3 letter previously to 5 letter now
AAI, VVI , DDD
Dr.S.Parthasarathy MD DNB PhD

9. What do the letters tell ??
Dr.S.Parthasarathy MD DNB PhD

10. Dr.S.Parthasarathy MD DNB PhD
Examples
The AAI mode can be programmed for a patient with normal AV conduction with symptomatic sinus bradycardia to ensure adequate heart rate.
The VVI mode can be programmed for a patient with AV block to ensure adequate ventricular rate.
Dr.S.Parthasarathy MD DNB PhD

11. Dr.S.Parthasarathy MD DNB PhD
Dual modes
the DDD mode can be programmed for patients
with complete AV block and normal sinus node function to ensure that each spontaneous atrial depolarization is followed by a ventricular depolarization.
This mode will provide AV sequential or ‘physiological pacing’ because the paced ventricular rate tracks the spontaneous atrial rate.
Dr.S.Parthasarathy MD DNB PhD

12. Dr.S.Parthasarathy MD DNB PhD
AAI
Block
Dr.S.Parthasarathy MD DNB PhD

13. DDD or VDD depends on atrial rate
Dr.S.Parthasarathy MD DNB PhD

14. Image dual chamber pacing
Dr.S.Parthasarathy MD DNB PhD

15. The fourth and fifth positions
Rate modulation – in exercise
LV and RV pacing
CRT
Dr.S.Parthasarathy MD DNB PhD

16. Dr.S.Parthasarathy MD DNB PhD
ICDs
Implantable cardioverter defibrillators (ICDs) are devices capable of detecting a ventricular arrhythmia and delivering a defibrillatory shock.
Devices are now implanted in a subcutaneous pectoral pocket with transvenous leads.
Dr.S.Parthasarathy MD DNB PhD

17. Dr.S.Parthasarathy MD DNB PhD
Life
The lithium-powered pacemakers can last 5 to 10 years for dual-chamber pacing and 7 to 12 years for single-chamber pacing.
The silver-vanadium oxide batteries used in ICDs typically last for 5 to 8 years.
Minimum check 12 months before surgery
Dr.S.Parthasarathy MD DNB PhD

18. Dr.S.Parthasarathy MD DNB PhD

19. Dr.S.Parthasarathy MD DNB PhD
How to identify ??
Before p wave – spike - normal QRS – atria
QRS wide with spike – ventricular pacing
Two spikes in dual pacing
Dr.S.Parthasarathy MD DNB PhD

20. sense RV and single, dual and triple chamber available
Dr.S.Parthasarathy MD DNB PhD

21. Dr.S.Parthasarathy MD DNB PhD
Pacemaker syndrome
hypotension, syncope, vertigo, light-headedness,fatigue, exercise intolerance, malaise, weakness, lethargy, dyspnoea, and induction of congestive heart failure
Possibly normal VA conduction interference with AV conduction
May be due to atrial dilation
Dr.S.Parthasarathy MD DNB PhD

22. Perioperative considerations
Dr.S.Parthasarathy MD DNB PhD

23. Preoperative evaluation
Systemic illness especially CVS
review of all available medical records, ECGs,
and chest X-rays.- patient and attender
Cardiac consultation
obtaining the manufacturer's identification card
complete blood count, urinalysis,
coagulation screening, serum electrolytes, BUN, blood sugar,
Dr.S.Parthasarathy MD DNB PhD

24. Preoperative considerations
A preoperative history of vertigo, syncope in a patient with a pacemaker could reflect pacemaker dysfunction
Pulse rate 10 % less than the set rate – battery ?
Irregular pulse – sensing ??
Also due to inflammation and irritation causing multiple VPCs
Dr.S.Parthasarathy MD DNB PhD

25. Dr.S.Parthasarathy MD DNB PhD
Pacemaker is working ??
Pacing spikes
Get the rate slowed down , carotid massage, valsalva or edrophonium
Not slowing down – then place a magnet over it to convert to fixed rate device
Dr.S.Parthasarathy MD DNB PhD

26. Dr.S.Parthasarathy MD DNB PhD
Pacemaker – preop
(a) battery life,
(b) programmed pacing mode such as VVIR, DDDR,
C)pacemaker dependency,
(d) intrinsic rhythm,
(e) magnet rate and rhythm -- newer programmable devices ??
(f) prior recorded arrhythmic events, and
(g) pacemaker lead parameters
Dr.S.Parthasarathy MD DNB PhD

27. Dr.S.Parthasarathy MD DNB PhD
What to know preop
Dr.S.Parthasarathy MD DNB PhD

28. So basically – preop is divided
Patient
Pacemaker
Dr.S.Parthasarathy MD DNB PhD

29. Dr.S.Parthasarathy MD DNB PhD
Plan
electromagnetic interference (EMI) there ??
Rate adaptive functions and
anti tachyarrhythmia programming – suspend
availability of temporary pacing and defibrillation equipment
Dr.S.Parthasarathy MD DNB PhD

30. Dr.S.Parthasarathy MD DNB PhD
Monitors
Hand on pulse
Others (routine )
Pacemaker mediated tachycardia has been induced
by intraoperative somatosensory evoked potential
PA catheter and CVP are not directly related to PPM but the disease and surgery – beware of guidewire --
paced PA catheters !!
Dr.S.Parthasarathy MD DNB PhD

31. Dr.S.Parthasarathy MD DNB PhD
EMI
anaesthetic technique should be used
according to the need of the patient
Electromagnetic interference
Dr.S.Parthasarathy MD DNB PhD

32. Dr.S.Parthasarathy MD DNB PhD
Diathermy –
PPM Senses but uncertain – it does go to asynchronous mode
PPM senses as R wave and stops pacing ??
Danger
Dr.S.Parthasarathy MD DNB PhD

33. Dr.S.Parthasarathy MD DNB PhD
Diathermy
Assure that the electrosurgical receiving plate is positioned so the current pathway does not pass through or near the CIED system.
NO to cautery’s electrical field to the pulse generator or leads.
short, intermittent and irregular bursts at the lowest feasible energy levels.
bipolar electrocautery system or ultrasonic (harmonic) scalpel
Dr.S.Parthasarathy MD DNB PhD

34. Dr.S.Parthasarathy MD DNB PhD
Other considerations
Radiofrequency ablation
Avoid direct contact between the ablation catheter and the pulse generator and leads.
For electroconvulsive therapy, disable the ICD
Radiation therapy is not associated with EMI
Avoid focusing the lithotripsy beam near the pulse generator.
Pacemaker malfunction can occur in patients undergoing ESWL,
MRI is generally contraindicated in patients with CIEDs.
Dr.S.Parthasarathy MD DNB PhD

35. Dr.S.Parthasarathy MD DNB PhD
TURP
Coagulation current used during TURP procedure has no effect,
but the cutting current at high frequencies (up to 2500 kc/sec) can suppress the output of a bipolar demand ventricular pacemaker.
Dr.S.Parthasarathy MD DNB PhD

36. Dr.S.Parthasarathy MD DNB PhD
Bipolar PPM – better
Dr.S.Parthasarathy MD DNB PhD

37. Dr.S.Parthasarathy MD DNB PhD
Be ready
1. atropine
2. isoprenaline
Dr.S.Parthasarathy MD DNB PhD

38. Dr.S.Parthasarathy MD DNB PhD
Potassium
An acute increase in extracellular potassium concentration as in patients with myocardial ischemia
Rapid potassium replacement in chronic hypokalaemic patients
use of depolarizing muscle relaxants in patients with burns, trauma or neuromuscular disease may increase the RMP to less negative value, thus making the capture easier.
Dr.S.Parthasarathy MD DNB PhD

39. Dr.S.Parthasarathy MD DNB PhD
Other intraop factors
Significant acid–base, electrolyte problems
transfusion of blood,
myocardial ischaemia,
high blood concentrations of local anaesthetics
can increase capture thresholds of the leads and alter lead impedance.
Dr.S.Parthasarathy MD DNB PhD

40. Defib intraop required ??
1.Place the paddles more than 15cm away from the device 2.The paddles perpendicular to the path of the implanted leads 3.Use the lowest possible energy
Dr.S.Parthasarathy MD DNB PhD

41. Postoperative management
Cardiac rate and rhythm should be monitored continuously throughout the immediate postoperative period.
Postoperative interrogation and restoration of CIED function are basic elements of postoperative management.
Dr.S.Parthasarathy MD DNB PhD

42. Dr.S.Parthasarathy MD DNB PhD
Summary
Indications
Coding
Life
Pacemaker syndrome
Preop evaluation
Monitors
Anaesthesia – EMI- asynchronous – Rate mod
Post op
Dr.S.Parthasarathy MD DNB PhD

43. Dr.S.Parthasarathy MD DNB PhD
Thank you all
Dr.S.Parthasarathy MD DNB PhD