PACEMAKER AND ANESTHETIC CONSIDERATIONS

PRESENTER : Dr Sanjay Ram

MODERATOR : Dr Harshavardhan
INDEX

A. Indications
B. Pacemaker : Introduction
C. Classification of Pacemaker
D. Anaesthetic management of patient with permanent pacemaker
I. Preoperative evaluation
II. Intraoperative management
III. Postoperative management
E. Summary
F. References
INTRODUCTION
• 1899 : Prevost and Batteli noted almost as an afterthought that direct
electric shock could terminate ventricular fibrillation in dogs.
• Hooker and colleagues showed 3 decades later that the passage of electric
current across the heart can initiate and terminate ventricular fibrillation.
• 1947, Beck saved the first human life by the successful use of cardiac
defibrillation in a 14-year-old boy who developed ventricular fibrillation
during a thoracic procedure and went on to achieve full recovery.
• These early achievements provided the foundation for the landmark work of
Mirowski and Mower, which ultimately led to the development of ICDs in
humans in 1980.
• During the past 3 decades, an increase has occurred in the numbers of
patients with pacemakers and ICDs for the correction of cardiac arrhythmias
DEVELOPMENT OF
PACEMAKERS
INDICATIONS

• Artificial pacing is generally indicated for the treatment of symptomatic bradycardia of any
origin.
• Two major indications for permanent pacing
• Failure of impulse formation
• Failure of cardiac conduction.
• Clinically most common indications for pacemakers
• sick sinus syndrome
• complete heart block
SOME COMMON TERMINOLOGY USED IN
PACEMAKER
•Pulse generator
• Includes – energy source (battery – Li-iodide 5-10yrs ; Zn batteries – 2-3 yrs)
• Electric circuits – for pacing and sensory functions
• Leads – insulated wires connecting pulse generator and electrodes
• Electrode – exposed metal end of the lead in contact with the endocardium and epicardium
• Unipolar pacing – one electrode - the cathode (negative pole) or active lead
• Current flows – cathode  stimulates heart myocardium & adjacent tissue  returns to anode
(positive pole ) on the casing of pulse generator
• More likely to pick up extracardiac signals and myopotentials
• Pacemaker spikes are large
SOME COMMON TERMINOLOGY USED IN
PACEMAKER
• Bipolar leads
• Two separate electrodes: both located close to each other (therefore, small circuit  less
chances of extraneous noise disturbance; signals are sharp) within the chamber that is
being paced
• Anode (positive pole)
• Cathode (negative pole)
 SOME COMMON TERMINOLOGY USED IN
PACEMAKER
• Endocardial pacing (– transvenous pacing) – leads/electrodes passed through a vein to the
right atrium or right ventricle .
• Can be unipolar /bipolar
• Epicardial pacing
• Electrode inserted through the epicardium into the myocardium
• generally done following cardiac surgery
• Can be unipolar /bipolar
• Pacing threshold
• Minimum amount of energy required to consistently cause depolarization & contraction of the heart
• Measured in terms of amplitude (V/mA) and duration (msec)
• Sensitivity
• Minimal voltage level of the patient’s intrinsic R wave /P wave that must be exceeded for the pacemaker to
sense that R/P wave & to activate the sensing circuit of the pulse generator  inhibition/ triggering of the
pacing circuit
SOME COMMON TERMINOLOGY USED IN
PACEMAKER
• Resistance
• The impedance to the flow of circuit
• Combination of
• Resistance in leads
• Resistance through patient tissues
• Polarization when voltage & current are delivered to the tissues
• Very high resistance – conductor fracture/ poor connection to pacemaker
• Very low resistance – insulation failure
• Hysteresis
• Useful in sick sinus syndrome
• Longer escape interval after a sensed event  greater opportunity to heart to beat on its own
• Pacemaker is programmed to upper and lower rate & a programmable lower hystetresis rate
SOME COMMON TERMINOLOGY USED IN
PACEMAKER
• Runaway pacemaker
• Pacemaker dysfunction – fast & erratic spikes
• Generator dysfunction
• Battery failure
• Damage due to leakage of tissue fluids into the pulse generator
• Treatment with antiarrhythmic drugs or cardioversion - INEFFECTIVE
• Necessary to change the pacemaker to an asynchronous mode , or reprogram it to lower outputs.
• If patient is hemodynamically unstable  temporary pacing f/b change of pulse generator
CIED(CARDIOVASCULAR IMPLANTABLE
ELECTRONIC DEVICES)

• Includes
1. Pacemakers – for bradyarrhythmias
2. ICD (Implantable Cardioverter Defibrillator) – for tachyarrhythmias
3. CRT (Cardiac Resynchronization Therapy) - a biventricular pacing technique - for
systolic dysfunction( low LVEF) with conduction delays
4. Implantable loop recorder
5. Hemodynamic monitors
CLASSIFICATION OF PACEMAKER
• Five-letter coding system : NBG pacemaker code after being adopted by both the
NASPE (now known as the Heart Rhythm Society) and BPEG.
i. The first letter describes the chamber(s) that the pacemaker can pace,
ii. the second letter describes the chamber(s) that it senses,
iii. the third letter describes the response of the pacemaker to sensed intrinsic activity.
iv. The last two letters describe additional features such as rate responsiveness that are
commonly omitted when not used.
• For example,
• VVI pacing mode : paces in the ventricle, can sense intrinsic activity in the ventricle,
and inhibits pacing when it senses intrinsic activity.
• VOO pacing mode paces in the ventricle but does not sense intrinsic activity; nor does
it inhibit pacing­it simply paces regardless of the heart's electrical activity
CLASSIFICATION OF PACEMAKER

• On the basis of mode of pacing

• Asyn­chronous pacing,
• Single-chamber demand pacing,
• Dual-chamber demand pacing
 ASYNCHRONOUS PACING
* Fixed-rate (e.g., AOO, VOO, DOO)
* Modes pace at a programmable preset rate that is independent of the inherent heart rate .
* Can be atrial, ventricular, or dual chamber.

SINGLE CHAMBER DEMAND PACING

• Atrial/Ventricular-only anti bradycardia pacing.
• paces at a pre set rate only when the spontaneous heart rate drops below the programmed pre set rate.
• Indication- complete heart block with chronic atrial flutter, AF & long ventricular pauses.

DUAL CHAMBER DEMAND PACING

• Two leads: unipolar or bipolar are used. Atrium is stimulated first , then after an adjustable PR interval
ventricle is stimulated .
• Preserve the normal atrioventricular contraction sequence.
• Indication- AV block, carotid sinus syncope & sinus node disease.
CLASSIFICATION OF PACEMAKER
• As per the method of insertion, location of leads
• Transvenous
• Transcutaneuos
• Epicardial
• Transesophagel
 TEMPORARY
PACING

TRANSCUTANEOUS PACING TRANSVENOUS PACING

 Electrode placed via femoral, brachial, IJV or

 External electrode pads and power device
subclavian vein
 Large electrodes over precordium & back at  90% success rate in absence of fluroscopy under
level of heart ECG guidance
 Output: 0-140 mA  Atrial J-shaped electrodes and balloon tipped
 Terminate: Tachy-arrhythmia ventricular electrodes

 Pacing rate: 0-180 bpm  Externally paced generator with output 0-l0mA

 Sensing facility (VVI pacing possible)  All pacing modes available

INDICATIONS OF TEMPORARY PACING
A. Unstable brady-dysrhythmias
B. Unstable tachy-dysrhythmias
C. Third degree Atrioventricular block

Endpoint reached after resolution of the problem or permanent pacemaker implantation.

INDICATION OF PERMANENT PACING

A. Sinus Node Dysfunction
B. Atrial Fibrillation
C. AV Block
D. Chronic BBB
E. Cardiomyopathy
F. Cardiac Transplant
G. Prolonged QT interval
H. LV systolic dysfunction – biventricular / septal
PACEMAKER FAILURE
• Pacemaker failure has three etiologies:

1) Failure to capture:
a. Myocardial ischemia/infarction,
b. Acid-base disturbance,
c. Electrolyte abnormalities,
d. Abnormal anti-arrhythmic drug levels.
e. External pacing might further inhibit pacemaker.

2) Lead failure

3) Generator failure.
 Implantable Cardioverter Defibrillator (ICD)

 Battery powered device to deliver

sufficient energy to terminate VT / VF.

 Superior to anti-arrhythmic therapy in

preventing death in malignant
ventricular tachy-dysrhythmias.
INDICATIONS FOR ICDS
A. Ventricular Tachycardia
B. Ventricular Fibrillation
C. Brugada Syndrome (RBBB, ST-segment elevation in V1 to V3)
D. Arrhythmogenic RV Dysplasia
E. Long Q-T Syndrome
F. Hypertrophic cardiomyopathy
G. Prophylactic use in patient who has cardiomyopathy with EF ≤ 35% &
Post-MI patients with EF ≤ 30% .
Anaesthetic Management
 PREOPERATIVE EVALUATION
• Routine systemic workup, paying particular attention to cardiovascular disorders .
• The comprehensive evaluation includes
• Com­plete blood count,
• Urinalysis,
• Coagulation screening with prothrombin time and partial thromboplastin time,
• Serum electrolytes,
• Blood urea nitrogen,
• Blood sugar,
• Chest radio­graph, and
• ECG.
• Special attention should be paid to the history, symptoms, and signs of myocardial infarction,
congestive heart failure, and arrhythmia.
• Serum electrolytes, especially potassium level, must be in the normal range.
 PREOPERATIVE EVALUATION

• For the patient with a CIED, recent guidelines have recommended that all CIEDs be properly
interrogated within 3 to 6 months before surgery. This evaluation includes:
I. Establish whether a patient has a CIED
II. Define the type of CIED
III. Determine dependency on pacing function of the CIED
IV. Determine CIED function and programming details
V. Determine magnet behaviour and whether CIED requires reprogramming on the day of surgery to
avoid inappropriate device behaviour from EMI.
 PREOPERATIVE EVALUATION

I. Determining whether a patient has a CIED

a) A focused history including but not limited to the patient interview,
medical records review, review of available chest radiograph, ECG, or any
available monitor or rhythm strip information,
b) A focused physical examination (e.g., checking for scars , palpating for
device)

II. Defining the type of device by

a) obtaining the manufacturer's identification card from the patient or other source,
b) ordering chest radiography studies if no other data are available, or
c) referring to supplemental resources (e.g., manufacturers' databases, pacemaker
clinic records, consultation with a cardiologist)
 PREOPERATIVE EVALUATION
III. Determine dependency on pacing function of the CIED

• Determined by one or more of the following:

I. a verbal history or an indication in the medical record that the patient

has experienced a brady-arrhythmia that has caused syncope or other
symp­toms requiring CIED implantation,
II. a history of successful AV nodal ablation that resulted in CIED
placement.
 PREOPERATIVE EVALUATION
IV. Determine CIED function and programming details -
• Ideally assessed by interrogating the device.
• Device interrogations provide information on the status and
current programmed settings of a PPM or ICD.
• The important primary information for ANESTHESIOLOGISTS include
a) Battery life
b) Programmed pacing mode such as VVIR, DDDR
c) Pace­maker dependency
d) Intrinsic rhythm
e) Behaviour to a magnet
f) Prior recorded arrhythmic events
g) Pacemaker lead parameters (including pacing threshold, ability to
sense intrinsic activity, and lead impedance).
 PREOPERATIVE EVALUATION
• Preparation for patient safety and proper maintenance of the
device during a proce­dure includes the following:
 Determining whether EMI is likely to occur during the planned
procedure, as well as the location of the EMI
 Properly positioning the electrocautery grounding pad so the path of
conduction across the device is minimized to the fullest extent
 Advising the surgeon performing the procedure to minimize prolonged bursts or
monopolar cautery or use other less interfering sources of energy including bipolar
electrocautery or harmonic
 Ensuring the availability of temporary pacing and defibrillation equipment
 Evaluating the possible effects of anaesthetic techniques and of the procedure on
CIED function and patient-CIED interactions .
CHOICE OF ANAESTHESIA

• Should be used according to the need of the patient

• No guidelines favouring regional anaesthesia
• Few case reports of use of regional anaesthesia in obstetric cases available
• A PACED HEART CANNOT COMPENSATE FOR HYPOTENSION BY TACHYCARDIA – SPINAL
ANAESTHESIA SHOULD BE USED CAUTIOUSLY – PREFERABLY AVOIDED IN CASE OF
ANTICIPATED BLOOD LOSS & FLUID SHIFT
• Regional nerve blocks can be given safely
• Graded epidural analgesia can be used
• General anaesthesia can be used safely with precautions
•
INTRAOPERATIVE MANAGEMENT
MONITORING
• Properly functioning, regulary checked & serviced equipments & monitors for provision of
anaesthesia & management of potential complications( failed intubaton to CPR)
• Standard ASA monitoring
• Continuous peripheral pulse monitoring
• palpation of the pulse,
• auscultation of heart sounds,
• pulse plethysmography or oximetry,
• a tracing of arterial wave form,
• ultrasound peripheral pulse monitoring
• Pulse oximetry
• ECG
• The artifact filter on the ECG monitor should be disabled to detect the pacing spikes .
• The ECG monitor should be set in diagnostic mode instead of monitoring mode
• NIBP
• Arterial line and central venous pressure or pulmonary artery pressure monitoring - only if
the patient has poor ventricular function.
 INTRAOPERATIVE MANAGEMENT

• A complete array of drugs and equipment must be immediately available for cardio­
pulmonary resuscitation.
• The minimal requirements include ECG monitor, a trans­cutaneous external pacing and direct
current (DC) defibrillator, and the usual drugs for resuscitation.
 INTRAOPERATIVE MANAGEMENT
• Setting up the transcutaneous external pacer and defi­brillator
• prefer applying defibrillating electrodes such as Zoll® Pads to paddles - electrodes can be
placed before surgery at the desirable positions and connected to a
defibrillator/pacemaker for pacing and defibrillation.
• The electrodes should be placed as far (more than 6 in. or 15 cm) from a CIED as
possible.
• The three recommended electrode placements are as follows:
INTRAOPERATIVE MANAGEMENT
 INTRAOPERATIVE MANAGEMENT
• Special considerations in case of CIED
• NITROUS OXIDE AND PPM
• It has been reported that nitrous oxide could cause pacemaker malfunction by increasing
gas in the prepectoral pacemaker pocket.
• Despite air evacuation with antibiotic solution before closure of the prepectoral pocket, a
small amount of air remains entrapped in the pocket.
• In general, this small amount of air should have no clinical significance.
• Nitrous oxide is 35 times more soluble in blood than nitrogen.
• When nitrous oxide is used for anesthesia, the amount of nitrous oxide diffused from
blood to the air pocket is much more than the amount of nitrogen diffused from the air
pocket to blood. Therefore, this causes an expansion of the gas in the pocket that leads
to loss of anodal contact and pacing system malfunction.
• It is advisable not to use nitrous oxide in a patient with a newly implanted pacemaker
 INTRAOPERATIVE MANAGEMENT
• Special considerations in case of CIED
• ELECTROCAUTERY & CIED
• The responses of PACEMAKERS to electrocautery or other EMI include the following:
• Asynchronous pacing
• Inhibition of pacing
• Reset to backup mode
• Myocardial burns, rare
• Ventricular fibrillation, rare
• The responses of ICDs include the following:
• Inhibition of pacing
• Asynchronous pacing
• Inappropriate tachy therapy
• Inhibition of tachy therapy
 INTRAOPERATIVE MANAGEMENT
• Special considerations in case of CIED
• ELECTROCAUTERY & CIED
• Safest way to prevent intraoperative EMI response - appropriate reprogramming.
• Precautions taken to minimize the effects of electrocautery:
• Place the cautery grounding plate as close to the operative site and as far from the CIED as possible to
make sure that the current pathway does not pass through or near the CIED system.
• For some cases, the grounding plate might need to be placed on a site different from the thigh (e.g., the
superior posterior aspect of the shoulder contralateral to the CIED generator position for a head and
neck case).
• Do not use cautery within 15 cm of the pacemaker because it may interfere with the battery circuitry. If
in contact with a break in the insulation of the electrode, it may cauterize the myocardium at the
electrode tip , rendering it insensitive to pacing impulses.
• Limit cautery use to 1-second bursts every 10 seconds to prevent repetitive asystolic periods (if possible).
• If the pacemaker is inhibited by the cautery, place a high-powered magnet over the demand
nonprogrammable pacemaker to convert it to fixed-rate mode.
• Using bipolar electrocautery forceps or harmonic scalpel reduces EMI.
INTRAOPERATIVE MANAGEMENT
• Special considerations in case of CIED
• MAGNET AND CIED
• The effect of placing a magnet over a pacemaker or ICD can vary quite
considerably depending on the device manufacturer, model, and individual
programmed modes.
• This information may be obtained by consulting the device manufacturer's repre­
sentative.
• Most pacemakers will switch to a fixed-rate pacing mode when a magnet is placed.
• However, the response of a pacemaker to a magnet placement may also include
the following:
• Asynchronous pacing without rate responsiveness
• No response
• Brief (10 to 100 beats) asynchronous pacing
• Continuous or transient loss of pacing
 INTRAOPERATIVE MANAGEMENT
• Special considerations in case of CIED
• Succinylcholine and CIED
• succinylcholine fassiculations may generate sufficient myopotentials for pacemaker inhibition
(unipolar devices) or ventricular tracking (adaptive-rate devices) .
• Therefore, it is advisable to program the pacemaker to a non-sensing (asynchronous) mode for
pacemaker-dependent patients either by reprogramming prior to the procedure or using a
magnet during the case
• Etomidate and ketamine should be avoided – causes myoclonic movements
• Avoid perioperative hypothermia  shivering may affect pacemaker functioning
 INTRAOPERATIVE MANAGEMENT
• Special considerations in case of PPM
• PACING THRESHOLD & ITS ANESTHETIC IMPLICATIONS
• Minimum amount of energy required to consistently cause depolarization
& contraction of the heart
• Measured in terms of amplitude (V/mA) and duration (msec)
Factors which INCREASE pacing threshold Factors which DECREASE pacing threshold
1-4 weeks after implantation Increased catecholamines
Myocardial ischemia/ infarction Stress, anxiety
Hypothermia/ hypothyroidism Sympathomimetic drugs
Hyperkalemia, acidosis/alkalosis Anticholinergics
Antiarrythmics (class 1A, 1B, 1C) Glucocorticoids
Severe hypoxia/ hyperglycemia Hyperthyroidism/ hypermetabolic states
 INTRAOPERATIVE MANAGEMENT
• Special considerations in case of PPM
• PACING THRESHOLD & ITS ANESTHETIC IMPLICATIONS
• If pacing threshold increases more than that of pacemaker  pacemaker
spike will be seen on ECG but will not be followed by QRS complex 
FAILURE TO CAPTURE

• FAILURE TO PACE  When pacemaker fails/ does not fire  no spike is

seen on ECG
 INTRAOPERATIVE MANAGEMENT
• Anesthetic agents that are safe are
• Premedication :
• Benzodiazepines : midazolam (0.05-0.15 • Inhalational agent :
mg/kg)
• Isoflurane
• Opioids :
• Sevoflurane
• Fentanyl (4 - 20 µgm/kg)
• Desflurane
• Sufentanil (0.25 - 2 µgm/kg)
• Alfentanil (25 - 100 µgm/kg) • Muscle relaxants
• Remifentanil ( 1 - 2 µgm/kg)
• Atracurium (0.5 mg/kg)
• Inducing agent :
• Vecuronium (0.1 – 0.2 mg/kg)
• Thiopental(3-4 mg/kg)
• Rocuronium (0.6 - 1.0 mg/kg)
• Propofol(1-2.5 mg/kg)
 INTRAOPERATIVE MANAGEMENT

• MANAGEMENT OF INTRAOPERATIVE VENTRICULAR TACHYCARDIA

• Advise the surgeon performing the procedure to terminate all sources of EMI.
• For a patient with an ICD AND MAGNET-DISABLED THERAPIES:
• Remove the magnet to re-enable anti-tachycardia therapies.
• Observe the patient and the monitors for appropriate CIED therapy. This can be
delayed for as long as 10 to 12 seconds as the ICD is charging.
• If the activities mentioned in the preceding text do not restore ICD function, proceed
with emergency external defibrillation.
• Advise individual performing the procedure to terminate all sources of EMI while
magnet is removed.
INTRAOPERATIVE MANAGEMENT

• MANAGEMENT OF INTRAOPERATIVE VENTRICULAR TACHYCARDIA

• For a patient with an ICD and programming-disabled therapies:
• Re-enable therapies through programming if the programmer is immediately
avail­able and ready to be used.
• Observe the patient and the monitors for appropriate CIED therapy.
• If the activities mentioned in the preceding text do not restore ICD function,
• proceed with emergency external defibrillation.
• Position defibrillation/cardioversion pads or paddles as far as possible from
the CIED generator.
INTRAOPERATIVE MANAGEMENT

• MANAGEMENT OF INTRAOPERATIVE VENTRICULAR TACHYCARDIA

• For external defibrillation
• Position defibrillation/cardioversion pads or paddles as far as possible from
the CIED generator.
• If it is technically impossible to place the pads or paddles in locations that
help to protect the CIED, defibrillate/cardiovert the patient in the quickest
possible way and be prepared to provide pacing through other routes .
• Use a clinically appropriate energy output.
 POSTOPERATIVE MANAGEMENT
• Cardiac rate and rhythm should be continuously monitored throughout the immedi­ate
postoperative period.

• Backup pacing capability and cardioversion-defibrillation equipment should be immediately

available at all times.
Special precautions
• Shivering & fasciculations should be avoided
• If pacemaker is activity rate responsive - ventilation should be kept controlled
& constant
• If pacemaker is temperature rate responsive - avoid hypo/hyperthermia
 CONFIRMING THE FUNCTIONALITY OF CIED
 Postoperative interrogation and restoration of CIED function are basic elements of
postoperative management
 CIEDs that should be interrogated postoperat­ively before discharge
 CIEDs that were reprogrammed or deactivated before surgery so that baseline settings can
be restored
 Patients who underwent hemodynamically embarrassing surgeries such as cardiac surgery
or significant vascular surgery
 Patients who experienced significant intraoperative events, including cardiac arrest,
requiring temporary pacing or cardiopulmonary resuscitation and/or tachyarrhythmias
requiring external electrical cardioversion during surgery
 All other individuals should have their devices evaluated as an outpatient within the next 3
months.
 Manage potential CRMD dysfunction due to EMI

1.Electrocautery.
Assure that electrosurgical receiving plate is positioned so that
current pathway does not pass through CRMD.
Advise surgeons to avoid proximity of cautery to PM or leads.
Advise surgeons to use short, intermittent, and irregular bursts at
the lowest feasible energy levels.
Advise surgeons to reconsider use of bipolar electrocautery system.

2. Radiofrequency ablation.
Advise surgeons to avoid direct contact between the ablation
catheter and PM and leads.
Advise surgeons to keep radiofrequency current path as far away
from PM and leads.
3. Lithotripsy.
Advise surgeons to avoid focusing the lithotripsy beam near pulse
generator.
If the lithotripsy system triggers on the R wave, consider preoperative
disabling of atrial pacing.
4. MRI.
MRI is generally contraindicated in patients with CRMDs.
If MRI must be performed, consult with the ordering physician,
cardiologist, radiologist and CRMD manufacturer.

5. Radiation therapy.
Radiation therapy can be safely performed.
Surgically relocate the CRMD if the device will be in the field of radiation.

6. Electroconvulsive therapy.
No significant damage if CRMD disabled
Consult with the ordering physician, cardiologist, CRMD manufacturer.
SUMMARY
REFERENCES

• Practice Advisory for the Perioperative Management of Patients

with Cardiac Rhythm Management Devices: Pacemakers and
Implantable Cardioverter Defibrillators, ASA , Anesthesiology
2005; 103: 186–198.
• Miller’s Anaesthesia 8th edition
• Barash 7th edition
• Kaplan’s Cardiac Anesthesia
THANK
YOU