What constitutes pacemaker dependent?

[whiteorgo]

Been encountering some patients with pacemaker/AICD recently, and i know the general rule is that if surgery is ABOVE umbilicus AND the patient is pacemaker dependent, you set it in asynchronous mode.

But what exactly does pacemaker dependence mean? is it a certain percentage of how much they're paced or depending on their underlying rhythm? Just unclear on this criteria.

Also, if the surgery is ABOVE umbilicus but the patient is NOT pacemaker dependent, what do you guys do? can you still just leave it alone since pacemaker likely won't interfere?

Thank you!

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[deleted171991]

Managing Cardiovascular Implantable Electronic Devices (CIEDs) During Perioperative Care - Anesthesia Patient Safety Foundation

My own experience:

Pacer-dependent = somebody who won't be able to produce enough cardiac output (i.e. ventricular rate) absent pacer activity. I use my judgment (absent cardiology notes). When in doubt, I put on Zoll pads.

If the surgery is above the umbilicus and the patient is not pacer-dependent, I just watch the EKG carefully, and advise the patient/surgeon to have the device interrogated as soon as possible after the surgery.

Newer devices are smart. I always try to get an electrophysiologist/rep input if I have time. Many times they tell me to leave the thing alone. For pacer-dependent patients, it's always wise to have the device switched to an asynchronous mode preop.

 

[DM27]

A lot of this is unfortunately not very clear and depends on why they have the pacemaker. Defining dependence may be your individual level of comfort, reading a recent interrogation and discussing it with the surgeon.

If they have a pacemaker for a 3rd degree block or are s/p AV node ablation and are paced >90% of the time you can safely say that you will likely not get away with not adjusting the settings prior to a relevant surgery.

If it’s someone with SSS or some in between AV node dysfunction it’s harder to tell. If their limit rate is 50 or 60 and they’re paced 90% of the time you can safely say that you will be subject to a bradycardic intrinsic rhythm at times during the surgery if you do nothing about the pacemaker and honestly this may be fine if they’re not having hemodynamic issues during their bradycardic periods. If you have someone with the ability to interrogate you can have them suspend pacer function and see what the intrinsic rate and corresponding BP are. Many people with pacemakers have them for bradycardia episodes that are infrequent in general. In these scenarios you can see a higher percentage of pacing and just decide you’re going to turn it asynchronous to be safe and this will likely be fine. The main downside is that if the patients intrinsic rate climbs to one similar to the set DOO or what have you rate then your risk for an R on T event and VFib starts to climb.

If it’s just a PPM you can leave it be for surgery above the umbilicus as all EMI will do is inhibit pacing. If it’s an AICD/PPM then you need to disable the AICD whether by magnet or programming.

 

[repititionition]

https://www.onlinecjc.ca/article/S0828-282X(11)01240-2/fulltext

 

[anbuitachi]

theres no way for us to tell without knowing complete history and interrogation. So to me i assume pace maker dependence if patient is 100% or close to it paced. whether they are actually dependent or not is different. could just from sinus brady like someone said, and is paced upwards, but when rate drops back down, patient is still stable.

 

[dchz]

Managing Cardiovascular Implantable Electronic Devices (CIEDs) During Perioperative Care - Anesthesia Patient Safety Foundation

My own experience:

Pacer-dependent = somebody who won't be able to produce enough cardiac output (i.e. ventricular rate) absent pacer activity. I use my judgment (absent cardiology notes). When in doubt, I put on Zoll pads.

If the surgery is above the umbilicus and the patient is not pacer-dependent, I just watch the EKG carefully, and advise the patient/surgeon to have the device interrogated as soon as possible after the surgery.

Newer devices are smart. I always try to get an electrophysiologist/rep input if I have time. Many times they tell me to leave the thing alone. For pacer-dependent patients, it's always wise to have the device switched to an asynchronous mode preop.

I came here to say exactly this.... the new avatar is making FFP into a reasonable person???! 😛

 

[deleted171991]

I came here to say exactly this.... the new avatar is making FFP into a reasonable person???! 😛

😵

 

[Mman]

When in doubt, I put on Zoll pads.

anybody ever successfully transcutaneously pace somebody in the OR? I've never seen it done myself.

 

[DM27]

I have done it a few times. It is not pretty and I do not find it to work reliably well at all. You often need to really crank up the output and you basically have someone flopping like a fish on the table. It's definitely a very short term temporizing measure until you either can alleviate the issue chemically or have a transvenous in place.

 

[pgg]

I've never seen it work ... but there's a small sample size and bias in what I've seen attempted. 🙂

 

[fakin' the funk]

But what exactly does pacemaker dependence mean? is it a certain percentage of how much they're paced or depending on their underlying rhythm? Just unclear on this criteria.

Like porn, you know it when you see it