Anaesthesia for the patient with pacemaker

1. Anaesthesia for the patient with pacemaker Case presentation B Albinska

2. PATIENT MEDICAL HISTORY • 74 y old lady • IHD, MI – 2001, • Angina on exertion • Good tolerance of walking on the ground level • Recurrent AF • Dual chamber pacemaker • Hypothyroidism • 1988 – GA followed by fast AF

3. Medication • Warfarin • Amiodaron • Ramipril • Simvastatin • Thyroxine • Diazepam • GTN – last use 6/12 ago • Previously on B-blockers and Ca channel blockers

4. Investigations • Angiogram - normal coronary artheries • Echo – EF 50-60%, septal & apex dyskinesis, mild regurgitation of aortic & mitral valves, no enlargement of any chamber • ECG – widened QRS complexes with occasional pacing • Pacemaker – checked 6 month ago

5. Blood tests • HB – 13.5 • WCC – 7 • Platelets – 304 • Na – 138 • K – 4.2 • U – 6.7 • Crea – 146 • INR – 2.6

6. Present Medical History • Left eye tumour for urgent biopsy

7. Action plan • Patient was assessed before operation • Warfarin stopped for 3 days • Admission the day before operation • LMWH started on admission • If cautery during operation – only bipolar • Check pacemaker before discharge

8. Pre-op assessment on the day of operation • Patient in optimal condition • ECG – no differences comparing to the previous • INR 2.1 • Anxiety

9. Anaesthesia • Patient arrived to theatre • ECG – tachycardia 130/ min • Induction –Fentanyl, Propofol, antyemetic GA/LMA • Rhythm slowed down, pacemaker started pacing • Spontaneous ventilation • Stable during operation • Cautery – not used • Fully awake in recovery room

10. Post – op • Patient discharged in the evening • Pacemaker not checked because of unavailability of technician on Friday evening