Annals of Cardiac Anaesthesia 2005; 8: 61–63
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
arrhythmias. Such patients are being increasingly
subjected to noncardiac surgery. We describe the
anaesthetic management for popliteal to anterior
tibial artery bypass grafting and hernioplasty in
two patients with ICD.
Case: 1
A 54-year-old diabetic male patient underwent
coronary artery bypass graft (CABG) surgery. Two
months later, he was admitted with severe pain in the
right leg and around the heel of the same side, which
was diagnosed as diabetic foot. ICD was implanted two
weeks after the CABG because of recurrent episodes of
ventricular tachycardia (VT) poorly responsive to
amiodarone.
Echocardiography revealed left ventricular ejection
fraction (LVEF) of 45% with hypokinesia of
interventricular septum and apex. Peripheral angiogram
showed 100% occlusion of popliteal artery and anterior
tibial artery was getting filled from the collaterals.
Patient had developed fever and raised white cell counts
which was managed with appropriate antibiotics. The
patient was scheduled to undergo popliteal to anterior
tibial artery bypass graft. He was premedicated with
lorazepam 2 mg and ranitidine 150 mg at night and on
the morning of surgery, morphine sulphate 5 mg
intramuscularly (IM) and lorazepam 2 mg per oral were
administered 90 minutes before surgery. Monitoring
during surgery included continuous two lead
electrocardiogram (lead II and V5), oxygen saturation,
Address for Correspondence: Dr. Altaf Bukhari, Fellow in Cardiac
Anaesthesia, Dept. of Anaesthesia, Escorts Heart Institute and Research
Centre, Okhla Road, New Delhi -110025
Phone: 26825000, 26825001 Extn 4125, Tele-Fax: 51628442
Annals of Cardiac Anaesthesia 2005; 8: 61–63
Key words:- Implantable cardioverter defibrillator, Peripheral vascular
surgery, Hernioplasty, Epidural anaesthesia
ACA-04-108 CaseReport.p65 61
Case
AICD 61
direct arterial pressure, arterial blood gas analysis,
central venous pressure through left external jugular
vein, and urine output. All monitoring lines were
inserted under local anaesthesia. An external pulse
generator and external pacing were kept ready in the
operating room (OR). External counter shock paddles
were checked and kept ready in the OR. A 16G epidural
catheter (Portex, Kent, UK) was inserted in the 3rd lumbar
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
sensory block was obtained. Oxygen was given via nasal
prongs at 4 L/min. The patient did not need any sedation
or anxiolysis as he continued to sleep following complete
pain relief.
An electrocautery grounding pad was placed beneath
the right buttock. The ICD was disabled before the start
of surgery using a noninvasive programming device
(Medtronic Inc, Minneapolis, USA). Popliteal to anterior
tibial artery bypass grafting was performed and there was
no adverse event during the procedure. A range of
antiarrhythmic drugs and external pacing were kept
standby to treat any life threatening arrhythmia. After
completion of the procedure which lasted for about five
hours during which one top up dose of bupivacaine
(0.5%) was given, the ICD was enabled and the patient
was transferred to the intensive care unit (ICU) for
observation. The intraoperative period remained
uneventful and no arrhythmias were noted. The patient
did not have any significant haemodynamic changes
during the procedure except that the systemic arterial
pressure stabilised to 120/70 to 140/90 mm Hg from 190/
100 mm Hg, after epidural administration of local
anaesthetic. Two units of blood were tranfused during
the procedure to optimise haemtocrit to 30%. Acid base
balance was checked after 15 min of release of vascular
clamps, which was within normal limits. Monitoring in
the ICU included continuous ECG, arterial pressure and
pulse oximetry. An infusion of 0.125% bupivacaine with
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
36 hours after ensuring that the patient could move his
lower limbs. Intraoperatively blood sugar levels
were measured thrice and were found to be less than 200
1/5/2005, 12:21 PM
 62 Bukhari et al. Anaesthetic Management of Patients with AICD
mg/dl each time. Preoperatively patient was receiving a
total of 30 units of regular insulin per day. After 36 hours,
150 µg buprenorphine diluted in 10 ml normal saline was
injected via the epidural catheter and the catheter was
removed. The patient had an uneventful recovery and
the management of diabetic foot was continued.
Case: 2
A 59-year-old male patient with left indirect inguinal
hernia was admitted for left sided hernioplasty. The
patient had undergone CABG six months back and an
ICD was implanted 4 months back because of recurrent
episodes of VT nonresponsive to amiodarone.
Echocardiography revealed, LVEF of 25% with trivial
mitral regurgitation. The chest X-ray showed an ICD in
situ and enlarged cardiac size. The haematological, liver
and kidney function tests were normal.
Patient was premedicated with diazepam 5 mg and
ranitidine 150 mg at night before surgery and on the
morning of surgery, morphine sulphate 5 mg IM with
lorazepam 2 mg per oral were administered 90 min
before surgery. The intraoperative monitoring and
management of ICD was similar to that in the first
patient. An 18G epidural catheter (Portex, Kent, UK) was
introduced into the 4th lumbar interspace with the patient
in left lateral position. After a 3 ml test dose of 2%
lidocaine hydorchloride, 15 ml of 0.5% bupivacaine was
injected and a T10 sensory block was obtained. Oxygen
was administered via nasal prongs at 4 L/min and
midazolam 2 mg was given intravenously for sedation.
Left inguinal herniorrhaphy was performed and there
was no adverse event during the procedure. Five
hundred ml of ringer’s solution was administered
intravenously and patient remained haemodynamically
stable. After completion of the procedure, which lasted
for 1 hour 15 min, the ICD was enabled and the patient
was transferred to the ICU. Monitoring in the ICU
included continuous ECG, arterial pressure and pulse
oximetry. An infusion of 0.125% bupivacaine with 50
µg of fentanyl diluted in 50 ml 0.9% saline at 6 ml/hour
was continued via the epidural catheter for the next 24
hours. After 24 hours, 150 µg buprenorphine diluted in
10 ml normal saline was injected via the epidural
catheter and the epidural catheter was removed. The
recovery of the patient was uneventful and he was
discharged from the hospital on the following day.
Discussion
The first ICD was implanted in India at Escorts
Heart Institute and Research Centre in 1996, in a
ACA-04-108 CaseReport.p65 62
Annals of Cardiac Anaesthesia 2005; 8: 61–63
patient who suffered recurrent cardiac arrests
despite a trial of multiple antiarrhythmic drugs.1
ICD has significantly reduced the risk of sudden
cardiac death in patients with known life
threatening ventricular arrhythmias.2,3 The ability
of an ICD to provide therapy within 5 to 15 sec of
arrhythmia detection allows defibrillation success
rate approaching 100%.4
An ICD system consists of a pulse generator
and leads for detection and therapy of
tachyarrhythmias. It may provide antitachycardia,
antibradycardia pacing, synchronized or non-
synchronized shocks, telemetry and diagnostic
storage. Many devices use adaptive rate pacing to
modify the pacing rate for changing metabolic
needs. The ICD batteries contain up to 20,000 J of
energy. Most ICD designs use two capacitors in
series to achieve maximum voltage for
defibrillation. 5 Cardioversion with energy
exceeding 2 J results in skeletal and diaphragmatic
muscle depolarization and is painful to the
conscious patient. High energy discharges of 10-
40 J, delivered asynchronously are used to treat
ventricular fibrillation (VF).5 ICDs terminate VF
successfully in 98% of cases.6 Supraventricular
tachycardia (SVT) remains the most common
aetiology of inappropriate shock therapy. 7
According to one report, antitachycardia pacing
successfully terminated spontaneous VT in greater
than 90% of cases.8 Approximately 20% of ICD
patients require pacing for bradycardia and 80%
of these benefit from dual chamber pacing.9 A
neuraxial block in the form of epidural analgesia
can lead to sympathetic block, causing bradycardia.
In patients, undergoing vascular surgery,
heparinisation also poses a risk of an epidural
haematoma.
Most patients with ICD have poor LVEF with
coexisting systemic disease. Primary management
of the patient includes evaluation and optimization
of coexisting disease.
For a pacemaker dependent patient the device
should be reprogrammed to an asynchronous
mode, if electrocautery is to be used and
tachycardia sensing and adaptive rate pacing
should be programmed off. Alternative facilities
1/5/2005, 12:21 PM
 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
should be available. The cautery grounding tool
should be placed as far as possible (at least 15 cm)
in such a way that the pulse generator and the leads
are not in the current pathway between it and the
electrocautery. Only the lowest possible energies
and short bursts of cautery should be used to
minimize adverse effects of electromagnetic
interference. If electrocautery is to be used within
15 cm of ICD, a compatible programming device
must be available in the OR as well as a pulse
generator should be accessible. 10 If external
defibrillation is required the pads or paddles
should be placed 10 cm from the pulse generator
and implanted electrodes. Other things like use of
ligatures instead of cautery or bipolar instead of
unipolar cautery can be employed to minimise the
risk of ICD malfunction. A less desirable solution
that may have to be considered is lead disruption
and temporary explantation of pulse generator.10
In both cases we reprogrammed (deactivated)
the ICD before commencing surgery and
reactivated it after electrocautery was no more
required. In the first patient internal juglar vein
(IJV) was not cannulated, because the ICD was
placed recently and there is always a chance of
displacement of the freshly placed ICD leads. Left
external jugular vein was cannulated using a 16G
References
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implantable cardioverter-defibrilator. Efficacy,
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ACA-04-108 CaseReport.p65 63
cannula (single lumen). The blood flow to the limb
has been restored and his diabetic foot is healing.
In the second case a central venous sheath 7.5 F
was placed in the right IJV for emergency
trasvenous pacing, as the ICD placement was not
recent. The surgical procedure was uneventful.
Transient metabolic and electrolyte imbalance as
well as drugs may increase pacing threshold. In
both these cases epidural anaesthesia was used as
the technique of choice which besides facilitating
surgery and postoperative analgesia, has been
shown to have beneficial effect on preload and
transmyocardial blood flow distribution.11
Although bupivacaine is more cardiotoxic than
lignocaine, the toxicity is unlikely to occur with a
single epidural injection and low dose
postoperative infusion.12
To conclude, perioperative management of
patients with cardiac rhythm management devices
is challenging. It has been a complex and constantly
evolving field of technology. An understanding of
the basic principles of these devices as well as
making use of available resources and consulting
the hospital responsible for its follow up or device
manufacturer is strongly encouraged to make
anaesthesia safer for these high risk cases.
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L, Martinez A. Conversion rates of induced versus
spontaneous ventricular tachycardia by a third generation
cardioverter defibrillator. Pacing Clin Electrophysiol 1993;
16: 170-173
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P. The value of DDD pacing in patients with an
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Electrophysiol 1997; 20: 177-81
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Noncardiac surgery and pacemaker cardioverter
defibrillator management. J Cardiothroacic Vasc Anesth
1998; 12: 221-24
11. Bloomberg S, Emanuellson H, Kvish H. Effects of epidural
anesthesia on coronary arteries and arterioles in patients
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