Ayman M.

Kamaly, MD
Professor of Anesthesiology
kamaly3@hotmail.com

Anesthesiologists

Do it … while you sleep !!

Overview:
1958: 1st Battery operated pacing devices. 1980: Implantable Cardioverterdefibrillator (ICDs). Today: > 2000 pacemaker models, produced by 26 companies.

advances in CRMD technology & expanding indications for pacing. Aging. will lead to growing numbers of patients with CRMD.000 adults & children are undergoing Cardiac Rhythm Management Device (CRMD) implantation annually. .Epidemiology: No reliable Egyptian data. USA data: > 250.

“Our ability to care for these patients requires attention to their primary medical problems. Those patients often have significant comorbid diseases and need procedures of varying complexities. as well as understanding these devices”.This will increase the chances to be confronted with patients having CRMD (not uncommon). .

 Hypertrophic Obstructive Cardiomyopathy (HOCM).  Dilated Cardiomyopathy (DCM). Bryce et al.  S A Node Disease.Permanent Pacemaker Indications:  Symptomatic Sinus Bradycardia. 134:1130-41. .  Symptomatic A V Node Disease. 2001. Ann Intern Med.  Long Q T Syndrome.

Cardiac Rhythm Management Devices (CRMD) basic components  Impulse generator (1/2 life 5-10 yrs)  Lead:  Unipolar.  Bipolar.  Multiplolar. .

How CRMD Works?! Basic: Track the native electrical rhythm. atrium and ventricle. it stimulates the ventricle. More complex: Sense &/or stimulate both. Much More Complex: “Rate Modulation” . When doesn't sense a heart beat within a ‘normal beat-to-beat time’.

Rate Modulation Sensors Available Body activity (vibration) Respiratory rate Minute ventilation Right ventricular stroke volume Right atrial pressure Systolic time intervals Blood temperature Under Investigation QT interval Mixed venous oxygen saturation Atrial rate Blood PH Evoked pressure Paced depolarization integral .

• BPEG: British Pacing & Electrophysiology Group. Revised 2002) Position I: Paced Chamber(s) O = None A = Atrium V = Ventricle Position II: Sensed Chamber(s) O = None A = Atrium V = Ventricle Position III: Response(s) to Sensing O = None I = Inhibited T = Triggered Position IV: Programmability O = None R = Rate Modulation Position V: Multisite Pacing * O = None A = Atrium V = Ventricle D = Dual (A + V) D = Dual (A + V) D = Dual (T + I) D = Dual (A + V) * = When 2 atria or 2 ventricles are paced.Generic Pacemaker Code (NASPE/ BPEG. • NASPE: North American Society of Pacing & Electrophysiology. .

Hazard: Competes with the native intrinsic rhythm → arrhythmias induction. VOO. . Discharges irrespective of the native heart rate.Examples and Types of Pacing Modes: Asynchronous: (AOO. & DOO) Fixed (preset rate) rate pacemaker.

which senses the intrinsic P wave and causes inhibition or triggering of the pacemaker. thus maintaining A-V synchrony. . A single lead in the Rt. AAT) Atrium is paced and the impulse passes down the conducting pathways.Single Chamber Atrial Pacing (AAI. Useful in sinus arrest & sinus bradycardia (adequate AV-conduction) Inappropriate for chronic AF & long ventricular pauses.. Atr.

It senses the intrinsic ‘R’ wave and thus inhibits the pacemaker function.Single Chamber Ventricular Pacing (VVI. Af. Indications: Complete HB with chronic AF. VVT) VVI: The most widely used pacing mode. ventricle is sensed & paced. & long ventricular pauses. .

and VDD) Using 2 leads (Rt. DVI. SA node disease. After an adjustable PR interval. both the atrium and ventricle can be sensed and paced. Atr.g. & Rt. DDI.) 1st: atrium is stimulated to contract. ventricle is stimulated (preserve normal AV contraction sequence). A. Advantages: mimic SR.) .S. so beneficial when atrial contraction is important for ventricular filling (e.Dual Chamber AV Sequential Pacing (DDD. In DDD system. vent. indications: AV block.

Verapamile*. Quinidine*. Anesthetic drugs (both. Sotalol. Catecholamines. -Blockers*. Procainamide*.Factors Influencing CRMD Pacing Threshold Effect Drugs Other Factors  Flecainide. Amiodarone. inhalational & intravenous)   Increase Threshold Possibly Decrease Threshold      Myocardial ischemia/infarction Hyperkalaemia Severe Acidosis or Alkalosis Hypothyrodism* Hyperglycemia* Pheochromocytoma Hyperthyroid Hypermetabolic states No Proven Effect * Possibly Atlee. Encainide. Lidocaine*. Glucocorticoids. Atropine. 1999 . Propafenone.

Never intended to treat pacemaker emergencies or prevent EMI effects . Magnet-activated switches were incorporated into pacemakers to produce pacing behavior that demonstrates remaining battery life.Effect of the Magnet Application on Pacemaker Function.

Magnet application results in a non-sensing asynchronous mode with a fixed pacing rate (magnet rate). Use of magnet during surgery is not without risk. (diathermy/cautery). magnets can be used to protect the pacemakerdependent patient during EMI.Thus. Asynchronous pacing may trigger malignant rhythm. .

.N o t A l l Pa ce m a ke r s Sw i t c h e s t o a Co n t i n u o u s A s y n c h ro n o u s Mo d e W h e n a Magnet is Applied. generator may unpredictably reprogrammed with a new ‘surprise programme’. in the presence of EMI. In programmable pacemakers. Most current devices should be considered programmable unless known otherwise.

We Care !! ..Anesthesiologists You Sleep .

How to Deal with a Patient with CRMD .

Assess: (1) severity. (continuity of leads) • ECG. (Spike) • Bioch (s. • CXR. Routine preoperative evaluation: • CAD (50%) HTN (20%) & DM (10%). status (3) medication. K+) . Preoperative Evaluation: 1. (2) current functional.Stepwise Approach Patient with a CRMD: I.

ECG. medical records.Preoperative Evaluation (Cont. CXR. palpate for device).): 2. • Inquire about the initial indication for the pacemaker & pre-implantation symptoms (dizziness. . • Focused physical examination (check for scars. fainting). Confirm whether a patient has a CRMD: • Focused history: interview.

4. If no other data is available: CXR (X . • No spontaneous ventricular activity when programmed to VVI mode at the lowest programmable rate.Ra y c o d e ).): 3. Determine patient dependency on CRMD pacing. Define the type of CRMD.Preoperative Evaluation (Cont. • • Obtain manufacturer’s ‘I D c a rd ’ from patient. .

Preoperative Evaluation (Cont. • Get the device I N T E R RO G AT E D (by Cardiologist) & get a copy !! . Evaluation of CRMD function.): 5.

while ECG is monitored. slow down HR (carotid massage or Valsalva manoeuvre). pulse) !! If VVI mode: if intrinsic HR is > set rate. • .) • Ensure that the electrical pacing impulse creates a mechanical systole (preph. Evaluation of CRMD function (Cont.): 5.Preoperative Evaluation (Cont.

• Deactivate all ‘Rate Responsive’ !! ‘Activity’ rate responsive: shivering and fasciculations  ‘Minute ventilation’ rate responsive: (RR & Vt) should be kept controlled  ‘Temperature’ rate responsive Temp kept constant. E M I is likely to occur : • Reprogram to Asynchronous mode.  • Disable Antitachyarrhythmia functions if present (if CRMD is ICD). • Temporary pacing and defibrillation equipment should be immediately available (all CRMD). Preoperative Preparation 1. . If Intraop.II.

if CVL placement is planned. Preoperative Preparation (Cont.  CXR to document the position of the Coronary Sinus lead.II. . Evaluate the possible effects of anesthetic techniques on CRMD function. (CS lead displacement).) 2.

line).  Waveform Display: pulse oximeter. Intraoperative Management 1.  Preferably with Respiratory Rate monitoring.III. Monitor CRMD operation.  ECG:  Ability to detect pacemaker discharge (disable “artifact filter” ). A. .  Monitor peripheral pulse:  Manual palpation.

III. Ch. can inhibit or trigger stimulation.: fasciculation.) 2. Agents suppresses AV or SA node (potent opiates or dexmedetomidine) may render patient ‘truly pacemaker dependant’. Nitrous Oxide ??! • . (according to programmed pacing modes): • Succ. • Etomidate & ketamine: myoclonic movements. Myoclonic movements. • • • Anesthetic Technique: Should be dictated by patient’s underlying physiology &/or procedure. Intraoperative Management (Cont.

) 3. Use Bipolar or ultrasonic (harmonic) (√√) A. Isupril should be ready.  Asynchronous Mode (magnet or programmer). Frequency: 1-second every 10 seconds (to prevent repeated asystolic periods). Assure that the current does not pass through or near the CRMD Distance: Not within 15 cm of pacemaker. .III. EMI–Induced CRMD Potential Dysfunction Avoid Unipolar (χ χ).  Emergency Tools: Temporary pacing (transvenous. Electrocautery:  If unipolar used:     Grounding plate: as far as possible from the pacemaker site. Atropine.  Pure “cut” is better than “Coag”. Intraoperative Management (Cont. trans cutaneous).

EMI–Induced CRMD Potential Dysfunction (Cont.Intraoperative Management (Cont.  If triggers on the ‘R-wave’.) 3.) B. disable atrial pacing.III. Nature of Procedure:  Lithotripsy (ESWL):  Avoid beam focusing near the generator.  Radiology:  Plain X-ray & CT: Do Not affect pacemaker function  MRI: Contraindicated Generally .

 External pacemaker should be available.Intraoperative Management (Cont.III.) 3.) B.):  Radio-therapy:  Safe (Surgically relocate CRMD outside radiation field  ECT:  ECT itself safe (little current flows within the heart)  Succinylcholine and seizure (!!!)  Reprogram to asynchronous mode. . Nature of Procedure (Cont. EMI–Induced CRMD Potential Dysfunction (Cont.

Emergency Defibrillation or Cardioversion. As far as possible from the pulse generator. . 2.IV. Perpendicular to the major axis of the generator and leads to the extent possible by placing them in an ‘anterior–posterior’ location.  Follow existing ACLS guidelines (energy level & paddle placement).  Minimize the current flow through the generator & lead system by positioning the paddles : 1.

(cardiologist/manufacturer) . Postoperative Management  ICU Setup (Continuous ECG monitor.V. backup pacing & defibrillation).  Assure that all CRMD settings are restored:  Interrogate CRMD.

Thanks for your Attention !! .

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