The document discusses cardiac pacemakers and implantable cardioverter defibrillators (ICDs). It covers the history, components, functions, types of pacing modes, indications for use, problems that can occur, and considerations for anesthetic management of patients with these devices. The key points are that pacemakers are used to treat bradycardia while ICDs treat tachycardia/fibrillation. Care must be taken with electromagnetic interference and device function needs to be considered for any procedures.
A patient with pacemaker presents a complex challenge to the attending anaesthesiologist. The mode of management will be according to the type of pacemaker implanted. This presentation discusses in brief the peri-operative consideration in a patient with pacemaker.
A patient with pacemaker presents a complex challenge to the attending anaesthesiologist. The mode of management will be according to the type of pacemaker implanted. This presentation discusses in brief the peri-operative consideration in a patient with pacemaker.
A transesophageal echocardiogram, or TEE, is an alternative way to perform an echocardiogram. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. It has several advantages and some disadvantages compared with a transthoracic echocardiogram.
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
A transesophageal echocardiogram, or TEE, is an alternative way to perform an echocardiogram. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. It has several advantages and some disadvantages compared with a transthoracic echocardiogram.
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
Artificial Cardiac pacemaker |medical device that generates electrical impulses NEHA MALIK
A pacemaker is a device that sends small electrical impulses to the heart muscle to maintain a suitable heart rate or to stimulate the lower chambers of the heart (ventricles). A pacemaker may also be used to treat fainting spells (syncope), congestive heart failure and hypertrophic cardiomyopathy.
Pacemaker powerpoint presentation med surgNehaNupur8
pacemaker - artificial pump to the heart, this contained definition, components,working, types, indication, methods of pacaing, temporary and permanent pacemaker, signs of failure of pacemaker , medical and nursing management of patient with pacemaker.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
2. OBJECTIVES
1.Bascics of CIEDs functions
2.Indication for their use.
3.Anaesthetics management
pre-operative
Intraoperative
Postoperative
4.Specials situations
5.summary.
3. INTRODUCTION
Term Cardiac implantable electronic device( CIED) includes
1 .pacemaker
2. ICD (implantable cardioverter defibrillator)
4. HISTORY
1958- 1st battery operated pacemaker
1969- Av sequential pacing
1980- 1st AICD
1985- AICD was approved by FDA
1988- Rate modulation
5. IMPORTANT TERMINALOGY WITH
PACEMAKER
Pulse Generator
Leads
Electrode
Unipolar Pacing
Bipolar Leads
Endocardial Pacing
Epicardial Pacing
Pacing Threshold
R Wave Sensitivity
6. COMPONENTS
1.Generator:
containing batteries and electrical circuits
2.Electrode:
exposed metal connected to heart.
it may be endo,epi, or myocardial
3.lead:
Insulated wire connecting the 2 other part
7.
8. ELECTODE S ARE EITHER
UNIPOLAR BI-POLAR
Cathode electrode inside the heart Cathode is distal within the heart
Anode on the case of pulse generator anode is shortly proximal on the same
lead in the heart
Larger pathway exposes the device to
more EMI
Smaller pathway….less EMI
11. PACING THRESHOLD
This is the minimum amount of energy required to consistently cause
depolarization and therefore contraction of the heart.
Pacing threshold is measured in terms of both amplitude and duration for
which it is applied to the myocardium
13. R WAVE SENSITIVITY
It is the measure of minimal voltage of intrinsic R wave, necessary to
activate the sensing circuit of the pulse generator and thus inhibit or
trigger the pacing circuit.
The R wave sensitivity of about 3 mV on an external pulse generator will
maintain ventricle inhibited pacing
15. TEMPORARY PACING
When permanent pacemaker is not available or pending its insertion.
1. trans venous
2.trans cutaneous
3.trans oesopgeal
4. trans thoracic
16.
17. PERMANENT:
Implanted with long life batteries of
mercuric zink-3year or
lithium -10years
or MRI compatible device are available
18. Technique of permanent pacing
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
19. To understand language of Pacemakers Coding system was developed
originally by the international conference on heart disease and
subsequently modified by the
- NASPE/BPEG (North American society of pacing and
electrophysiology/British pacing and electrophysiology group) alliance
21. First letter-the chamber being paced
Second letter-the chamber being sensed
Third letter-response to sensing (I and T indicates inhibited or triggered
responses, respectively).
Fourth and Fifth positions-programmable and ant tachyarrhythmia
functions, but these two are rarely used.
An R in fourth position indicates that the pacemaker incorporates a sensor
to modulate the rate independently of intrinsic cardiac activity such as with
activity or respiration
22. TYPES OF PACEMAKER MODE
1. Asynchronous/Fixed Rate
2. Synchronous/Demand
3. Single/Dual Chamber Sequential (A & V)
4. Programmable/nonprogrammable
23. ASYNCHRONUS MODE(AOO, VOO
AND DOO)
It is the simple form of fixed rate pacemaker which discharges at a preset
rate irrespective of the inherent heart rate.
Can be used in cases with no ventricular activity.
Disavantage-
it competes with the patient’s intrinsic rhythm and results in induction of
tachyarrythmias.
Continuous pacing wastes energy and also decreases the half-life of the
battery
24. Single Chamber Atrial Pacing (AAI,
AAT)
Atrium is paced and the impulse passes down the conducting pathways,
thus maintaining atrioventricular synchrony.
A single pacing lead with electrode is positioned in the right atrial
appendage, which senses the intrinsic P wave and causes inhibition or
triggering of the pacemaker.
Useful in patients with sinus arrest and sinus bradycardia provided
atrioventricular conduction is adequate.
Inappropriate for chronic atrial fibrillation and long ventricular pauses.
25. Single Chamber Ventricular Pacing
(VVI, VVT)
VVI is the most widely used form of pacing in which ventricle is sensed and
paced.
It senses the intrinsic R wave and thus inhibits the pacemaker function.
Indication- complete heart block with chronic atrial flutter, atrial fibrillation
and long ventricular pauses.
Single chamber ventricular pacing is not recommended for patients with
sinus node disease, as these patients are more likely to develop the
pacemaker syndrome
26. Dual Chamber AV Sequential Pacing (DDD,
DVI, DDI, and VDD)
Two leads used-unipolar or bipolar, one for the right atrial
appendage and the other for right ventricular apex.
The atrium is stimulated first to contract, then after an
adjustable PR interval ventricle is stimulated to contract.
They preserve the normal atrioventricular contraction
sequence, and are indicated in patients with AV block, carotid
sinus syncope, and sinus node disease
27. Dual Chamber AV Sequential Pacing (DDD)
Advantages- they are similar to sinus rhythm and are beneficial in
patients, where atrial contraction is important for ventricular filling (e.g.
aortic stenosis).
Disadvantage-
pacemaker-mediated tachycardia (PMT) due to ventriculoatrial (VA)
conduction in which ventricular conduction is conducted back to the
atrium and sensed by the atrial circuit, which triggers a ventricular
depolarization leading to PMT.
This problem can be overcome by careful programming of the pacemaker.
28. Programmable Pacemaker
Pacemakers, which not only sense the atrial or ventricular activity but also
sense various other stimuli and thus, increase the pacemaker rate.
The various factors, which can be programmed are pacing rate, pulse
duration, voltage output, R wave sensitivity, refractory periods, PR interval,
mode of pacing, hysteresis and atrial tracking rate.
Various types of sensors have been designed which respond to the
parameters such as vibration, acceleration, minute ventilation, respiratory
rate, central venous pressure, central venous pH, QT interval, preejection
period, right ventricular stroke volume, mixed venous oxygen saturation,
and right atrial pressure.
29. PROBLEM ASSOCIATED WITH CIED
1.Related to placement
2. Battery failure
3. Arrhythmias induction
4. Diaphragmatic or skeletal muscle stimulation
5. Myopotenial interference
6. Pacemaker syndrome
30. 7.Micro –shock hazards
8. Related to electrode placement or traction
9.False discharge of AICD by benign morphology or rate of the heart
10.EMI interference
31. Pacemaker Syndrome
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 haemodynamic induced by
ventricular pacing
These include hypotension, syncope, vertigo lightheadedness,fatigue,
exercise intolerance, malaise, weakness, lethargy, dyspnoea. and even CHF.
32. INDICATION FOR PACEMAKER
1. Sinoatrial (SA) node—sick sinus syndrome, tachy-brady arrhythmia,
symptomatic sinus bradycardia, hypersensitive carotid sinus syndrome, or
vasovagal syncope
2. Second-degree AV block regardless of type or site of block, with
associated symptomatic bradycardia.
3. Third-degree AV block at any anatomic level associated with bradycardia,
arrhythmia, asystole (>3.0 s) and after catheter ablation.
4. Chronic bifascicular block.
5. Right bundle branch block (RBBB) and left anterior hemi block with
hemodynamic symptoms
6. RBBB and left posterior hemi block with hemodynamic symptom
33. Long Q-T syndrome: documented pause-bradycardia–induced torsade de
pointes and in low risk patients with LQT3
Syncope without an electrocardiogram (ECG) diagnosis
Cardiomyopathy—patients with medically refractory hypertrophic
obstructive cardiomyopathy or decompensated heart failure in patients
with dilated cardiomyopathy despite optimal medical therapy (e.g.,
biventricular pacing)
RBBB and left posterior hemi block with hemodynamic symptom
34. IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR (ICD)
An ICD responds to dysrhythmia by delivering an internal electrical shock
within 15 seconds.
The ICD system consists of a pulse generator and leads for dysrhythmia
detection and current delivery.
In addition to internal defibrillation, an ICD can produce anti-tachycardia
and anti-bradycardia pacing and synchronized cardioversion
35.
36. INDICATION FOR ICD
Cardiac arrest resulting from VT/VF not resulting from a transient or reversible cause
Spontaneous sustained VT with structural heart disease
Syncope of undetermined origin with clinically relevant, haemodynamically significant
sustained VT or VF induced at electrophysiology study (EPS
Ischemic cardiomyopathy (EF ≤30%) without a recent myocardial infarction (within the last 4
weeks) or revascularization in the past 3 months.
Ischemic or non-ischemic dilated cardiomyopathy (EF ≤35%) with (NYHA) class II or III heart
failure symptoms stable for the past 9 months.
Brugada syndrome
37. WHERE WE ENCOUNTER WITH THE
AICD
A. FOR THIER INSERTION OF AICD IN CATH LAB
Anaesthetic management depends upon patients situation and condition
of the patients
B Pacemaker in situ patient
posted for elective or emergency procedure
ICU
ECT OR radiation therapy
38. PREOPERATIVE ASSESSMENT
HISTORY
1.Cause and date of insertion and maintenance
2. ID card and recommendations
3. Specialists evaluation report
4.Battery and proper function
5. Anticoagulation
6.Pain over pulse generator
7.Comorbiditis and medications.
39. What is the type of the device and program mode
Is the device functioning properly
How dependent is the patient on the device (as an anti-bradycardia
function)
What is the probability of electromagnetic interference in theatre and how
do we minimise the risk?
40. If an ICD is present, deciding the manner in which the ant tachycardia
therapies shall be suspended (e.g. by a programming device or by
temporarily applying a magnet to the device).
Determining that the device is functioning as intended
41. INVESTIGATIONS
12 LEAD ECG:
pacing rate to compare with ID CARD
Absence of electrical spike
spike not followed by QRS OR P wave
paced chambers
CHEST X-RAY
Lead position
Paced position
Type of CIED
42.
43.
44.
45.
46.
47. Determining that a CIED is present and defining the functionality of the
device (e.g. pacemaker or ICD).
Determining whether significant EMI will be present during the planned
procedure that might affect the programmed behaviour of the CIED.
Determining whether the patient is dependent on ant bradycardia pacing
and whether or not reprogramming of the pacemaker mode is required.
48. 1.Identify manufacturer ,type and mode of CIED
2. Have it interrogated by a specialist with a documented written report
3.determine patients underlying rhythm/ rate for backup pacing
support.
4. If present turn off all rate and anti tachycardia response
49. 5.Consider increasing pacemaker rate to optimize oxygen delivery in major
cases
6. Correct any electrolyte abnormality prior to elective surgery
7.emergency drugs should be readily available
8. Confirm magnet response if it is planned
50. IMPORTANT INFORMATION GIVEN TO
CIED TEAM
Intended surgical procedure
Location of pulse generator
Patient position during the procedure
Type of electro cautery to be used
Other sources of EMI likely to be present
Whether cardio version or defibrillation will be necessary
51. INTRAOPERATIVE
Ensuring the availability of a backup source of pacing, defibrillation, or
both.
Maintaining vigilance and monitoring in accordance with ASA standards
so as to rapidly detect any haemodynamic compromise as a result of
interference with CIED function.
Management of EMI.
Rapid implementation of the backup source of pacing, defibrillation, or
both as required
52. MONITORING
1 Frequent palpation of patients pulse is very important
2 ECG
3 Continuously monitor peripheral pulsation with pulse oximeter or arterial
waveform
4. CVC OR PAC ; better avoided if CIED recently inserted <2weeks as they
cause lead dislodgment, safe after 6 week as fibrosis around leads makes it
more stable
5.ETCO2 NIBP TEMPRATURE pulse oximeter
53. CONDUCT OF ANESTHESIA
REGIONAL ANESTHESIA
Consider safe
anticoagulant are used, coagulation profile should be checked and
guidelines should follow
54. GENERAL ANESTHESIA
Etomidate can cause myopotential interference.
Succinylcholine is better avoided as it may cause myopotentiaL interference
Drugs & Equipment A complete array of drugs and equipment must be
immediately available for cardiopulmonary resuscitation.
55. MAINTENANCE
Avoid drugs and situation that can increasing pacing threshold
AVOID that drug that supress AV OR SA nodes- like dexmeditomedine
N20 Avoided in a patient with newly implanted pacemaker as it causes an
expansion of gas in the pocket, which leads to loss of anodal contact and
pacing system malfunction.
56. MAGNETIC REPONSE
Application of magnet is not an advisable practice in all CIED
each CIED Has specific response to magnet;
1 Asynchronous mode
2 Turn of transiently
3 Turn of permanently
4.reprogramming
58. ADVERSE EVENTS INTERACTION WITH
EMI AND PACEMAKER
Damage to the device, the leads, or site of lead implantation
Failure to deliver pacing, defibrillation, or both
Changes in pacing behaviour
Inappropriate delivery of a defibrillatory shock (if an ICD is present)
Inadvertent electrical reset to backup pacing modes
59. Electro cautery / diathermy
Electro cautery remains one of the most common causes of EMI; it uses
radio frequency current to cut or coagulate tissues and is usually applied in
a unipolar configuration between the handheld instrument (cathode) and
the anode plate attached to the patient's skin
The radio frequency is usually between 300 AND 500khz
60. Measures to decrease the possibility of
adverse effects due to electro cautery
Bipolar cautery
unipolar cautery (grounding plate should be placed close to the operative
site and as far away as possible from the site of pacemaker)
Electro cautery should not be used within 15cm of pacemaker. Programme
to asynchronous mode.
Provision of alternative temporary pacing.
Drugs (isoproterenol and atropine).
Careful with Defibrillation if required ( away paddles, lowest energy
required
61. Specific Perioperative Consideration
Transurethral Resection of Prostate (TURP) and Uterine Hysteroscopy
Coagulation current used during TURP procedure has no effect, but the
cutting current at high frequencies (up to 2500 kc/sec) can suppress the
output of a bipolar demand ventricular pacemaker.
During application of cutting current there was a loss of pulsatile arterial
flow, which returned with interruption of ESU.
Thus when ESU use is anticipated reprogramming of pacemaker
preoperatively to the asynchronous (fixed rate) mode should be performed
62. Electroconvulsive Therapy-
ECT appears safe for patients with pacemakers and little current flow heart
within because of the high impedance of body tissue,
but the seizure may generate myopotentials which may inhibit the
pacemaker.
Thus ECG monitoring is essential and pacemakers should be changed to
nonsensing asynchronous mode (fixed mode)
63. Postoperative care
Full compete re check of pacemaker with technician.
Re-programming back to the original setting.
Anti-tachycardia therapies of implantable defibrillators should obviously
be reprogrammed to their original settings
64. Is a
CIED
present?
No Yes
Pacemaker ICD
EMI during
procedure ?
No Yes
Deactivate
ICD /
magnet
Patient
pacemaker
dependent?
No Yes
CIED to EMI source
15 cm?<
No reprogramming
required
No Yes
Asynchronous
mode
Consult CIED
team if
reprogramming
required
65. summary
Fully aware of the functional capabilities of pacemakers and ICD’s
Magnet application over pacemaker devices converts it into an asynchronous mode
most of the time.
Magnet application over ICD inhibits its anti-arrhythmia function but does not convert it
into an asynchronous mode. If the pacemaker function should be retained then the
device has to be reprogrammed.
66. The greatest threat during surgery is EMI from electro cautery.
MRI is contraindicated in patients with CIED
Primary principles to avoid EMI during surgery should be known and
followed in the operating room. Harmonic scalpel or bipolar electro
cautery should be used when possible.
67. ECG and peripheral pulse should be continuously monitored intraoperative
and postoperatively
Facilities for emergency defibrillation should be available in the operating
room. Before delivering an external defibrillator shock, removal of magnet
and observation for inherrant ant tachyarrhythmia function of ICD should
be observed. ACLS guidelines should be followed.