From the Guidelines
Anesthetic management of patients with pacemakers requires careful preoperative assessment, intraoperative monitoring, and specific precautions to ensure patient safety, as outlined in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.
Key Considerations
- Before surgery, obtain details about the pacemaker including type, indication, manufacturer, settings, and date of last check.
- Evaluate the patient's underlying cardiac condition and dependency on the pacemaker.
- Preoperatively, consult with a cardiologist to optimize pacemaker settings, potentially reprogramming to asynchronous mode (VOO, DOO) for pacemaker-dependent patients to prevent electromagnetic interference.
Intraoperative Precautions
- Apply electrocautery grounding pad away from the pacemaker.
- Use bipolar cautery when possible, and keep monopolar cautery bursts short with minimal power settings.
- Position the cautery grounding pad so current doesn't cross the pacemaker.
- Maintain continuous ECG monitoring, have a magnet available to convert to asynchronous mode if needed, and ensure defibrillation equipment is readily accessible.
Postoperative Care
- Confirm proper pacemaker function and reprogram to original settings if changed.
- These precautions are necessary because electromagnetic interference from surgical equipment can inhibit pacing, trigger inappropriate pacing, or damage the device, potentially causing life-threatening arrhythmias in pacemaker-dependent patients, as noted in the 2007 ACC/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery 1.
Additional Recommendations
- Avoid central venous catheterization on the side of the pacemaker to prevent lead displacement.
- Hemodynamically, maintain adequate preload and avoid drugs that significantly alter heart rate or blood pressure.
- Patients with ICDs who have preoperative reprogramming to inactivate tachytherapy should be on cardiac monitoring continuously during the entire period of inactivation, and external defibrillation equipment should be readily available, as recommended in the 2014 ACC/AHA guideline 1.
From the Research
Anaesthetic Considerations for Pacemaker Patients
The anaesthetic management of patients with permanent pacemakers requires careful consideration of several factors, including the type of pacemaker, the patient's underlying cardiac condition, and the potential interactions between the pacemaker and anaesthetic equipment.
- The number of people with pacemakers is increasing steadily, with over 25,000 people in Britain having pacemakers, as noted in a study from 2.
- A review of the indications for permanent pacing, the types of pacemakers used, and the assessment and management of pacemaker patients for anaesthesia is essential for safe management, as outlined in 2.
Preoperative Assessment and Management
Preoperative assessment and management of patients with pacemakers are crucial to ensure safe anaesthesia.
- The anaesthetic management of patients with pacemakers or implanted automatic defibrillators requires special consideration, including the need for collaboration with a cardiologist in difficult cases, as discussed in 3.
- A multidisciplinary approach to the perioperative management of patients with cardiac implantable electronic devices (CIEDs) is now advocated, with the main intent of promoting safe management and reducing the likelihood of adverse outcomes, as stated in 4.
Intraoperative Management
Intraoperative management of patients with pacemakers requires careful attention to the potential interactions between the pacemaker and anaesthetic equipment.
- The use of monopolar electrosurgery ('Bovie') and significant fluid or blood component administration may require postoperative re-interrogation of the pacemaker, as suggested in 5.
- The anaesthesia team must be familiar with the basics of current CIED technology and the essential tenets of perioperative CIED management, as discussed in 4.
Postoperative Management
Postoperative management of patients with pacemakers is also critical to ensure safe recovery.
- Postoperative re-interrogation of the pacemaker is warranted if an operative event includes the use of monopolar electrosurgery ('Bovie') or significant fluid or blood component administration, as recommended in 5.
- The role of beta-blockers in the treatment of cardiac arrhythmias is significant, and their use may be relevant in the perioperative management of patients with pacemakers, as discussed in 6.