Implanted cardiac pacemakers and defibrillators in anaesthetic practice

Unstable gynaecological patient with an ankle monitor: implications of US Immigration and Customs Enforcement's Alternatives to Detention programme in the healthcare setting

We review the case of an unstable gynaecological patient in the USA who presented with profuse vaginal bleeding after spontaneous miscarriage and was ultimately diagnosed with a uterine arteriovenous malformation managed with interventional radiology embolisation of her uterine artery. Her case was complicated by the presence of an ankle monitoring device which had been placed by US Immigration and Customs Enforcement as part of the Alternatives to Detention programme in which she was enrolled during her immigration proceedings. The device prompted important considerations regarding the potential use of cautery, MRI compatibility and device-related trauma, in addition to causing significant anxiety for the patient, who was concerned about how the team's actions could affect her immigration case. Discussion of her course and shared perspective highlights the unique clinical and medicolegal considerations presented by the expanded use of ankle monitoring devices for electronic surveillance (or 'e-carceration') of non-violent immigrants and others.

Anesthetic considerations and successful management of a patient with permanent pacemaker for cervical spine instrumentation

Patients with permanent pacemaker posted for cervical spine instrumentation pose special challenges for modern-day anesthesiologist since the field of surgery is in proximity to the pacing apparatus. The important considerations in this regard are pacemaker dependency, prior reprogramming to asynchronous mode, perioperative interference with pacemaker function due to electrolyte, acid-base disturbances, and electromagnetic interference leading to pacemaker failure and hemodynamic compromise. We report successful anesthetic management of a patient of postlaminectomy kyphosis with compressive myelopathy with permanent pacemaker in situ who underwent C5–C6 corpectomy and instrumentation under general anesthesia.

Perioperative management of patients with cardiac implantable electronic devices

The use of implantable cardiac devices in people of all ages is increasing, especially in the elderly population: patients with pacemakers, cardioverter-defibrillators or cardiac resynchronization therapy devices regularly present for surgery for non-cardiac causes. This review was made in order to collect and analyze the latest evidence for the proper management of implantable cardiac devices in the perioperative period. Through a detailed exploration of PubMed, Academic Search Complete (EBSCO), ClinicalKey, Cochrane (Ovid), the search software UpToDate, textbooks and patents freely available to the public on Google, we selected 33 monographs, which matched the objectives of this publication.

Pacemakers and implantable cardioverter defibrillators--general and anesthetic considerations

A pacemaking system consists of an impulse generator and lead or leads to carry the electrical impulse to the patient's heart. Pacemaker and implantable cardioverter defibrillator codes were made to describe the type of pacemaker or implantable cardioverter defibrillator implanted. Indications for pacing and implantable cardioverter defibrillator implantation were given by the American College of Cardiologists. Certain pacemakers have magnet-operated reed switches incorporated; however, magnet application can have serious adverse effects; hence, devices should be considered programmable unless known otherwise. When a device patient undergoes any procedure (with or without anesthesia), special precautions have to be observed including a focused history/physical examination, interrogation of pacemaker before and after the procedure, emergency drugs/temporary pacing and defibrillation, reprogramming of pacemaker and disabling certain pacemaker functions if required, monitoring of electrolyte and metabolic disturbance and avoiding certain drugs and equipments that can interfere with pacemaker function. If unanticipated device interactions are found, consider discontinuation of the procedure until the source of interference can be eliminated or managed and all corrective measures should be taken to ensure proper pacemaker function should be done. Post procedure, the cardiac rate and rhythm should be monitored continuously and emergency drugs and equipments should be kept ready and consultation with a cardiologist or a pacemaker-implantable cardioverter defibrillator service may be necessary.

Dilated cardiomyopathy: an anaesthetic challenge

Idiopathic dilated cardiomyopathy is a primary myocardial disease of unknown etiology characterized by left ventricular or biventricular dilation and impaired contractility. Depending upon diagnostic criteria used, the reported annual incidence varies between 5 and 8 cases per 100,000 populations. Dilated cardiomyopathy is defined by presence of: a) fractional myocardial shortening less than 25% (>2SD) and/or ejection fraction less than 45% (>2SD) and b) Left Ventricular End Diastolic Diameter (LVEDD) greater than 117% excluding any known cause of myocardial disease. Such cases are always a challenge to the anesthesiologist as they are most commonly complicated by progressive cardiac failure. We report the anesthetic management of a patient with dilated cardiomyopathy undergoing surgery for carcinoma breast.

Implications of a permanent cardiac pacemaker in peripheral nerve blockade

Patients with permanent cardiac pacemakers (PPMs) are vulnerable to electromagnetic interference from electrical equipment used in the operating room environment. Electromagnetic interference may lead to PPM malfunction with potential harmful effects to the patient. Conventional techniques for peripheral nerve blockade include the use of electrical nerve stimulation (NS) for nerve localization. The hazards of NS, especially when applied near the implanted PPM sites, are not known. In the absence of available guidelines regarding the safe use of NS in the setting of an implanted PPM, we recommend a combined guidance approach for peripheral nerve blockade using ultrasound for nerve localization along with low-current NS for nerve identification.

[Implantable pacemakers and defibrillators: implications for anesthesia and perioperative management]

The technological complexity of implantable devices for managing arrhythmias, specifically pacemakers and defibrillators, has increased spectacularly since their introduction a few decades ago. A growing number of patients with these devices are undergoing surgery and it is therefore essential to understand how they work and what the real associated risks are. Manuals and reference works on anesthesia may provide little information on these devices and their perioperative management. It is no longer satisfactory to place a magnet over these devices during surgery and assume that this action will protect the patient from the possible effects of electromagnetic interference. This review examines the basic principles and operation of implantable pacemakers and defibrillators, the relevant nomenclature, and the sources and effects of electromagnetic interference; the current recommendations for the perioperative management of patients fitted with these devices are also discussed.

Pacemakers: some of the risks and complications you are not warned about

Pacemaker technology has advanced rapidly over the last decade. A lot of everyday interference can be regarded as transient. The media tend to cover stories of relatively insignificant transient interference incurred by pacemaker wearers while many manuals gloss over the high risks, some potentially life-threatening. These include the reliability of pacemakers and the use of monopolar diathermy which can generate electromagnetic interference, potentially causing a pacemaker to malfunction.

Electrocautery-induced asystole in a scoliosis patient with a pacemaker

Pediatric heart condition management may include a variety of implanted cardiac devices. Monopolar electrocautery (Bovie) produces significant electromagnetic interference to these devices. This interference can alter the function of a cardiac generator resulting in a variety of complications including impaired cardiac output and asystole. We report the case of a 16 plus 2-year-old girl who presented with idiopathic scoliosis and a past medical history significant for complete congenital heart block treated with a DDD*** pacemaker. During surgery, the use monopolar electrocautery caused the patient to develop asystole and loss of pulsatile blood pressure. Electrocautery was subsequently terminated, the patient then returned to a normal sinus rhythm and blood pressure normalized.