Anaesthetic consideration in patients with cardiac implantable electronic devices scheduled for surgery

Emergency Neurosurgery in a Patient With Pacemaker: The Double Trouble

Perioperative management of a patient with multiple comorbidities, being taken up for an emergency neurosurgical procedure presents a unique set of challenges to the anesthetist as it requires quick preoperative evaluation in order to avoid any delay in the surgery and limit the extent of cerebral injury. This case report highlights the perioperative management of a 55-year-old obese male patient, with a history of hypertension and coronary artery disease with a permanent pacemaker presenting to the emergency with weakness of right upper and lower limbs, suggestive of an acute stroke due to intracerebral hemorrhage. The patient was taken up for emergency decompressive craniectomy in view of increasing intracranial pressure and deteriorating consciousness. The pacemaker could not be changed to asynchronous mode in the preoperative period due to the non-availability of a magnet and trained personnel from the company of the pacemaker to change the settings immediately. Intraoperatively, all the necessary precautions for the prevention of pacemaker-related complications were followed. After the completion of the surgery, the patient was shifted to the neuro-intensive care unit for postoperative management.

Revolutionizing Cardiac Anesthesia: A Comprehensive Review of Contemporary Approaches Outside the Operating Room

This review article provides a comprehensive examination of the evolution of cardiac anesthesia, emphasizing contemporary approaches beyond the traditional operating room (OR) setting. Tracing the historical roots of cardiac anesthesia from its inception in the mid-20th century, the narrative explores the significant paradigm shift driven by technological advancements and changing procedural approaches. The review highlights the emergence of non-OR environments, such as hybrid operating rooms, catheterization laboratories, and electrophysiology labs, as integral spaces for cardiac interventions. Key findings underscore the importance of patient selection, preoperative assessment, and specialized anesthetic management in optimizing outcomes. Implications for the future of cardiac anesthesia include the potential for enhanced patient-centered care, reduced complications, and improved resource utilization through the integration of advanced technologies. The call to action involves encouraging ongoing research and fostering collaboration among healthcare professionals to refine protocols further, address challenges, and propel the field toward continued innovation in contemporary cardiac interventions.

Risk of cardiac implantable device malfunction in cancer patients receiving proton therapy: an overview

Age is a risk factor for both cardiovascular disease and cancer, and as such radiation oncologists frequently see a number of patients with cardiac implantable electronic devices (CIEDs) receiving proton therapy (PT). CIED malfunctions induced by PT are nonnegligible and can occur in both passive scattering and pencil beam scanning modes. In the absence of an evidence-based protocol, the authors emphasise that this patient cohort should be managed differently to electron- and photon- external beam radiation therapy (EBRT) patients due to distinct properties of proton beams. Given the lack of a PT-specific guideline for managing this cohort and limited studies on this important topic; the process was initiated by evaluating all PT-related CIED malfunctions to provide a baseline for future reporting and research. In this review, different modes of PT and their interactions with a variety of CIEDs and pacing leads are discussed. Effects of PT on CIEDs were classified into a variety of hardware and software malfunctions. Apart from secondary neutrons, cumulative radiation dose, dose rate, CIED model/manufacturer, distance from CIED to proton field, and materials used in CIEDs/pacing leads were all evaluated to determine the probability of malfunctions. The importance of proton beam arrangements is highlighted in this study. Manufacturers should specify recommended dose limits for patients undergoing PT. The establishment of an international multidisciplinary team dedicated to CIED-bearing patients receiving PT may be beneficial.

Preoperative Assessment and Optimization of Cardiopulmonary Disease in Noncardiac Surgery

More than 50 million surgical procedures are carried out every year in the United States with the estimated risk of major adverse cardiac events perioperatively between 1.4 and 3.9%. Given that the majority of surgeries are elective, this allows ample opportunity to identify patients at higher risk of perioperative adverse events and optimize them for surgery. Preexisting cardiopulmonary disease is a major risk factor for adverse events perioperatively and can lead to significant morbidity and mortality. It can predispose patients to perioperative myocardial ischemia and infarction, perioperative pulmonary complications, and perioperative stroke among other complications. This article details an approach to preoperative interview and examination, indications for preoperative testing, and strategies for optimization in patients with underlying cardiopulmonary disease. It also includes guidelines on optimal timing of elective surgery in certain clinical scenarios that can escalate perioperative risk. Through the use of thorough preoperative assessment, targeted preoperative testing, and multidisciplinary optimization of preexisting disease, perioperative risk can be decreased significantly and perioperative outcomes improved.

Anaesthetic Management of Major Abdominal Oncosurgery in a Patient With an Automated Implantable Cardioverter-Defibrillator (AICD): A Case Report

Ischaemic cardiomyopathy with low ejection fraction (EF) poses a perioperative challenge to the anesthetist due to the risk of hemodynamic instability, cardiovascular collapse, and heart failure. More so when a patient has an Automated Implantable Cardiovertor Defibrillator (AICD) in situ. We report the anesthetic management of a patient with ischaemic cardiomyopathy with an EF of 20% and AICD in situ posted for open right hemicolectomy. Dynamic hemodynamic monitoring with preparedness to manage fluid shifts, hemodynamic fluctuations, and adequate pain management is essential to successful anesthetic management in patients with an AICD, where programming is not possible.

Sudden Occurrence of Pacemaker Capture Failure during Irreversible Electroporation Ablation for Prostate Cancer in Post-COVID-19 Patient: A Case Report

Irreversible electroporation (IRE) ablation is a novel treatment option for localized prostate cancer. Here, we present a case of an abrupt and fatal arrhythmia during the IRE procedure in a prostate cancer patient with an implanted permanent pacemaker. A 78-year-old male patient with a pacemaker due to sick sinus syndrome and syncope was scheduled for IRE prostate ablation surgery under general anesthesia. He had a history of recovering from coronavirus disease 2019 (COVID-19) after having been vaccinated against it and recovered without sequalae. Pacemaker interrogation and reprogramming to asynchronous AOO mode was carried out before surgery, however, sinus pause occurred repeatedly during ablation pulse delivery. After the first sinus pause of 2.25 s there was a decrease in continuous arterial blood pressure (ABP). During the delivery of the second and third pulses, identical sinus pauses were observed due to failure to capture. However, the atrial-paced rhythm recovered instantly, and vital signs became acceptable. Although sinus pause recovered gradually, the duration thereof was increased by the delivery of more IRE pulses, with a subsequent abrupt decrease seen in blood pressure. The pacemaker was urgently reprogrammed to DOO mode, after which there were no further pacing failures and no hemodynamic adverse events. For patients with pacemakers, close cardiac monitoring in addition to the interrogation of the pacemaker during the electromagnetic interference (EMI) procedure is recommended, especially in the case of having a disease that may aggravate cardiac vulnerability, such as COVID-19.

The perioperative management of small animals with previously implanted pacemakers undergoing anaesthesia

OBJECTIVE

There is little information in the veterinary literature about the perioperative management of small animal patients with previously implanted pacemakers undergoing elective or emergency non-cardiac procedures. The purpose of this article is to review the current literature with regard to human patients, with previously implanted pacemakers, undergoing general anaesthesia. Using this and the current information on pacemakers and anaesthesia in dogs and cats, we provide recommendations for small animal patients in this situation.

DATABASES USED

Google Scholar, PubMed and CAB Abstracts using and interlinking and narrowing the search terms: "dog", "cat", "small animals", "anaesthesia", "pacemaker", "perioperative", "transvenous pacing", "temporary pacing". Scientific reports and human and small animal studies from the reference lists of the retrieved papers were reviewed. In addition, related human and veterinary cardiology and anaesthesia textbooks were also included to create a narrative review of the subject.

CONCLUSIONS

The best perioperative care for these animals comes from a multidisciplinary approach involving the anaesthetist, cardiologist, surgeon and intensive care unit team. When such an approach is not feasible, the anaesthetist should be familiar with pacemaker technology and how to avoid perioperative complications such as electromagnetic interference, lead damage and reprogramming of the device. The preanaesthetic assessment should be thorough. Information regarding the indication for pacemaker placement, complications during the procedure, location, type and programming of the pacemaker should be readily available. The anaesthetic management of these veterinary patients aims to preserve cardiovascular function while avoiding hypotension, and backup pacing should be available during the perioperative period. Further prospective studies are needed to describe the best perioperative care in small animals with a previously implanted pacemaker.

Challenges during Electroconvulsive Therapy—A Review

Electroconvulsive therapy (ECT) is one of the most successful treatment techniques employed in psychiatric practice. ECT is usually administered as a last resort to a patient who fails to respond to medical management or on an urgent basis as a life-saving procedure when immediate response is desired. It is performed under general anesthesia and is often associated with autonomic changes. All attempts should be made to minimize the resulting hemodynamic disturbances in all the patients using various pharmacological methods. Anesthesiologists providing anesthesia for ECT frequently encounter patients with diverse risk factors. Concurrent cardiovascular, neurological, respiratory, and endocrine disorders may require modification of anesthetic technique. It is ideal to optimize patients before ECT. In this review, the authors discuss the optimization, management, and modification of anesthesia care for patients with various cardiac, neurological, respiratory, and endocrine disorders presenting for ECT to improve the safety of the procedure. It is not infrequent that an anesthesiologist also plays an important role in inducing a seizure. Proconvulsants such as caffeine, adjuvants like opioids, hyperventilation, and appropriate choice of anesthetic agent for induction such as etomidate or ketamine can help. The use of BIS monitoring to guide the timing of electric stimulation is also elaborated in this review.

Sudden onset pacemaker-induced diaphragmatic twitching during general anesthesia

BACKGROUND

Involuntary muscle contraction caused by extracardiac stimulation is a rare complication induced by a pacemaker. We report a case who developed sudden onset diaphragmatic contractions during general anesthesia caused by a DDD mode pacemaker.

CASE PRESENTATION

A 74-year-old woman with a permanent pacemaker was scheduled to undergo mastectomy. The pacing mode was switched from DDD to VOO intraoperatively to avoid electromagnetic interference. Immediately after returning the pacing mode to DDD after surgery, diaphragmatic contractions occurred, mimicking bucking type of movements. After switching the pacing to A-sense V-pace, the twitching ceased. Because no structural problems were noted, and the twitching disappeared after terminating atrial pacing, diaphragmatic contractions might be caused by stimulation of the right phrenic nerve located near the right appendage where the electrode was installed.

CONCLUSION

The potential risk of muscle twitching should be carefully evaluated preoperatively especially in patients with atypical position of pacemaker leads.