Anesthesia for AICD and Pacemaker Insertion – Flashcards
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Control room of cath/EP lab
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free of X-ray, personnel can monitor imaging, mapping and ablation
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Limitation of cath(PE) labs for anesthesia
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- remote location - limited drug/fluid supply - unfamiliar staff - patient little far from you
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Most common cath lab procedures
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- pacemaker & implantable cardioversion/defibrillator (ICD) implantation (CS or MAC) - PM/ICD generator change (CS or MAC) - PM/ICD lead change (GETA) - biventricular (BiV) implantation (MAC or GETA) - radiofrequency ablation (RFA) of atrial or ventricular arrhythmias (MAC or GETA)
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Anesthesia for pacemaker & implantable cardioversion/defibrillator (ICD) implantation
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CS or MAC
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Anesthesia for PM/ICD generator change
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CS or MAC
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Anesthesia for PM/ICD lead change
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GETA
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Anesthesia for biventricular (BiV) implantation
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MAC or GETA
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Anesthesia for radiofrequency ablation (RFA) of atrial or ventricular arrhythmias
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MAC or GETA
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What is a pacemaker
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implanted device that provides electrical stimuli, causing cardiac contraction when intrinsic myocardial electrical activity is inappropriately slow or absent 1 (single) 2 (dual) 3 (BiV) chamber devices
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What is an automatic implantable cardioverter/defibrillator
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specialized device designed to directly treat dysrhythmias
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When do we use PMs over AICDs? AICDs over PMs?
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PM: profound bradycardia or chronotropic insufficiency can be a sole cause of HF AICDS: HF and LV dysfunctions correlating with risk of sudden cardiac death
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Single chamber pacemaker
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Uses one lead in the upper OR lower chamber of the heart (right)
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Duel chamber pacemaker
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Uses one lead in the upper chamber AND one lead in the lower chamber of the heart (right)
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Biventricular pacemaker
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uses three leads in RA, RV, LV (via coronary sinus vein)
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Pulse generator
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houses battery and tiny computer
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Leads
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wires that send impulses from pulse generator to heart muscle and senses hearts electrical activity. each impulse causes heart to contract. PM can have 1-3 leads
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How is single/dual PM placed
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- 5 cm incision with subQ pocket below clavicle to hold device. - percutaneous lead placement via cephalic vein cutdown by subclavian vein cannulation (seldinger) - Leads placed/secured in RV and/or RA
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Cardiac resynchronization therapy (BIV)
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1 lead RA, 1 lead in RV, 1 lead LV in coronary sinus to allow synchronized pacing of both ventricles (good for 3rd degree blocks) - long sheath introduced into RA and advanced into coronary sinus - or, LV lead can be placed epicardially by cardiac surgeon in OR
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*AICD placement and testing*
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- identical to dual chamber PM - ICD tested at end of procedure by inducing V-fib under deep sedation to confirm appropriate sensing/treatment
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When in a single or duel PM used
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make heart beat if heart's natural pacemaker (SA node) not functioning properly and has developed an abnormally slow heart rate or rhythm, or if the electrical pathways are blocked
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When is CRT - BIV or 3 lead used
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paces both ventricles at same time increasing amount of blood pumped by heart. Treats ventricular dyssynchrony (irregular conduction pattern in lower heart chambers) or HF - complete heart block
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How do we treat PM dependent patients during surgery
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- use temporary pacing catheter during generator change - no temporary pace, go for "quick" generator change even if no underlying ventricular rhythm (can cause big bradycardia or asystole) ** make sure pacing pads immediately available for backup
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Why would someone need a new lead? How do we treat lead changes?
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- infection, lead fracture, lead failure - may need "laser sheath" to free leads from intravascular/intracardiac adhesions (can go bad fast)
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*Complications from lead replacement*
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- large pneumothorax - intrathoracic bleeding (SVC tear or perforation) - tamponade (worst)
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Preop evals for AICD or PM placement
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- airway (challenges with non-OR anesthesia) - previous anesthesia (sensitivity to sedatives) - allergies: shellfish (contrast dye), fish (protamine), antibiotics - cardiac hx - OSA/morbid obesity - positioning - GERD
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Cardiac hx to pay attention to with cardiac PM/AICD patients
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EF, CHF (ability to tolerate supine), arrhythmia classification, pulmonary HTN (avoid hypercapnia/hypoxemia)
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Positioning considerations with PM/AICD patients
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peripheral neuropathy, back pain- peripheral extremity position/padding
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Intubation technique with PM/AICD patients
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- have glidescope to decrease chance of airway trauma (esp with heparinization can lead to airway bleeding) - if EF <40% consider etomidate (or etomidate + propofol)
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GA patients versus MAC for recovery
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GA goes to PACU via us and RN MAC recover in EP lab with RNs after we give intraop report
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cardiac RNs ports versus cardiologists
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- give RN closest to patient (so drugs get to patient and not accidentally bolus) - cardiologist give direct into cardiac catheters (Nitroglycerine, Ca channel blockers)
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IV considerations for PM/AICD surgeries
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extension tubing for IV
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How long do AICD/PM surgeries usually take
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2-4 hours
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Drugs for AICD/PM surgeries under MAC
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mild-moderate sedation: fentanyl/midazolam with local or infusions of propofol/remifentanyl
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When will AICD/PM surgeries need GA?
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BiV ICD placements (pts with OSA, intolerance of supine position)
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antibiotic prophylaxis for AICD/PM surgeries
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per guidelines
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Risk of AICD/PM surgeries
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perforation of heart with tamponade is an infrequent but known risk, be prepared for volume expansion and vasoactive medication resuscitation
