Intraoperative pacemaker failure in an infant

Pacemakers in children can present clinical challenges during surgery. We present a case report of an infant whose pacemaker reverted to a backup mode when electrocautery was used during surgery. The resulting bradycardia did not respond either to a magnet placed over the generator or to iv atropine. The circulation was supported by isoproterenol until the pacemaker was re-programmed by the manufacturer. Such devices require care and understanding if problems during surgery are to be avoided.     

Final arrest of a pacemaker after use of electrocautery

A case is reported of irreversible damage being caused to a permanent programmable pacemaker by electrocautery used in the epigastric region. The pacemaker was rapidly replaced, and the patient had no adverse effects of this accident. The use of monopolar electrocautery in patients who have one of the new generation of programmable pacemakers is very dangerous. Bipolar forceps can reduce the level of interference between electrocautery units and pacemaker electrodes. With programmable pacemakers, the generator instruction manual should be consulted before surgery, as placing a magnet on the generator may not necessarily convert it to the asynchronous mode. When the use of electrocautery is unavoidable, external cardiac pacing electrodes should be placed on the patient, with an external cardiac pacemaker ready.     

Electrocautery and pacemakers: management of the paced patient subject to electrocautery

Electrocautery, commonly used during surgery to maintain hemostasis, can have significant detrimental effects in the paced patient. Damage to the pulse generator, reprogramming of the pacemaker, changes in the capture threshold, and ventricular fibrillation can all be induced by electrocautery. Familiarity with the particular pacemaker in use is critical in minimizing these adverse effects. Preoperative evaluation of the patient's dependence on the pacemaker and evaluation of pacemaker function should be performed and documented. We recommend close intraoperative monitoring of heart rate and rhythm, and suggest that a pacemaker programmer be on hand in the surgical suite during the operation. A postoperative check of pacemaker function should be carried out so that electrocautery-induced pacemaker malfunction will not go unnoticed or uncorrected. Three cases are presented which clearly illustrate these points.     

Electrocautery-induced pacemaker malfunction during surgery

We report a case of electrocautery-induced pacemaker failure that resulted in asystole in a 15-year-old girl scheduled for cardiac surgery. Her pacemaker was converted to the asynchronous mode the night before surgery. Electromagnetic interference from the unipolar electrocautery caused a reduction in the battery voltage, which allowed the digital circuitry, but not the voltage control oscillator (VCO), to work properly. Eventually the battery current drain caused VCO "lock-out," and pacemaker and battery failure. This report demonstrates that electrocautery-induced pacemaker failure can occur, even after conversion to asynchronous mode.     

Electromagnetic interference of an external temporary pacemaker during maxillofacial and neck surgery.

Indirect inhibition of an external temporary pacemaker by electrocautery is reported. Before induction of general anesthesia for a hemimaxillectomy and radical neck dissection, a temporary transvenous demand pacemaker was inserted into a patient with a first-degree atrioventricular block and complete left bundle-branch block. Although we provided common precautions to prevent electromagnetic interference by electrocautery, pacing failure still occurred. It was thought to be caused by current dispersing from the active electrocautery electrode. This case suggests that occipital placement of the electrocautery ground plate should be considered during neck surgery in a patient requiring a temporary pacemaker.     

Intraoperative pacemaker dysfunction caused by the use of electrocautery during a total hip arthroplasty

Pacemaker dysfunction encountered during orthopedic procedures is a rare but potentially life-threatening complication. With an increasing number of orthopedic procedures performed on the aging population, it is not uncommon to encounter patients with pacemakers requiring major orthopedic intervention. Most, if not all, major orthopedic procedures performed today require the use of electrocautery for hemostasis. In this article we review the literature for pacemaker complications and report a case of pacemaker failure after a single use of the unipolar electrocautery on a patient undergoing a total hip replacement.     

Pacemaker backup-mode reversion and injury during cardiac surgery

Both electrocautery and internal defibrillation are routinely used in cardiac operations. The cases of 5 patients are presented in whom backup-mode reversion or injury of permanently implanted pulse generators occurred during a cardiac procedure. The theoretical explanations for backup-mode reversion and generator or tissue injury are discussed, and recommendations are made for the management of patients with a pacemaker who are to undergo a cardiac operation.     

Electrocautery-induced asystole in a scoliosis patient with a pacemaker

Pediatric heart condition management may include a variety of implanted cardiac devices. Monopolar electrocautery (Bovie) produces significant electromagnetic interference to these devices. This interference can alter the function of a cardiac generator resulting in a variety of complications including impaired cardiac output and asystole. We report the case of a 16 plus 2-year-old girl who presented with idiopathic scoliosis and a past medical history significant for complete congenital heart block treated with a DDD*** pacemaker. During surgery, the use monopolar electrocautery caused the patient to develop asystole and loss of pulsatile blood pressure. Electrocautery was subsequently terminated, the patient then returned to a normal sinus rhythm and blood pressure normalized.     

Interference between a dual-chamber pacemaker and argon electrocautery device during hepatectomy]

We report an unusual electromagnetic interference induced by an argon electrocautery device during a left hepatectomy on a dual chamber pacemaker, implanted for sinus node dysfunction in 87-year-old patient. Argon electrocautery induced inhibition of atrial stimulation and occurrence of irregular ventricular triggered activity. Normal pacemaker function resumed after electrocautery interruption. This case illustrates the need to focus on cardiac rhythm when a new electrical device is used in a pacemaker patient.     

Use of an Ultrasonic Scalpel as an Alternative to Electrocautery in Patients With Pacemakers

We report the safe and effective use of an ultrasonically activated scalpel as an alternative to unipolar electrocautery during surgical procedures in 4 patients with pacemakers. This scalpel provided adequate hemostasis without the adverse consequences of electromagnetic interference. As the scalpel was able to easily cut through the silicone connector sleeve of one generator, it is not recommended for routine generator replacement because it may damage existing pacing leads. However, its use during nonpacemaker operations in patients with pacemakers should be considered.     

Solitary plasmacytoma of L3 vertebral body treated by minimal access surgery: Common problem different solution!

Introduction

Solitary plasmacytoma of bone is a local primary bone tumour consisting of malignant plasma cells without systemic involvement.These tumours are known for large amount of blood loss, and the use of electrocautery is helpful in reducing blood loss and performing surgery in a relatively bloodless field; however, use of unipolar cautery in patients with indwelling cardiac pacemaker is known to cause arrhythmias and cardiac events.Minimally invasive techniques offer potential advantages over open techniques particularly in patients with spinal tumours, where massive amount of blood loss is expected, if open procedure is performed.Here, we present a case of solitary L3 plasmacytoma with progressive neurological deficit with chronic refractory anaemia with indwelling cardiac pacemaker treated by minimally invasive technique.

Materials and methods

A 71-year-old male presented with increasing back pain with Left L3 radiculopathy since 6 months and progressive left lower limb weakness since 5 days.The patient is a known case of chronic renal failure with chronic refractory anaemia. The patient has indwelling cardiac pacemaker for cardiac arrhythmias.Radiology was suggestive of L3 body plasmacytoma. L3 corpectomy and anterior column reconstruction with expandable cage and posterior stabilization by minimally invasive techniques were performed.

Results

Two years of follow-up showed no local recurrence. The patient is ambulatory unaided with no neurological deficit and backache.

Discussion

There is no consensus regarding appropriate surgical approach and perioperative strategies in treatment of solitary plasmacytoma. A solitary plasmacytoma was found in the spine of a patient with cardiac pacemaker where anaesthetic consideration, blood loss and the use of electrocautery were the limiting factors. Minimally invasive approach is a good option.     

Accidental deep hypothermia and circulatory arrest. Treatment with extracorporeal circulation

A 27-year old female was discovered at 4 a.m. lying in a wet field, the ambient temperature being of 4 degrees C. Her rectal temperature had fallen to 19 degrees C. She was comatose and failed to respond to noxious stimuli. Her pupils were dilated and fixed. Her respiratory rate was reduced to three to four breaths per min. Her blood pressure was not measurable and neither femoral or carotid pulse could be detected. The heart was in sinus rhythm with a rate of 40 b X min-1. During her transfer to hospital, she was ventilated with oxygen, a tidal volume of 300 ml and a rate of 10 b X min-1. On arrival in the emergency room, a short period of ventricular fibrillation preceded cardiac arrest. Cardiac massage and sodium bicarbonate infusion were continued during the transfer of the patient to the operating theatre. A femoro-femoral cardiopulmonary bypass was started with a bloodless priming, 3 mg X kg-1 heparin and a flow of 3,000 to 3,500 ml X min-1. Mean arterial pressure was maintained between 65 and 85 mmHg; cardiac massage was discontinued during the bypass. Within 50 min, ventricular fibrillation appeared, rectal temperature had increased to 33 degrees C. Electrical defibrillation (300 J) was successful. Cardiopulmonary bypass was stopped after 63 min. The postoperative course was uneventful, apart from transient pulmonary oedema. At the time of discharge, a week later, no loss of intellect or change in behaviour could be perceived.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hemodynamic effects of dopamine during thoracic epidural analgesia in man

The cardiovascular effects of dopamine were studied before and during thoracic epidural analgesia (TEA) in eight patients prior to abdominal aortic surgery. Dopamine was infused at rates of 2, 4, and 8 micrograms X kg-1 X min-1. Mean plasma dopamine concentration increased proportionally to the infusion rate. Before TEA, dopamine 8 micrograms X kg-1 X min-1 decreased systemic vascular resistance 4 +/- 4 mmHg min X 1-1 (m +/- SD) (P less than 0.05), but increased mean arterial pressure 15 +/- 12 mmHg (P less than 0.01), cardiac output 1.9 +/- 1.0 1 X min-1 (P less than 0.01), heart rate 10 +/- 9 beats X min-1 (P less than 0.05), and plasma norepinephrine concentration 544 +/- 252 pg X ml-1 (P less than 0.01). After the induction of TEA, which extended above the T2 dermatome and below the L2 dermatome, saline and albumin were infused to maintain central venous and pulmonary capillary wedge pressures. TEA reduced mean arterial pressure from 96 +/- 18 to 55 +/- 8 mmHg (P less than 0.01), cardiac output from 4.7 +/- 0.9 to 3.9 +/- 0.9 1 X min-1 (P = 0.05), systemic vascular resistance from 21 +/- 6 to 14 +/- 3 mmHg min X 1-1 (P less than 0.05), and plasma norepinephrine concentration from 394 +/- 141 to 207 +/- 73 pg X ml-1 (P less than 0.01). The plasma epinephrine concentration was reduced 49% after the induction of TEA.(ABSTRACT TRUNCATED AT 250 WORDS)     

Interaction between electrocautery and a pacemaker

Following a new case of inhibition of a sentinel pacemaker by the cutting current of an electrocoagulator during endoscopic urologic surgery, the mechanism of this complication is recalled. The non-selectivity of the pacemaker detector circuit is responsible for interpreting the electrical disturbances due to the electrocoagulator as cardiac activity. The problems seen with other types of stimulators are discussed, especially programmable stimulation where the use of a magnet can lead to variations in the stimulator frequency. The stimulating wire can also be responsible for accidents, such as myocardial burns, and rhythm disturbances. The safety rules for the use of the electrocoagulator in patients with a non programmable sentinel pacemaker.     

Effects of Ephedrine on Haemodynamics and Oxygen Consumption in the Dog During High Epidural Block with Special Reference to the Splanchnic Region

High lumbar epidural block was induced in seven dogs with 0.5% bupivacaine, causing a fall in mean arterial blood pressure (AP) from 19.2 +/- 3.2 to 10.5 +/- 3.2 kPa, owing to equal reductions in cardiac output (QT) and systemic vascular resistance (SVR). After the administration of ephedrine (a single injection of 200-300 micrograms X kg-1 b.w. followed by a continuous infusion of 10-20 micrograms X kg-1 b.w. X min-1) AP, QT and SVR rose to pre-epidural values. Furthermore, the hypokinetic circulation following the epidural block returned to normokinetic levels. Portal venous blood flow was increased from 16.5 +/- 6.2 to 25.5 +/- 4.3 ml X kg-1 b.w. X min-1 by ephedrine, while the hepatic arterial blood flow was unchanged and remained at its pre-epidural level. In spite of a slight rise in hepatic oxygen consumption from 1.2 +/- 0.4 to 1.6 +/- 0.6 ml X kg-1 b.w. X min-1, the percentages of oxygen extracted from the portal vein and the hepatic artery decreased significantly. It is concluded that ephedrine restores central and splanchnic haemodynamics in a desirable manner during high epidural anaesthesia.     

Rebreathing and ventilatory response to different fresh gas flows in the Bain and Lack systems. A clinical study

Thirty-four adults were studied during halothane anaesthesia with spontaneous breathing, while undergoing orthopaedic surgery. They were randomly divided into two groups according to whether the Bain (n = 18) or the Lack (n = 16) system was used. Respiratory flows were recorded and arterial blood gases drawn at different fresh gas flows (VF). The values obtained were compared with those recorded under non-rebreathing conditions (NRC). In the Bain system the proportion of rebreathers was 0.22, 0.25, 0.55 and 0.83 when the VF was 175, 150, 125 and 100 ml X min-1 X kg-1 body weight (b.w.), respectively. In the Lack system these proportions were 0.43, 0.55 and 0.92 at VF of 85, 70 and 55 ml X min-1 kg-1 b.w., respectively. The ventilatory response to rebreathing was an increase in minute ventilation (VE), keeping the partial pressure of arterial carbon dioxide (PACO2) almost unaltered. In the Bain system the VE X kg-1 X b.w. thus increased by 18% and 38% at VF of 125 and 100 ml X min-1 X kg-1 b.w., respectively, when compared to NRC (P less than 0.05). The corresponding increases in the Lack system were 15% and 37% at VF of 70 and 55 ml X min-1 X kg-1 b.w., respectively (P less than 0.01). In the Lack group also the PACO2 increased by 6% when a VF of 55 ml X min-1 X kg-1 b.w. was used compared to the value obtained under NRC (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Association nitroglycérine et remplissage vasculaire dans la chirurgie de l''aorte abdominale

Haemodynamic investigations were performed in nine patients during aortic surgery for Leriche's syndrome. Most of these patients had ischaemic heart disease without cardiac failure. Fluid loading was carried out before and during aortic clamping. It was controlled according to the optimal wedge pulmonary pressure determined the day before surgery. Only six of the nine patients receive nitroglycerin (NTG : 0.2 micrograms X kg-1 X min-1) throughout the operation. Before clamping, cardiac index was improved in patients treated with NTG. During clamping, the patients not treated with NTG showed a drop in cardiac index, an increase in peripheral resistance and in left cardiac work. After declamping, there were no haemodynamic differences between the two groups. Two patients not treated with NTG developed azotaemia postoperatively; one patient developed cardiac failure requiring a dopamine perfusion during surgery. In this series, the association of optimal volume loading with a peroperative perfusion of 0.2 micrograms X kg-1 X min-1 NTG gave a good haemodynamic stability.     

Does electromagnetic interference not occur to a bipolar pacemaker during TUR-P?

It has been reported that a unipolar pacemaker is more sensitive to electromagnetic interference (EMI) than a bipolar pacemaker. However, we experienced cases in which electrosurgery device interfered with a bipolar pacemaker, but not with a unipolar pacemaker during TUR-P. It has been suggested that EMI occurs to a bipolar pacemaker depending on sensitivity and electric resistance of a patient.     

Anesthesia for a patient with alcoholic heart disease and transient complete heart block]

A 70-year-old man who had been drinking a bottle of whisky each day was scheduled for laser resection of a tongue tumor. His electrocardiogram showed sinus bradycardia (heart rate was 35-40 bpm), and transient complete heart block was observed. Echocardiography showed hypertrophic cardiomyopathy. After a temporary transvenous pacemaker had been inserted, anesthesia was induced with thiopental and vecuronium bromide, and maintained with sevoflurane and fentanyl. Heart rate was 45.min-1 before the induction of anesthesia, and after the induction increased to 70-80.min-1. Analysis of heart rate variability suggested that the increase in heart rate was due to augmentation of sympathetic nervous activity after intubation and operation stress. After the operation his bradycardia improved gradually, and after 3 months heart rate settled at about 55.min-1. Cadiomyopathy is known to be one of the complications of alcoholism. It was reported that alcoholic heart disease was improved promptly by abstinence from alcohol. During his long hospitalization, abstinence might have improved his severe bradycardia. Thiopental is useful for induction of anesthesia in a patient with severe bradycardia from alcoholic cadiomyopathy.     

Management of patients with arrhythmias undergoing thoracic surgery

Recentry, surgical candidates have become older and have more surgical risk factors, perioperative patient management become more important than before. In the patients with significant arrhythmia observed in the preoperative period, examination of the baseline heart disease, i.e. myocardial ischemia or congestive heart failure, is mandatory and, if necessary, adequate treatment such as defibrillator, the implantation of a pacemaker, anticoagulation therapy, or other medical therapy should be performed. In the patients with atrial fibrillation, clinical prediction rules such as the congestive heart failure, hypertension, age>75, diabetes, previous stroke or transient ischemic attack (TIA) [CHADS 2] score have been developed to identify those patients at highest risk for thrombo-embolism and can be used when assessing the need for bridging anticoagulation by heparin prior to surgery. The electrical stimulus from electrocautery may inhibit demand pacemakers or may reprogram the pacemaker. An asynchronous or non-sensing pacemaker mode is recommended in patients who are pacemaker dependent and whose underlying rhythm is unreliable. The device has to be checked to ensure appropriate programming and sensing pacing thresholds after surgery. The implantable cardioverter defibrillator should be turned off during surgery and switched on in the recovery phase before discharge to the ward.