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Annals of Cardiac Anaesthesia 2005; 8: 61–63 Case

Bukhari et al. Anaesthetic Management of Patients with Report


Anaesthetic Management of Patients with Implantable

Cardioverter Defibrillator
Altaf Bukhari, MD, Sheetal Garg, MD, Yatin Mehta, MD, DNB, FRCA, FAMS
Department of Anaesthesiology and Critical Care, Escorts Heart Institute and Research Centre,
Okhla Road, New Delhi

T he use of implantable cardioverter defibrillators

(ICD) has significantly increased the life
expectancy of the patients with life threatening
direct arterial pressure, arterial blood gas analysis,
central venous pressure through left external jugular
vein, and urine output. All monitoring lines were
arrhythmias. Such patients are being increasingly inserted under local anaesthesia. An external pulse
generator and external pacing were kept ready in the
subjected to noncardiac surgery. We describe the
operating room (OR). External counter shock paddles
anaesthetic management for popliteal to anterior were checked and kept ready in the OR. A 16G epidural
tibial artery bypass grafting and hernioplasty in catheter (Portex, Kent, UK) was inserted in the 3rd lumbar
two patients with ICD. interspace with the patient in left lateral position. After
a 3 ml test dose of 2% lidocaine hydrochloride, 12 ml of
0.5% bupivacaine hydrochloride was injected and a T10
Case: 1
sensory block was obtained. Oxygen was given via nasal
prongs at 4 L/min. The patient did not need any sedation
A 54-year-old diabetic male patient underwent or anxiolysis as he continued to sleep following complete
coronary artery bypass graft (CABG) surgery. Two pain relief.
months later, he was admitted with severe pain in the
right leg and around the heel of the same side, which An electrocautery grounding pad was placed beneath
was diagnosed as diabetic foot. ICD was implanted two the right buttock. The ICD was disabled before the start
weeks after the CABG because of recurrent episodes of of surgery using a noninvasive programming device
ventricular tachycardia (VT) poorly responsive to (Medtronic Inc, Minneapolis, USA). Popliteal to anterior
amiodarone. tibial artery bypass grafting was performed and there was
no adverse event during the procedure. A range of
Echocardiography revealed left ventricular ejection antiarrhythmic drugs and external pacing were kept
fraction (LVEF) of 45% with hypokinesia of standby to treat any life threatening arrhythmia. After
interventricular septum and apex. Peripheral angiogram completion of the procedure which lasted for about five
showed 100% occlusion of popliteal artery and anterior hours during which one top up dose of bupivacaine
tibial artery was getting filled from the collaterals. (0.5%) was given, the ICD was enabled and the patient
Patient had developed fever and raised white cell counts was transferred to the intensive care unit (ICU) for
which was managed with appropriate antibiotics. The observation. The intraoperative period remained
patient was scheduled to undergo popliteal to anterior uneventful and no arrhythmias were noted. The patient
tibial artery bypass graft. He was premedicated with did not have any significant haemodynamic changes
lorazepam 2 mg and ranitidine 150 mg at night and on during the procedure except that the systemic arterial
the morning of surgery, morphine sulphate 5 mg pressure stabilised to 120/70 to 140/90 mm Hg from 190/
intramuscularly (IM) and lorazepam 2 mg per oral were 100 mm Hg, after epidural administration of local
administered 90 minutes before surgery. Monitoring anaesthetic. Two units of blood were tranfused during
during surgery included continuous two lead the procedure to optimise haemtocrit to 30%. Acid base
electrocardiogram (lead II and V5), oxygen saturation, balance was checked after 15 min of release of vascular
clamps, which was within normal limits. Monitoring in
Address for Correspondence: Dr. Altaf Bukhari, Fellow in Cardiac the ICU included continuous ECG, arterial pressure and
Anaesthesia, Dept. of Anaesthesia, Escorts Heart Institute and Research pulse oximetry. An infusion of 0.125% bupivacaine with
Centre, Okhla Road, New Delhi -110025
Phone: 26825000, 26825001 Extn 4125, Tele-Fax: 51628442
50 µg of fentanyl diluted in 50 ml of 0.9% saline at 5 ml/
hour was continued via the epidural catheter, for the next
Annals of Cardiac Anaesthesia 2005; 8: 61–63 36 hours after ensuring that the patient could move his
Key words:- Implantable cardioverter defibrillator, Peripheral vascular lower limbs. Intraoperatively blood sugar levels
surgery, Hernioplasty, Epidural anaesthesia were measured thrice and were found to be less than 200

ACA-04-108 CaseReport.p65 61 1/5/2005, 12:21 PM

62 Bukhari et al. Anaesthetic Management of Patients with AICD Annals of Cardiac Anaesthesia 2005; 8: 61–63

mg/dl each time. Preoperatively patient was receiving a patient who suffered recurrent cardiac arrests
total of 30 units of regular insulin per day. After 36 hours, despite a trial of multiple antiarrhythmic drugs.1
150 µg buprenorphine diluted in 10 ml normal saline was ICD has significantly reduced the risk of sudden
injected via the epidural catheter and the catheter was cardiac death in patients with known life
removed. The patient had an uneventful recovery and
threatening ventricular arrhythmias.2,3 The ability
the management of diabetic foot was continued.
of an ICD to provide therapy within 5 to 15 sec of
Case: 2 arrhythmia detection allows defibrillation success
rate approaching 100%.4
A 59-year-old male patient with left indirect inguinal
hernia was admitted for left sided hernioplasty. The An ICD system consists of a pulse generator
patient had undergone CABG six months back and an and leads for detection and therapy of
ICD was implanted 4 months back because of recurrent tachyarrhythmias. It may provide antitachycardia,
episodes of VT nonresponsive to amiodarone.
antibradycardia pacing, synchronized or non-
synchronized shocks, telemetry and diagnostic
Echocardiography revealed, LVEF of 25% with trivial
mitral regurgitation. The chest X-ray showed an ICD in storage. Many devices use adaptive rate pacing to
situ and enlarged cardiac size. The haematological, liver modify the pacing rate for changing metabolic
and kidney function tests were normal. needs. The ICD batteries contain up to 20,000 J of
energy. Most ICD designs use two capacitors in
Patient was premedicated with diazepam 5 mg and series to achieve maximum voltage for
ranitidine 150 mg at night before surgery and on the defibrillation. 5 Cardioversion with energy
morning of surgery, morphine sulphate 5 mg IM with exceeding 2 J results in skeletal and diaphragmatic
lorazepam 2 mg per oral were administered 90 min muscle depolarization and is painful to the
before surgery. The intraoperative monitoring and conscious patient. High energy discharges of 10-
management of ICD was similar to that in the first
40 J, delivered asynchronously are used to treat
patient. An 18G epidural catheter (Portex, Kent, UK) was
introduced into the 4th lumbar interspace with the patient ventricular fibrillation (VF).5 ICDs terminate VF
in left lateral position. After a 3 ml test dose of 2% successfully in 98% of cases.6 Supraventricular
lidocaine hydorchloride, 15 ml of 0.5% bupivacaine was tachycardia (SVT) remains the most common
injected and a T10 sensory block was obtained. Oxygen aetiology of inappropriate shock therapy. 7
was administered via nasal prongs at 4 L/min and According to one report, antitachycardia pacing
midazolam 2 mg was given intravenously for sedation. successfully terminated spontaneous VT in greater
Left inguinal herniorrhaphy was performed and there than 90% of cases.8 Approximately 20% of ICD
was no adverse event during the procedure. Five patients require pacing for bradycardia and 80%
hundred ml of ringer’s solution was administered of these benefit from dual chamber pacing.9 A
intravenously and patient remained haemodynamically
neuraxial block in the form of epidural analgesia
stable. After completion of the procedure, which lasted
for 1 hour 15 min, the ICD was enabled and the patient can lead to sympathetic block, causing bradycardia.
was transferred to the ICU. Monitoring in the ICU In patients, undergoing vascular surgery,
included continuous ECG, arterial pressure and pulse heparinisation also poses a risk of an epidural
oximetry. An infusion of 0.125% bupivacaine with 50 haematoma.
µg of fentanyl diluted in 50 ml 0.9% saline at 6 ml/hour
was continued via the epidural catheter for the next 24 Most patients with ICD have poor LVEF with
hours. After 24 hours, 150 µg buprenorphine diluted in coexisting systemic disease. Primary management
10 ml normal saline was injected via the epidural
of the patient includes evaluation and optimization
catheter and the epidural catheter was removed. The
recovery of the patient was uneventful and he was
of coexisting disease.
discharged from the hospital on the following day.
For a pacemaker dependent patient the device
Discussion should be reprogrammed to an asynchronous
mode, if electrocautery is to be used and
The first ICD was implanted in India at Escorts tachycardia sensing and adaptive rate pacing
Heart Institute and Research Centre in 1996, in a should be programmed off. Alternative facilities

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Annals of Cardiac Anaesthesia 2005; 8: 61–63 Bukhari et al. Anaesthetic Management of Patients with AICD 63

for pacing like transvenous or external pacing cannula (single lumen). The blood flow to the limb
should be available. The cautery grounding tool has been restored and his diabetic foot is healing.
should be placed as far as possible (at least 15 cm) In the second case a central venous sheath 7.5 F
in such a way that the pulse generator and the leads was placed in the right IJV for emergency
are not in the current pathway between it and the trasvenous pacing, as the ICD placement was not
electrocautery. Only the lowest possible energies recent. The surgical procedure was uneventful.
and short bursts of cautery should be used to
minimize adverse effects of electromagnetic Transient metabolic and electrolyte imbalance as
interference. If electrocautery is to be used within well as drugs may increase pacing threshold. In
15 cm of ICD, a compatible programming device both these cases epidural anaesthesia was used as
must be available in the OR as well as a pulse the technique of choice which besides facilitating
generator should be accessible. 10 If external surgery and postoperative analgesia, has been
defibrillation is required the pads or paddles shown to have beneficial effect on preload and
should be placed 10 cm from the pulse generator transmyocardial blood flow distribution.11
and implanted electrodes. Other things like use of
ligatures instead of cautery or bipolar instead of Although bupivacaine is more cardiotoxic than
unipolar cautery can be employed to minimise the lignocaine, the toxicity is unlikely to occur with a
risk of ICD malfunction. A less desirable solution single epidural injection and low dose
that may have to be considered is lead disruption postoperative infusion.12
and temporary explantation of pulse generator.10
To conclude, perioperative management of
In both cases we reprogrammed (deactivated) patients with cardiac rhythm management devices
the ICD before commencing surgery and is challenging. It has been a complex and constantly
reactivated it after electrocautery was no more evolving field of technology. An understanding of
required. In the first patient internal juglar vein the basic principles of these devices as well as
(IJV) was not cannulated, because the ICD was making use of available resources and consulting
placed recently and there is always a chance of the hospital responsible for its follow up or device
displacement of the freshly placed ICD leads. Left manufacturer is strongly encouraged to make
external jugular vein was cannulated using a 16G anaesthesia safer for these high risk cases.

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