SEMINAR ON PACEMAKER BY DR.SRAVANI VISHNUBHATLA

1. PACEMAKER
MODERATOR: DR KRISHNA CHAITANYA
ASSOCIATE PROFESSOR
DEPARTMENT OF ANAESTHESIOLOGY, MIMS
SPEAKER: DR V.SRAVANI

2. I. Sinoatrial node(SA node)
II. Atrio-ventricular node(AV node)
III. Atrioventricular bundle(AV
bundle) with its two limbs
IV. Sub endocardial plexus of
purkinje fibres
COMPONENTS OF CONDUCTING SYSTEM
OF THE HEART

3. Origin of impulse in SA node
Internodal pathways
0.03sec
Avnode (0.09sec delay)
the penetrating portion of the
A-V bundle(0.04sec)
passes into the ventricles.
THE ATRIOVENTRICULAR NODE DELAYS IMPULSE
CONDUCTION FROM THE ATRIA TO THE
VENTRICLES
0.13sec
Total delay
0.16sec

4. Heart blocks
 2nd degree type II block.
 3rd degree block.

5. BRADY ARRHYTHMIAS
 Sick sinus syndromes
 Drug toxicity

6.  LONG QT SYNDROMES
 BRUGADA SYNDROME

7. OBJECTIVES
 Basics of ICEDs functions.
 Indications for their use.
 Anaesthetic management;
 pre-operative
 intra-operative
 post operative
 Special situations.

8. HISTORY
 1958 : 1st operated pacemaker
 1969 : AV sequential pacing
 1980 : 1st ACD
 1985 : AICD approved by FDA
 1988 : Rate modulation

9. INTRODUCTION
 DEFINITION: A pace maker system is a device capable of
generating artificial pacing impulses and transferring them to
the heart.
 TYPES OF PACING: Temporary & Permanent
 Temporary pacing :
 Trans thoracic
 Trans cutaneous
 Trans esophagus
 Trans venous

10.  In permanent pacing, leads through the subclavian or
cephalic vein.
 Leads positioned in the right atrial appendage for atrial
pacing and right ventricular apex for ventricular pacing.
 The pulse generator lies in the subcutaneous pocket
below the clavicle.
 Epicardial lead placement is used when no transvenous
or if the chest is open.
TECHNIQUE OF PERMANENT PACING

11. PERMANENT
Implanted with batteries of mercury zinc “3 years” or lithium “10 years”.

13. COMPONENTS

16. BIPOLAR LEAD

18. code paced sensed response
indication
example
AOO Atrium None None Sick sinus
syndrome
VOO Ventricle None None Complete HB
VVI Ventricle Ventricle Inhibited Complete HB
& AF
DDD Both Both Inhibited
&Triggered
AV+SA nodal
disesae
DDI Both Both Inhibited AV+SA
disesae

19. AICDS....
AUTOMATED IMPLANTED CARDIOVERTER
DEFBRILLATOR

20. DEFIBRILLATION SHOCK
shock

21. OVER DRIVE PACING

22. 1-shock 2-Anti tachycardia
pacing
3-tachycardia
detection
4-Anti bradycardia
pacing
O=none O=none E=Electrocardiogra
m
O=none
A=Atrium A=Atrium H=Hemodynamic A=Atrium
V=Ventricle V=Ventricle V=Ventricle
D=Dual D=Dual D=Dual
NASPE/BPEG AICD codes

23. INDICATIONS OF CIEDS
PM
Some heart blocks
Symptomatic
bradycardia
bradyarrythmias
ICD
Tachyarrythmias
Long QTs
Brugada
CRT
Low
EF+BBB in
HOCM or
DCM

24. CRT
CARDIAC RESYNCHRONIZATION THERAPY
 Bi ventricular pacing is indicated for :
 moderate to severe heart failure
 patients with EF < 35%
 conduction delay disturbing right & left ventricular synchrony
 Done with sequential pacing of atria RV&LV.

26. KNOW THE INDICATION TO KNOW WHAT
YOU ARE DEALING WITH

27. Increase Decrease
1-4 weeks after implantation Increased catecholamines
Myocardial ischaemia/infaction Stress, anxiety
Hypothermia, hypothyroidism Sympathomimetic drugs
Hyperkalaemia, acidosis/alkalosis Anticholinergics
Antiarrythmics (class Ic,3) Glucocorticoides
•Antiarrythmics (class IA/B,2)* Hyperthyroidism
Severe hypoxia/hypoglycaemia Hypermetabolic status
Inhalation-local anaesthetics**
*possibly increase threasholds
** conflicting evidence, probably dose-related
FACTORS AFFECTING PACING THRESHOLDS

28. PROBLEMS ASSOCIATED WITH CIEDS
 Related to insertion access.
 Battery failure.
 Diaphragmatic or Skeletal
muscle stimulation.
 Myopotential interference.
 Pacemaker syndrome.

29.  Micro shock hazard.
 Related to electrode placement or traction.
 Flase discharge of AICD by benign morphology or rate of the
heart.
 Electromagnetic interference.(EMI).
PROBLEMS ASSOCIATED WITH CIEDS

30.  Some individuals, particularly those with intact
retrograde VA conduction, may not tolerate ventricular
pacing and may develop a variety of clinical signs and
symptoms resulting from deleterious haemodynamics
induced by ventricular pacing
 These include hypotension, syncope, vertigo, light
headedness,fatigue, exercise intolerance, malaise,
weakness, lethargy, dyspnoea. and even CHF.
 Reason - complex interaction of haemodynamic,
neurohumoral and vascular changes induced by the
loss of AV synchrony
PACEMAKER SYNDROME

31. EMI
ELECTRO MAGNETIC INTERFERENCE
 Electric signals picked up by CIED from any source may have
devastating sequalae on the heart.

34. Where do we encounter CIEDS
 For the insertion in cathlab :
 heart failure
 symtomatic bradycardia
 Malignant arrhythmias.

35. AFTER INSERTION
 For other surgeries.
 Having ECT.
 ICU.

36. ANAESTHETIC MANAGEMENT OF PATIENT
WITH CID
PREOPERATIVE
INTRAOPERATIVE
POSTOPERATIVE

37. PRE
OPERATIVE
ASSESSMENT
HISTORY
EXAMINATION
PREPARATION INVESTIGATIONS

38. Dependent
? Malfunction
?
Recommendations
? Comorbidities
?

39. HISTORY
 Specialist evaluation report.
 Id card,maintainance & recommendations....
 Cause and date of insertion.
 Battery and proper function.
 Anticoagulation.
 Comorbidities & medications.

40. EXAMINATION
 Tenderness over pulse generator.
 Pulse rate & regularity.

41.  12 lead ECG:
 pacing rate to compare with ID card
 Absence of electrical spike

42. LOSS OF CAPTURE.

43. PACED CHAMBERS

44. Chest X-ray:
 type of CIED and paced
chamber.
 lead type,position & fracture.
PACE MAKER

45. AICD CRT

46.  Serum potassium & electrolytes.
 hyperkalaemia
 hypokalaemia

47. PRE OPERATIVE PREPARATIONS
 Has interrogated by a specialist with a documented written
report.
 Identify manufacturer , type & mode of CIED.
 If present , turn off all RATE & ANTI TACHYCARDIA responses.
 Consider increasing PM rate to optimize oxygen delivery in
major cases.
 Correct any electrolyte abnormality prior to elective surgery.
 Emergency drugs should be readily available.
 Confirm magnet response if it is planned.

48. MAGNET RESPONSE

49. Magnet
response
Asynchronous
mode
Turn off
transiently
reprogramming
Turn off
permanently

50. Intra-
operative
Monitoring
General
Conduct
Regional

51. MONITORING
 A vigilant anaesthesiologist with; frequent palpation of patient’s
pulse , using oximetry or arterial wave form , is very important.
 ECG: disable artifact filter to detect pacing spikes.
 CVC&PAC : better avoided if CIED is recently inserted < 2weeks as
they can cause lead dislodgement , safe after 6 weeks.
 ETCO2, NIBP temperature & TEE are safe to use.

52. REGIONAL ANAESTHESIA
 It is considered safe.
 If anticoagulants are used, coagulation profile should be
checked & guidelines followed.

53. GENERAL ANAESTHESIA....
 Induction :
 Etomidate – can cause myopotential interference.
 Succinylcholine – is better avoided.
 consider: Defasciculation
 Asynchronous mode.

54. Maintenance:
 Consider avoiding sevo, iso & desflurane in patients with long
QT syndromes.
 Avoid N2O especially if the CIED is recently inserted.
 Avoid drugs that suppress AV or SA nodes not to render the
patient PM dependent.

55.  ESU Electro Surgical Unit... “ cautery”
 According to FDA 255 of 456 adverse events are due to electro
cautery.
 Hazards include:
 Inhibition of CIED.
 Random reprogramming.
 Myocardial burn.
 Unindicated shock if AICD is not deactivated.

56. UNIPOLAR CAUTERY
CUTTING MODE COAGULATION MODE

57. PRECAUTIONS WITH ESU USE
 Bipolar ESU IS SAFE.
 Monopolar pure cut is better than coagulation.
 Use short burst 1 second every 10 seconds to avoid prolonged
asystole.
 ESU current should be the lowest functioning.
 Never have the generator between cautery & ground plate.

58. • Should not be used within 15cm from generator “ safe below
umbilicus.”
• Change pace maker mode to asynchronous.
• Emergency transcutaneous pacemaker , emergency drugs &
equipments should be readily available.
PRECAUTIONS WITH ESU USE

59. POSTOPERATIVE
 In ICU with backup pacing capability.
 Avoid shivering.
 Turn on AICD.
 Re-evaluate PM function.
 Rate enhancement may be re-initiated.

60. DEFIBRILLATOR
 Avoid placing paddles over CIED.
 Better to keep a distance of 15cm from CIED.
 The lowest effective energy should be selected.
 May cause endocardial burn & acute increase in pacing
thershold.

61. ELECTRO-CONVULSIVE THERAPY
 Asynchronous mode to avoid myopotential interference.

62. MRI....
 Absolutely contraindicated in patients with CIEDs.
 MRI compatible CIEDs are now available.

63. LITHOTRIPSY
 Contraindicated only if PM is implanted in the abdomen.
 Avoid focusing the beam near PM & consider asynchronous
mode.

64. RADIATION THERAPY
 Generally safe.
 Consider repositioning the device if it is in the radiation field.

65. RADIO FREQUENCY ABLATION
 Avoid direct contact with pacemaker & keep it as far as
possible.

66. REFERENCES
 Stoelting coexisting diseases 2nd edition.
 Yao & Artusio 8th edition.
 Miller’s 9th edition.