Sick Sinus Syndrome

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acidbase1

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I have to take a guy to the OR with acute in chronic cholecystitis. (Now gangrenous) Perc chole drain was placed in January and is now no longer draining. Patient had been septic on and off for months, now it has to come out. He has SSS, refuses PPM. Has intermittent junctional bradycardia. He’s on the lower end of normal pressure wise, but not hypotensive. I’m going to place art line and have pacing capabilities periop along with sympathomimetics. Any other advice?

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transcutaneous pads and transvenous leads
 
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I have to take a guy to the OR with acute in chronic cholecystitis. (Now gangrenous) Perc chole drain was placed in January and is now no longer draining. Patient had been septic on and off for months, now it has to come out. He has SSS, refuses PPM. Has intermittent junctional bradycardia. He’s on the lower end of normal pressure wise, but not hypotensive. I’m going to place art line and have pacing capabilities periop along with sympathomimetics. Any other advice?

He is OK with temporary PM?
 
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This is a good topic. I would proceed just as you have described. I would use short acting meds for treatment of Brady or tachycardia. External pacing pads of course. May even place a central line/cordis so I could quickly insert pacing leads if needed. That depends on how symptomatic the pt is.
 
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So this is how it went down. Small dose narcotic, ketamine, whiff of prop, lidocaine—> Bradys down to low 30. Atropine... nothing. Ephedrine... nothing. Glyco... nothing. As I’m diluting out epi and messing with pacer (pads placed preinduction) he jumps back up to 80s. Stable as a rock the rest of the way.

Oh and I forgot to add, dude had severe AS. Poor candidate for AVR, refused TAVR.
 
No way in the world I would place transvenous pacing leads in this guy. I wouldn't even know where to find them.
I’m with you on this. I have never done it. I was mostly thinking cards could come in and do it but I’d have the access ready to go.
 
Oh and I forgot to add, dude had severe AS. Poor candidate for AVR, refused TAVR.
Ha ha. Well you forgot a lot. That’s f’ed up. How was his BP with a HR of 30. I’m assuming it was ok. Probably had a thick ass ventricle able to create respectable pressure.
 
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It was boarderline, around MAPs of 50-60s. Preinduction was 90-100s.
 
So this is how it went down. Small dose narcotic, ketamine, whiff of prop, lidocaine—> Bradys down to low 30. Atropine... nothing. Ephedrine... nothing. Glyco... nothing. As I’m diluting out epi and messing with pacer (pads placed preinduction) he jumps back up to 80s. Stable as a rock the rest of the way.

Oh and I forgot to add, dude had severe AS. Poor candidate for AVR, refused TAVR.

Why atropine and then glyco?
 
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Why would you put pads on if you are placing transvenous leads?

I would start with trancutaneous pads on. this would be plan A if pt goes into complete block actuely. This is my bridge if the patient recovers spontaneously in the OR, but it's not a long term solution. I also don't think you'd want the patient awake for this as it's pretty high voltage to capture sometimes.

A lot of things would make me think about transvenous pacing. It's better for long term because it is more targeted to the ventricle. I would also want this if the tranvenous has trouble capturing. This would be the bridge to pace maker and patient can be completely unsedated with this in. Furthermore, the fact that the patient is septic and you're introducing bacteria in the myocardium when you screw on the pacer should also be on the back of your mind. But it's no excuse to let the patient die.
 
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I would start with trancutaneous pads on. this would be plan A if pt goes into complete block actuely. This is my bridge if the patient recovers spontaneously in the OR, but it's not a long term solution. I also don't think you'd want the patient awake for this as it's pretty high voltage to capture sometimes.

A lot of things would make me think about transvenous pacing. It's better for long term because it is more targeted to the ventricle. I would also want this if the tranvenous has trouble capturing. This would be the bridge to pace maker and patient can be completely unsedated with this in. Furthermore, the fact that the patient is septic and you're introducing bacteria in the myocardium when you screw on the pacer should also be on the back of your mind. But it's no excuse to let the patient die.
Personally, I would go for transvenous pacing leads since the surgery is in the general vicinity of the pads. Plus it’s better capture.
 
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So this is how it went down. Small dose narcotic, ketamine, whiff of prop, lidocaine—> Bradys down to low 30. Atropine... nothing. Ephedrine... nothing. Glyco... nothing. As I’m diluting out epi and messing with pacer (pads placed preinduction) he jumps back up to 80s. Stable as a rock the rest of the way.

Oh and I forgot to add, dude had severe AS. Poor candidate for AVR, refused TAVR.
This changes everything. Would have cards place transvenous pacer prior to OR. no way I want to be pushing epi on a guy with severe AS if I could avoid it. If patient refuses then refuse the surgery.
 
What’s this guys fubctional status? Is he walking around and never gets lightheaded or has palpitations or syncopizes?

His clinical symptoms inform how worried you should be here. If he has no history suggesting severely symptomatic bradycardia or AS then you can probably stand down in terms of major disaster planning.

Assuming he actually has concerning symptoms then I think it’s malpractice to not have a placed and TESTED hot wire prior to a laparoscopy. Either consult a cardiologist , consult your CT anesthesia group, or hand it off to CT aneshesia
 
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I would. Placing a TVP is easy but they can dislodge, lose capture, etc... plus as you’re placing it could theoretically cause ventricular ectopy->VT.


Where exactly did you learn to place these? Certainly doesn’t seem like standard training at my program. Maybe in retrospect I’d pretreat with Gyco or atropine, for sure transcutaneous pads. No way would i be placing transvenous leads for the first time emergently by myself. For an elective procedure, that doesn’t seem like all that reasonable of a backup plan.
 
What’s this guys fubctional status? Is he walking around and never gets lightheaded or has palpitations or syncopizes?

His clinical symptoms inform how worried you should be here. If he has no history suggesting severely symptomatic bradycardia or AS then you can probably stand down in terms of major disaster planning.

Assuming he actually has concerning symptoms then I think it’s malpractice to not have a placed and TESTED hot wire prior to a laparoscopy. Either consult a cardiologist , consult your CT anesthesia group, or hand it off to CT aneshesia

why would it be malpractice? the guy has SSS with known intermittent junctional brady. The guy is still alive so clearly it hasn't killed him yet.

Where exactly did you learn to place these? Certainly doesn’t seem like standard training at my program. Maybe in retrospect I’d pretreat with Gyco or atropine, for sure transcutaneous pads. No way would i be placing transvenous leads for the first time emergently by myself. For an elective procedure, that doesn’t seem like all that reasonable of a backup plan.

Mostly TAVRs since their risk of CHB is so high, but in those rooms we can check with xray afterwards to confirm positioning...
 
Where exactly did you learn to place these? Certainly doesn’t seem like standard training at my program. Maybe in retrospect I’d pretreat with Gyco or atropine, for sure transcutaneous pads. No way would i be placing transvenous leads for the first time emergently by myself. For an elective procedure, that doesn’t seem like all that reasonable of a backup plan.
If you can float a swan you can do a transvenous pacing.
 
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What’s this guys fubctional status? Is he walking around and never gets lightheaded or has palpitations or syncopizes?

His clinical symptoms inform how worried you should be here. If he has no history suggesting severely symptomatic bradycardia or AS then you can probably stand down in terms of major disaster planning.

Assuming he actually has concerning symptoms then I think it’s malpractice to not have a placed and TESTED hot wire prior to a laparoscopy. Either consult a cardiologist , consult your CT anesthesia group, or hand it off to CT aneshesia
A general anesthesiologist should be able to handle any case that a CT anesthesiologist can. If your training is worth its salt that is. Advanced TEE is a different ballgame (and even that is debatable) but there's nothing here that a good anesthesiologist can't handle.
 
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Where exactly did you learn to place these? Certainly doesn’t seem like standard training at my program. Maybe in retrospect I’d pretreat with Gyco or atropine, for sure transcutaneous pads. No way would i be placing transvenous leads for the first time emergently by myself. For an elective procedure, that doesn’t seem like all that reasonable of a backup plan.

I probably should’ve prefaced my comment, I’m a cardiologist and an EP fellow....

That said, a TVP is a straightforward procedure. It’s not currently part of standard anesthesia training programs? I would’ve thought it would be.
 
I probably should’ve prefaced my comment, I’m a cardiologist and an EP fellow....

That said, a TVP is a straightforward procedure. It’s not currently part of standard anesthesia training programs? I would’ve thought it would be.

Unfortunately no. Not a lot of opportunity for them. As an above poster mentioned, the most common indication when we're involved is CHB post TAVR. I got to place two for that reason as a resident, but the cardiac anesthesiologist I was with for the case said he was jealous. He had been out of residency & fellowship for like 7 years or so and had never placed one. And I think I'm the only resident at my program who got to place any.
 
I probably should’ve prefaced my comment, I’m a cardiologist and an EP fellow....

That said, a TVP is a straightforward procedure. It’s not currently part of standard anesthesia training programs? I would’ve thought it would be.

Where would the anesthesia residents get these numbers for TVP? Do IM residents place a lot of TVPs??

As a resident i've only done TVP in the fluoro room. I've never done it without fluoro confirmation before

For most general anesthesiologist, TVP is a rescue procedure, so many people go thru residency without seeing a single case that require a TVP (except cardiac rotation), it's kind of like going thru residency without doing single cricothyrotomy
The toughest part i think isn't even placing the TVP, it's finding where they keep it..

A general anesthesiologist should be able to handle any case that a CT anesthesiologist can. If your training is worth its salt that is. Advanced TEE is a different ballgame (and even that is debatable) but there's nothing here that a good anesthesiologist can't handle.

i somewhat disagree with this statement. there are many procedures that a general anesthesiologist are not familar with or have only done a couple of during residency. while the general anesthesiologist may be able to get the patient thru the case, the outcomes may favor the CT trained anesthesiologist. There's a reason it's a 1 yr long fellowship. Sure a general anesthesiologist can almost be good at it if you load your electives with cardiac months... but not everyone do that.
 
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Good to know. To be honest we don’t do that many either. Doing general cards fellowship I only did a handful. Not that it’s a very technically challenging procedure that requires hundreds of attempts though....

I wonder how many ED residents and CC fellows are doing?
 
So this is how it went down. Small dose narcotic, ketamine, whiff of prop, lidocaine—> Bradys down to low 30. Atropine... nothing. Ephedrine... nothing. Glyco... nothing. As I’m diluting out epi and messing with pacer (pads placed preinduction) he jumps back up to 80s. Stable as a rock the rest of the way.

Oh and I forgot to add, dude had severe AS. Poor candidate for AVR, refused TAVR.


Why the lidocaine?

Profound bradycardia with lidocaine during anesthesia induction in a silent sick sinus syndrome patient. - PubMed - NCBI
 
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I don't think this has been mentioned here...probably because it is not very common...at all. But you could try transESOphageal pacing. I've never personally done it, but have read about it and seen presentations at it. In fact, I saw a case report on it at the SCA annual meeting a couple weeks ago. Of course, it would require the proper equipment which is probably hard to find. Other issues is you can only reliably atrial pace. Placement is easy, and you could place it right after induction, verify capture, and only use it if necessary.

As someone above noted, if you can float a swan, you can float a TV pacer. I did a handful in residency (three emergently in the ICU for unstable CHB after cardiac surgery in patients with either no or failed epicardial leads). Did a couple during TAVRs.
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And what was the atropine dose given? Why does this matter?

dose should be greater than 0.5mg or possible paradoxical bradycardic effect likely centrally mediated
 
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How much narc did they use???

50mcg fentanyl

Point being, it was neither the lidocaine or fentanyl. He had three episodes of Brady throughout the case and had many such events days leading up to surgery
 
I've never tried this, but apparently you can use the same epicardial leads and just stitch them onto the chest well. Serves like transcutaneous pads in a pinch or if you're having trouble with the pads.
 
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Good to know. To be honest we don’t do that many either. Doing general cards fellowship I only did a handful. Not that it’s a very technically challenging procedure that requires hundreds of attempts though....

I wonder how many ED residents and CC fellows are doing?
EM here. I think I placed two or three during my residency--which was above average. I've placed a few during my 3 years of attending hood, which I gather from talking to colleagues is atypical.
 
I've never tried this, but apparently you can use the same epicardial leads and just stitch them onto the chest well. Serves like transcutaneous pads in a pinch or if you're having trouble with the pads.

I wonder if this will hurt a lot more since the electric current is not distributed over a wider surface area
 
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I have to take a guy to the OR with acute in chronic cholecystitis. (Now gangrenous) Perc chole drain was placed in January and is now no longer draining. Patient had been septic on and off for months, now it has to come out. He has SSS, refuses PPM. Has intermittent junctional bradycardia. He’s on the lower end of normal pressure wise, but not hypotensive. I’m going to place art line and have pacing capabilities periop along with sympathomimetics. Any other advice?

I agree with others that transvenous pacing is your best bet here. This guy has a jacked up rhythm and needs a pacemaker *at baseline* let alone while septic and having a not-straightforward upper abdominal procedure.

I DISagree that placing a TVPM is anywhere close to the scope of a general anesthesiologist. My anecdotal experience is that I have done zero in 9 years of training and practice.

So, you park this dude in your ICU and get cards to do it urgently, or have them do it in the cath lab or whatever your local arrangement is. If your hospital can't do that, time to transfer.
 
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I've never placed a transvenous pacer. About 9 years of practice plus a CT fellowship at a somewhat reputable place.
But does that mean you couldn't do it?
I haven't either but i wouldn't have a problem with it.
 
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But does that mean you couldn't do it?
I haven't either but i wouldn't have a problem with it.

We all could probably do a diagnostic angio or place a tunneled HD cath or an open chest tube, doesn't mean it's in our scope of practice.
 
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