Vol 10 | Issue 3 | September-December 2024 | Page: 04-07 | Meera J. Pandey, Namita N. Davange, Vrushali S. Malegaonkar
DOI: https://doi.org/10.13107/jaccr.2024.v10.i03.248
Open Access License: CC BY-NC 4.0
Copyright Statement: Copyright © 2024; The Author(s).
Submitted: 07/07/2024; Reviewed: 04/08/2024; Accepted: 12/10/2024; Published: 10/12/2024
Author: Meera J. Pandey [1], Namita N. Davange [1], Vrushali S. Malegaonkar [1]
[1] Department of Anaesthesia, SMBT Medical College and IMSRC, Nasik, Maharshtra, India.
Address of Correspondence
Dr. Meera Pandey,
Assistant Professor, Department of Anaesthesia, SMBT Medical College and IMSRC, Nasik, Maharshtra, India.
E-mail: meerapandey8184@gmail.com
Abstract
Geriatric patients presenting for Total knee replacement have increased in numbers with increasing life span, easier acceptance for surgery and safer anaesthesia techniques. Patients with permanent pacemaker implant are always a challenge especially if associated with low ejection fraction. Ejection fraction measures effectiveness of pumping of heart and can determine progress or worsening of heart failure (25% of patients have acute exacerbation of heart failure perioperatively). Maintaining preload, afterload, heart rate and cardiovascular stability are paramount for safe anaesthesia. A proper knowledge of pacemaker dependency, prior reprogramming to asynchronous mode, interference with pacemaker function due to electrolyte imbalance, acid-base disturbance perioperatively, and electromagnetic interference by cautery can lead to pacemaker failure and hemodynamic instability. Newer implantable cardiac electronic devices are programmed to manage heart failure, but any malfunction can be catastrophic.
Keywords: Permanent Pacemaker, Cardiac failure, TKR, Low Ejection fraction (25%), Neuroaxial anaesthesia.
Introduction
Cardiac implantable electronic devices (CITDs) are used to treat patients with heart failure and arrhythmias. Table 1 shows different types of implantable electronic devices (IEDs). Extreme bradycardia, ventricular fibrillation and pulseless ventricular tachycardia are near fatal conditions managed by implantable permanent pacemakers [1]. In a recent survey from India Shenther et.al. reported about 37000 cardiac device implantations take place in India every year [2].
Geriatric patients with cardiac compromise presenting for surgery are on the rise with increased life expectancy. Heart failure is defined as structural or functional impairment in the filling of ventricles or ejection. To know effectiveness of the heart in pumping blood, ejection fraction measurement is used to diagnose progress of heart failure. Normal Ejection Fraction varies from 55% to 70%, while Ejection Fraction 40% to 55% indicates myocardial damage which may be due to past myocardial infraction but not necessarily Heart Failure [3]. However measurement <40% show evidence of Heart Failure or cardiomyopathy, Ejection Fraction <35% may result in many life threatening cardiac complications in perioperative perio [4]. Ejection Fraction <30% is associated with significant increase in mortality and myocardial infarcti [5]. Acute exacerbation of heart failure in perioperative period may occur in 25% of patients.
General anaesthesia has been the technique of choice for patients with heart failure undergoing major surgery. Recent guidelines suggest that neuroaxial blockade may be considered for patients with cardiac disease [6].
Case Report:
A 72-year-old male patient weighing 82 kg with diagnosis of osteoarthritis of knee joint scheduled for total knee replacement surgery. Past medical history revealed post angioplasty status 2 years ago followed by pacemaker implantation (CRT-P) (Fig. 1 & Fig. 4) after 3 months. Hematological and biochemical investigations reports were within normal limits. Two-dimensional echocardiography (Fig. 3)revealed Left Ventricular Ejection Fraction 25-30%, global hypokinesia, dilated Left Ventricular cavity, mild mitral regurgitation, mild tricuspid regurgitation, mild pulmonary hypertension, compromised left ventricular function, grade 2 diastolic dysfunction. Patient was on antiplatelet drugs which were stopped 5 days prior to surgery after cardiology consultation.
The pacemaker was identified to be Quadra Allure™ 3542 CRT-P (MODE: DDD) (Type CRT-P) (Fig. 1) in proper working condition. It was reprogrammed to asynchronous mode on the day of surgery just before induction (Fig. 2). Defibrillator and transcutaneous pacing equipment were checked and kept ready before induction of anaesthesia. All emergency drugs were kept ready for the surgery.
After explaining high risk nature for anaesthesia & surgery to the patient and relatives, informed consent was taken and the patient posted surgery. All standard monitors were attached, Preoperative vitals were normal, 18G and 20G IV lines secured. Anaesthesia was planned with Combined spinal epidural anaesthesia in sitting position.18 G epidural catheter was placed at the level of L3-L4, fixed at 10 cm; spinal anaesthesia given at L4-L5 interspace with 25 G Quinckes’s needle- 1 ml of injection containing Inj. Ropivacine 0.75% Heavy + Inj. Fentanyl 25 mcg , T10 level achieved after 20 mins. Tourniquet was inflated with a pressure of around 250 mmhg.
Inj. Noradrenaline (double strength i.e. 8 mg in 50 ml NS) started (at 4 ml/hr.) and titrated as per blood pressure with the help of syringe pump. Restrictive fluid therapy approach was done. Inj. 2% Lignocaine with Adrenaline 3cc epidural test done given. Inj. Ropivacine 0.5% Isobaric at 4 ml/hr epidural Infusion started. Blood pressure was maintained within normal range throughout the surgery. Total duration of surgery was 2.15 hr. Surgeon was requested to use only Bipolar cautery throughout the surgery. Tourniquet was deflated in graded manner. Total tourniquet timing was 80 mins, Blood loss after tourniquet release was only 50 ml.
The pacemaker was reprogrammed to DDD [dual chamber pacing] mode postoperatively. For pain relief USG guided Adductor canal nerve block was given with 25cc Inj. Ropivacaine 0.2% +Inj. Dexamethasone 8 mg. Epidural infusion stopped at the end of procedure. Patient was shifted to Intensive Care Unit with continuous Inj. Noradrenaline infusion, vigilant electrocardiogram monitoring. The postoperative course was uneventful.
Discussion:
Advanced biomedical engineering has established safe and efficient newer generation pacemakers, so many patients come for different surgeries with these devices in situ. Anaesthesiologists require thorough understanding of these new devices with wide range of programmes to take appropriate perioperative decisions. Personal for reprogramming of pacemaker should be readily available perioperatively.
Hemodynamic instability can occur due to electro cautery induced pacemaker failure in asynchronous mode [7]. It is best to avoid unipolar cautery with pacemaker in situ as electromagnetic interference (EMI) is maximum when compared to bipolar cautery. Autonomic reprogramming and inappropriate tachycardia can happen even in asynchronous mode [8, 9, 10]. In perioperative planning preparing for pacemaker failure is therefore an important aspect as it can lead to severe hypotension, arrhythmias or even asystole & cardiac arrest.
To manage pacemaker failure and hemodynamic instability crash cart and vasoactive agents, were kept ready for use and pads for external pacing with defibrillator were kept in place before induction. The recommended configuration of patient’s placement according to HRS (heart rhythm society) guidelines [11] is antero-posterior left anterior between nipple and xiphisternum, left infrascapular area when pulse generated is in the pectoral region. This configuration minimizes chest wall impedance as well as delivers shock perpendicular to pad assembly.
Continuous vigilant postoperative monitoring was done. Changes can often be missed leading to pacemaker dysfunction in postoperative period which can be dangerous. In patients with pacemaker, it is important to optimize preoperatively. Patients may be on Calcium channel blockers, angiotensin converting enzymes inhibitors, angiotensin II receptor blockers and diuretics. It has been found that patients with Heart failure have twice the incidence of postoperative death, increased pulmonary complications, myocardial infarction and renal complications [11].
It has been found that complications like, bleeding, septicemia, deep vein thrombosis, pulmonary embolism, myocardial infarction, stroke, pneumonia, difficult intubation, prolonged mechanical ventilation, renal complications is reduced in regional anaesthesia with or without general anaesthesia [12].
Cardiac output can improve with regional anaesthesia only or in combination with General anaesthesia which has advantage of reducing preload and afterload. To avoid myocardial hypoperfusion, hypotension must be prevented. Also subarachnoid blockade may be associated with inability to control the level of blockade which can result in considerable hemodynamic imbalance, so we gave spinal anaesthesia with low volume drug in sitting position. Epidural provides back up in case there was recession of level because of very low dose of spinal drug & the flexibility of graduated doses of local anaesthesia to titre the level of block & maintain hemodynamic stability. Nerve blocks such as Adductor canal nerve block can be given for postoperative pain relief, but Local anaesthesia toxicity is always a concern when large volumes are used as can further depress myocardium. To avoid this ropivacine was used in a limited permissive volume as it is more cardiostable. Tourniquet deflation in a graded manner helps to avoid sudden hypotension as redistribution happens in a graded manner over time [13].
The statement by European society of cardiologist and anaesthesiologist published in 2014 recommended that combined spinal epidural alone can be considered as the anaesthesia technique of choice in patients with heart disease after careful assessment of risk/ benefit ratio. We believe combined spinal epidural with low dose spinal anaesthesia & titrated epidural top ups or infusion can be answer to anaesthesia for orthopaedic surgery of lower limb in these type of patients.
Conclusion:
A cardiac patient with pacemaker and low ejection fraction always poses challenges to the anesthesiologist. A thorough preoperative examination, counselling, understanding pacemaker and its modes along with continuous cardiac monitoring and close loop communication with the surgeon will help in smooth conduction of the case. A low dose spinal with epidural top ups as a backup is a gold standard for all high-risk cardiac patients.
References
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| How to Cite this Article: Pandey M, Davange N, Malegaonkar V | Anaesthesia Management in a Patient with Low Ejection Fraction and Permanent Pacemaker for TKR Surgery | Journal of Anaesthesia and Critical Care Case Reports | September-December 2024; 10(3): 04-07. https://doi.org/10.13107/jaccr.2024.v10.i03.248 |
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