From the Guidelines
The anesthetic management for a patient with complete heart block and a pacemaker undergoing hemiarthroplasty should prioritize careful preoperative assessment, intraoperative monitoring, and specific considerations for both the cardiac condition and the orthopedic procedure, with a focus on minimizing electromagnetic interference and maintaining hemodynamic stability, as recommended by the most recent guidelines 1.
Preoperative Assessment
Preoperatively, the pacemaker should be interrogated within 3-6 months before surgery to confirm proper functioning, battery status, and current settings, as suggested by the 2009 ACCF/AHA focused update 1. The anesthesiologist should document the manufacturer, model, indication, and mode of the pacemaker.
Intraoperative Management
For the procedure, either general or regional anesthesia can be used, with regional techniques (spinal or epidural) often preferred as they provide excellent postoperative pain control and reduce the risk of deep vein thrombosis. If general anesthesia is chosen, standard induction agents like propofol (1.5-2.5 mg/kg) or etomidate (0.2-0.3 mg/kg) can be used, with maintenance via volatile agents or total intravenous anesthesia.
- Intraoperatively, electromagnetic interference should be minimized by:
- Placing the electrosurgical return electrode (grounding pad) away from the pacemaker generator
- Using short, intermittent, bipolar cautery when possible
- Continuous ECG monitoring is essential, and a magnet should be immediately available to convert the pacemaker to asynchronous mode if needed.
- Hemodynamic stability is crucial, with prompt treatment of hypotension using vasopressors like phenylephrine (50-100 mcg boluses) or ephedrine (5-10 mg boluses), as recommended by the safety guideline for reducing the risk from cemented hemiarthroplasty for hip fracture 1.
Postoperative Care
Postoperatively, the patient should be monitored in a high-dependency unit initially, with the pacemaker rechecked to ensure proper functioning. This approach addresses both the cardiac concerns related to the complete heart block and pacemaker while ensuring adequate anesthesia for the orthopedic procedure. The anesthesiologist should also be aware of the potential risks of bone cement implantation syndrome (BCIS) and take steps to minimize its occurrence, including maintaining vigilance for signs of cardiorespiratory compromise and using vasopressors and/or fluids to maintain systolic blood pressure within 20% of pre-induction values throughout surgery 1.
From the Research
Anaesthetic Management for Hemiarthroplasty in Patients with Complete Heart Block and Pacemaker
The anaesthetic management of a patient with complete heart block and a pacemaker undergoing a hemiarthroplasty involves several key considerations:
- Preoperative Assessment: Evaluation of the patient's pacemaker function and complete heart block is crucial before surgery 2, 3.
- Monitoring: Continuous hemodynamic monitoring is essential during the perioperative period to quickly identify any potential issues with the pacemaker or the patient's heart rhythm 2, 3.
- Anaesthetic Technique: The choice of anaesthetic technique should be tailored to the individual patient, with consideration given to the use of regional anaesthesia, such as spinal anaesthesia, which may be beneficial in maintaining haemodynamic stability 3.
- Pacemaker Management: The pacemaker should be checked preoperatively and its function verified during surgery, with a temporary pacemaker available if needed 2, 3.
- Multimodal Anaesthesia: The use of multimodal general anaesthesia, which combines different agents to minimize side effects, may be beneficial in managing nociception and pain control during and after surgery 4.
Key Considerations
- Haemodynamic Stability: Maintaining haemodynamic stability is critical in patients with complete heart block and a pacemaker, and the anaesthetic technique should be chosen with this goal in mind 3.
- Pacemaker Function: The pacemaker's function should be closely monitored during surgery, and any issues should be quickly addressed to prevent complications 2, 3.
- Patient-Specific Factors: The patient's individual factors, such as their overall health and medical history, should be taken into account when developing the anaesthetic plan 5, 6.