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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
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.
References
1. Mehta Y, Dhole S, Kler TS. AICD implantation and its flutter that elicits inappropriate implantable cardioverter
implications for the anaesthesiologist. Ind Heart J 1996; discharge. Pacing Clin Electrophysiol 1997; 20: 125-27
48: 68-70 8. Porterfield JG, Porterfield LM, Smith BA, Bray L, Voshage
2. Rosenthal ME, Josephson ME. Current status of L, Martinez A. Conversion rates of induced versus
antitachcardia devices. Circulation 1990; 82: 1889-99 spontaneous ventricular tachycardia by a third generation
3. Kelly PA, Cannom DS, Garan H, et al. The automatic cardioverter defibrillator. Pacing Clin Electrophysiol 1993;
implantable cardioverter-defibrilator. Efficacy, 16: 170-173
complications and survival in patients with malignant 9. Geelan P, Lorga Filho A, Chauvin M, Wellens F, Brugada
ventricular arrhythmias. J Am Coll Cardiol 1988; 11: 1278- P. The value of DDD pacing in patients with an
86 implantable cardioverter defibrillator. Pacing Clin
4. Michael H, Gollob, Seger JJ. Current status of the Electrophysiol 1997; 20: 177-81
implantable cardioverter defibrillator. Chest 2001; 119: 10. Mehta Y, Swaminathan M, Juneja R, Saxena A, Trehan N.
1210-221 Noncardiac surgery and pacemaker cardioverter
5. Groh WJ, Lynee D, Fore Doughlas PZ. Advances in the defibrillator management. J Cardiothroacic Vasc Anesth
treatment of arrhythmias; implantable cardioverter 1998; 12: 221-24
defibrillator: Am Fam Physician 1998; 57: 297-307 11. Bloomberg S, Emanuellson H, Kvish H. Effects of epidural
6. Saksena S. The impact of implantable cardioverter anesthesia on coronary arteries and arterioles in patients
defibrillator therapy on health care systems. Am Heart J with coronary artery disease. Anesthesiology 1990; 73: 840-
1994; 127: 1193-1200 847
7. Schumacher B, Tebbenjohanns J, Jung W, Korte T, Pfeiffer 12. Reiz S, Nath S. Cardiotoxicity of local anaesthetic agents.
D, Luderitz B. Radiofrequency catheter ablation of atrial Br J Anaesth 1996; 58: 736-746