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10. Pacing & CIEDs Flashcards

1
Q

temporary cardiac pacing 4

A

transcutaneous
transesophageal
transvenous
epicardial

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2
Q

transcutaneous is preferred when?

A

an emergency

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3
Q

3 disadvantages to transcutaneous pacing

A

painful
least effective capture
ventricular only pacing

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4
Q

transcutaneous pacing CI

A

severe hypothermia

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5
Q

two placement options for transesophageal pacing

A

pill electrode swallowed
flexible catheter

flexible catheter can be inserted

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6
Q

what does transesophageal pacing pace? atria? ventricle?

A

atria

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7
Q

what current does transesophageal pacing require

A

high current
>20 mA

>20mA

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8
Q

advantage to transesophageal

A

no need for xray or cath lab

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9
Q

disadvantage to transesophageal

A

uncomfortable and requires sedation

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10
Q

when is transvenous pacing indicated?

A

stable or transcutaneous isnt working (inability to capture)

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11
Q

why does transvenous pacing take longer?

A

central line must be placed

pacing leads must be inserted through central line guided with balloon

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12
Q

how is transvenous pacing function controlled?

A

external pacemaker box

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13
Q

advantages to transvenous pacing 3

A

can place atrial and ventricular leads
more effective capture
doesnt require as much energy

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14
Q

what is the energy requirement for capture for transvenous pacing

A

1.5-3mA

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15
Q

disadvantages to transvenous pacing 2

A

more time consuming to establish (cant in emergency)
expert placement required

requires expert placement

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16
Q

epicardial pacing

A

common with cardiac surgery
leads are sewn into myocardium
controlled with external box

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17
Q

what do we pace at during cardiac surgery?

A

20mA

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18
Q

CIEDs

A

cardiovascular implantable electronic devices

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19
Q

what is a CIED

A

permanent pacemaker

placed into pocket by surgeon

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20
Q

what does a CIED consist of?

A 
pulse generator (new SA node)
pacing wires that have been inserted through subclavian vein into heart
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21
Q

what does the pulse generator act like

A

SA node

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22
Q

3 types of CIEDs

A

pacemaker
automated implantable cardioverter defibrillators (AICDs or ICDs)
chronic resynchronization therapy (CRT)

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23
Q

biventricular devices are typically

A

ICDs

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24
Q

two reasons for patients to receive a pacemaker

A

pace pts with slow heart rates
improve timing of atrial or ventricular beats in complete heart block

improve timing of atrial and ventricular beats for pts with complete heart block

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25
Q

single chamber

A

pacing lead in either RA or RV

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26
Q

single ventricle lead will pace

A

both ventricles

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27
Q

shocking coils allow

A

defibrillation

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28
Q

dual chamber

A

pacing lead in both RA and RV

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29
Q

what is an ICD?

A

CIED with specialized pacing lead placed in right ventricle that has a built in shocking coil

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30
Q

what can ICDs sense

A

arrythmias
heart contractions

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31
Q

intravascular ICD provide

A

pacing
synchronized cardioversion
antitachycardia pacing
defib

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32
Q

subcutaneous ICDs indication

A

only indicated for defib (cannot pace or sync cardioversion)

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33
Q

biventricular pacemakers or cardiac resynchronization therapy device

A

instead of the ventricles being paced by one lead they are paced by by two leads:
1 in RV
1 in coronary sinus to pace LV

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34
Q

what is the advantage of biventricular pacemakers?

A

2 ventricular leads improves ventricular synchrony in patients with a history of heart failure

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35
Q

5 intravascular CIED placement method

A

1- skin above subclavian is localized
2- a pouch under skin is created
3- pacing wires placed through subclav vein via fluoroscopy
4- pulse generator is programmed by pacemaker rep, then leads are attached
5- device is sewn underneath skin

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36
Q

what do you need to do if the device is an ICD

A

the shock function may need to be tested
when they test the ICD, give a small propofol bolus prior to shock

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37
Q

capture

A

cardiac cells responding to pacemaker stimulation

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38
Q

insert capture ecg

A

capture

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39
Q

pacing threshold

A

minimum current that capture is observed

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40
Q

transvenous/epicardial approach capture current

A

1.5-3mA

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41
Q

transcutaneous approach capture current

A

40-80mA

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42
Q

why do we want to avoid high voltages?

A

cause discomfort
incr risk of myocardial damage

myocardial damage

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43
Q

pacing threshold

A

the current that you found capture

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44
Q

maintenance threshold

A

10% higher than pacing threshold to decrease chance of losing capture

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45
Q

sensitivity threshold

A

how sensitive the pacemaker is to sensing electrical activity in heart

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46
Q

if the sensitivity is too high?

A

not pace as much as it should

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47
Q

if the sensitivity is too low?

A

it may pace when it is not supposed to

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48
Q

intrinsic heart rate

A

HR set by SA node
60-100bpm

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49
Q

paced HR

A

HR that comes from battery operated pacemaker
~60bpm

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50
Q

how can you tell on ecg if the beat is paced?

A

there is a pacer spike prior to a p wave or qrs complex

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51
Q

will pacemaker spikes automatically come up on the ecg?

A

no you must enable the pacemaker setting on the monitor

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52
Q

insert pacer spike ecg

A

pacer spike

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53
Q

two potential sources of heart beat in pt with pacemaker

A

SA node (intrinsic HR)
pacemaker (paced HR)

pacemaker

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54
Q

why is it dangerous to have two potential sources of heart beats?

A

if they both go off it can be mistimed and lead to r-on-t phenonmenon and lead to vfib/vtach

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55
Q

insert R on T phenomenon ecg

A

R on T phenomenon

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56
Q

Insert R on T Vfib

A

R on T leading to Vfib

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57
Q

what is demand mode

A

a pacing mode that makes it so that only one source (SA or pacemaker) is providing current to the heart

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58
Q

demand mode senses

A

the intrinsic heart rate

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59
Q

in demand mode, is the pacer always pacing

A

no
pacer only paces if needed

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60
Q

what prevents mistimed beats and arrhythmias?

A

sensing by the pacemaker in demand mode

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61
Q

when the pacemaker can sense it is

A

in demand mode

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62
Q

in demand mode the pacemaker will

A

stop pacing when they can sense
start pacing when they cannot sense

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63
Q

if the intrinsic rate is faster than the paced rate, the pacemaker will?

A

be suppressed

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64
Q

if the paced rate is faster than the intrinsic rate then the intrinsic rate will

A

be suppressed

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65
Q

effect of cautery on pacemaker

A

pacemakers sense surgical cautery and interpret it as electrical activity of the heart

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66
Q

will pacemakers pace during cautery?

A

nope

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67
Q

pacemaker dependent

A

whenever a patient is reliant on their pacemaker to have a normal cardiac output

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68
Q

asynchronous mode

A

pacemaker cannot sense anything and they start pacing constantly

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69
Q

asynchronous pacers will pace

A

constantly regardless of intrinsic rate

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70
Q

advantage of asynchronous mode

A

pacemaker cannot sense cautery
pacemaker will not stop during cautery

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71
Q

problem with asynchronous mode

A

it is possible for the two sources to be simultaneously pacing
can lead to r-on-t phenomenon and vfib

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72
Q

when is asynchonous mode safe?

A

when the intrinsic rate is slower than the paced rate

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73
Q

pacemakers should only be placed in asynchonous mode if

A

pacing rate is high
the pt’s intrinsic HR is slow

patients intrinsic HR is slow

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74
Q

pacing rate in asynchronous mode

A

programmed for pace rate to increase to 80-100 bpm

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75
Q

before putting in asynchronous mode what should the anesthetist check?

A

confirm intrinsic rate is slower than asynchronous rate

consider beta blocker

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76
Q

when could asynchronous mode be necessary?

A

pacemaker dependent pt is experiencing profound cautery induced bradycardia

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77
Q

how to convert pacemaker to asynchronous mode

A

place magnet over it
or
pacemaker rep can reprogram prior to surgery

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78
Q

why is rate modulation programed into pacemaker?

A

the pacemaker can sense incr movement or minute ventilation and incr the rate to provide higher CO during exercise

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79
Q

antitachycardia pacing (ATP)

A

senses tachycardia and paces faster than intrinsic rate to suppress it

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80
Q

what rhythms can ATP be effective for

A

afib
aflutter
svt
monomorphic vtach

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81
Q

if several attempts at ATP prove ineffective what will the pacemaker do?

A

shock the heart

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82
Q

indications for pacemaker 5

A 
sinus brady
sick sinus syndrome (malfunctioning SA node)
3rd degree av block
mobitz type II heart block
afib with slow ventricular response
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83
Q

what pacemaker should be used for chronic sinus brady or SSS

A

atrial pacing

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84
Q

what type of pacemaker should be used for afib with slow ventricular response?

A

ventricular because atrial wouldnt work because it has constant electrical activity

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85
Q

pacing spike before QRS is what type of pacing

A

ventricular pacing

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86
Q

where is the ventricular lead placed

A

close to septum and causes left and right ventricles to contract

87
Q

Leadless right ventricular pacemaker location

A

RV via femoral access

88
Q

Leadless pacemaker advantages

A

decr risk of:
- lead infection
- vascular thrombosis
- lead dislodgement
- lead fracture

89
Q

leadless pacemaker disadvantages

A

no defib
does not respond to magnets

90
Q

what type of pacemaker should be used for 3rd degree av block?

A

dual chamber

atrial lead senses when there is activity and signals for ventricular pace

91
Q

how does dual chamber pacemaker fix complete heart block 2

A

atrial lead senses when atria contract
ventricular leads programmed to pace

ventricular lead pace 120-200 msec after atria contracts

92
Q

when dos the ventricular lead pace in dual chamber for heart block?

A

120-200 msec after every atrial contraction

93
Q

newer pacemaker for complete heart block

A

single chamber pacemaker where it has sensing portion in RA and the pacing portion in the RV

94
Q

insert DC pacemaker w/DC pacing

A

DC pacemaker w/DC pacing

95
Q

DC pacemaker w/both atrial and ventricular pacing spikes

A

patient has both:
SA node dysfunction
slow AV conduction

96
Q

DC pacemaker w/atrial pacing

A

DC pacemaker w/atrial pacing

97
Q

DC pacemaker w/atrial pacing

A

SA node is slow
AV node is normal

98
Q

DC pacemaker w/ventricular pacing

A

DC pacemaker w/ventricular pacing

99
Q

DC pacemaker w/ventricular pacing

A

SA node is normal
AV conduction is slow

100
Q

ventricular only pacing w/o P waves

A

underlying afib

101
Q

ventricular only pacing w/p waves

A

underlying complete heart block

102
Q

DC pacemaker w/normal ECG

A

SA node is normal
AV node conduction is normal

103
Q

will you see a atrial pacing spike with the single chamber pacemaker for complete heart block?

104
Q

biventricular pacemakers are AKA

A

cardiac resynchronization therapy (CRT)

105
Q

what do biventricular pacemakers have in addition to a normal RV lead

A

LV lead inserted via coronary sinus

106
Q

advantage of having a lead in both ventricles in biventricular pacemakers

A

improves timing of ventricular beats
incr SV/CO
decr myocardial O2 demand

107
Q

what does an ICD have?

A

specialized ventricular pacing lead that has a built in shocking coil that senses and shocks tachyarrhythmias

108
Q

who are ICDs usually placed in?

A

CHF pts bc they are more prone to tachyarrhythmias

109
Q

what are ICDs capable of?

A

pacing and defibrillating

110
Q

traditional ICD

A

RV lead capable of pacing and shocking

111
Q

S-ICD

A

CANNOT pace
only indicated for defib

only defibtrillate

112
Q

advantage to S-ICD

A

no need to replace fibrosed leads

just as effective as transvenous

113
Q

disadvantages to S-ICD

A

not indicated in pts who require antibrady pacing, CRT, or antitachycardia pacing
higher energy requirements
not for ventricular arrhythmias at rates lower than 170bpm

114
Q

why are ICDs dangerous

A

can be inappropriately triggererd to shock whenever cautery is used

115
Q

an ICD thinks cautery is

A

vfib
it will defibrillate

116
Q

what are ICDs programmed energy to shock

117
Q

two ways to prevent accidental shock from an ICD during surgery

A

1 disable the shock function of the ICD (programmer or magnet over the ICD)
2 keep electrical current away from the ICD

118
Q

how many cm should the grounding pad be placed away from ICD

119
Q

what are alternatives to unipolar cautery

A

bipolar or harmonic scalpel

120
Q

harmonic scalpel

A

cuts via vibration and seals tissue with protein denaturation

121
Q

advantages to harmonic scalpel

A

cuts thicker tissue than bovie
less smoke
less thermal damage

122
Q

disadvantages to harmonic scalpel

A

takes longer to cut and coagulate tissue
can only coagulate as it cuts

can only coagulate as it cuts

123
Q

magnet on ICD does what

A

diable the shock function only

124
Q

does the magnet on ICD convert the pacing to asynchronous mode?

125
Q

can cautery induced bradycardia occur with magnet on ICD?

126
Q

how to prevent cautery induced bradycardia during surgery for pacemaker dependent pts with ICD?

A

ask pacemaker rep to reprogram ICD before surgery to allow it to become asynchronous with magnet placement

127
Q

when should the shock function of an ICD be disabled?

A

if surgeon plans on using cautyer
if surgical site is above the umbilicus

128
Q

pacemaker dependent patient has a magnet placed over their ICD what will happen during cautery

A

no shock, possible brady or asystole

129
Q

pacemaker interrogation

A

15min procedure that checks the function and battery life of pacemaker
waves wand and connects to computer

130
Q

pacemaker checks are

A

scheduled at regular intervals over the pts life

recommended by doctor prior to elective procedure

131
Q

how often should pacemaker be checked

A

every year

132
Q

how often should ICDs be checked?

133
Q

preop management of CIED

A

obtain/document results of last pacemaker interrogation and intraoperative recommendations by calling number on card in wallet or bracelet

134
Q

9 things for anesthesia to know in preop CIED pts

A 
1 type of device (pacemaker vs ICD)
2 programmability of device
3 underlying rhythm
4 pacemaker dependent?
5 does it have rate modulation
6 pacemaker capture effectively
7 what is magnet response?
8 adequate battery life
9 manufacturers perioperative recommendations?
135
Q

normal battery life

A

7-10 years

136
Q

adequate battery life for surgery

137
Q

intraoperative management supplies and drugs CEID

A

external pacemaker
magnet

atropine
epi

138
Q

postop management CEID

A

all devices should be interrogated or reprogrammed to original function after surgery
not discharged until interrogated

139
Q

study;s have shown that magnet application over ICD have not always:

A

suspended antitachyarrythmic function
produce asynch pacing for demand pacemaker
produce safe asynch pacing

140
Q

a male pt has a regular demand pacemaker w/the following ECG

is he pacemaker dependent?

141
Q

a male pt has a regular demand pacemaker w/the following ECG

what is the effect of cautery on HR?

142
Q

a male pt has a regular demand pacemaker w/the following ECG

what will magnet placement do?

A

change to asynchronous mode
incr pacing to 80-100 bpm

143
Q

a male pt has a regular demand pacemaker w/the following ECG

should we place a magnet?

144
Q

this pt has an intravascular ICD with the following ECG. Cautery is planned.

What is magnet placement most likely to do?

A

disable shock

145
Q

this pt has an intravascular ICD with the following ECG. Cautery is planned.

should a magnet be placed on this patient?

146
Q

a male pt has a regular demand pacemaker and he goes asystolic when cautery is used. How should he be managed during surgery?

A

place a magnet

147
Q

a female pt w/intravascular ICD is pacemaker depended. Shock function was disabled by pacer rep prior to surgery. During surgery she becomes asystolic when cautery is used. How should she be managed?

A

switch to bipolar cautyer
or
reprogram ICD

148
Q

a male pt has a regular demand pacemaker and his ECG is showing all P waves are preceded by pacing spikes. If cautery is not being used, how do you explain the ECG?

A

perhaps the rate modulation was not disabled?

we expect constant HR

149
Q

first letter chamber classification

A

what chambers have pacing leads

150
Q

second letter chamber classification

A

what chambers can sense electrical activity

151
Q

third letter chamber classification

A

how pacemaker responds after it senses electrical activity

152
Q

fourth letter chamber classification

A

programmability

153
Q

fifth letter chamber classification

A

antitachyarrhythmia function

154
Q

options for first letter

A 
a= atria
v= ventricle
d= dual
155
Q

options for second letter

A 
a= atria
v= ventricle
d= dual
o= none
156
Q

what does it mean when the second pacemaker letter is O?

A

it is in asynchronous mode

157
Q

options for third letter

A 
I= inhibits
T= triggered
D= Dual (t+i)
O= none
158
Q

third letter I

A

inhibit itseld from pacing
(demand mode)

159
Q

third letter T

A

triggered to pace

160
Q

third letter D

A

dual = pacemaker is triggered and inhibited

161
Q

when can the pacemaker be triggered and inhibited

A

complete heart block
- atrial lead inhibits iself from pacing
- atrial lead triggers ventricular to pace

162
Q

third letter O

A

if the 2nd letter is O the 3rd letter will also be O

indicates asynchronous mode

163
Q

pacemaker code for pt with sinus brady

164
Q

pacemaker code for pt with slow afib/aflutter

165
Q

pacemaker code for pt with complete heart block

166
Q

right ventricular pacemaker code for pt with complete heart block

167
Q

pacemaker code for pt with sinus brady and magnet on pacemaker

168
Q

AAI

A

single lead in RA for pts
demand pacing

169
Q

AAI indications

A

sinus brady
SSS

170
Q

AOO

A

asynchronous pacing from RA activated by magnet

171
Q

VVI

A

single lead in RV
demand pacing

172
Q

VVI indication

173
Q

VOO

A

asynchronous pacing with the lead in the RV activated by magnet

174
Q

DDD

A

leads in RA and RV for pts with complete heart block

175
Q

DOO

A

asynchonous pacing with leads in RA and RV activated by magnet

176
Q

DOO RV is programmed to pace when

A

120-200 msec after each atrial beat

177
Q

VDD

A

specialized lead in RV that has a sensing portion in the RA

178
Q

VDD indication

A

complete heart block with normal functioning SA node

179
Q

can pt with pacemaker have MRI

180
Q

CT scan and pacemaker

A

some ICDs receive interference

181
Q

are ICDs or pacemakers more sensitive to radiation therapy?

182
Q

what to do if pt with ICD and radiation therapy

A

shielded as much as possible and moved if it lies directly in radiation field

183
Q

radiofrequency ablation

A

waves to ablate areas of the heart/terminate arrhythmias

acceptable with certain precautions

184
Q

emergency defibrillation for pt with pacemaker

A

place the defib pads away from pacemaker

185
Q

TENS

A

transcutaneous electrical nerve stimulation

used to relieve acute or chronic pain

186
Q

TENS and CIEDs

A

reported to interfere with ICDs to cause inappropriate shock

cautioned about use

187
Q

ECT

A

electroconculsive therapy
transcutaneous electrodes placed on head to induce a tonic clonic seizure
treat depressio

188
Q

how often is ECT performed

A

twice weekly for usually 3-4 weeks

189
Q

what is too short or too long of seizure?

A

too short: < 10s
too long: > 120s

>120 sec

190
Q

which is more important the length or seizure or current delivered?

A

current delivered

191
Q

cardiovascular effects of ECT

A

initial parasympathetic discharge (brady and hypotension) then sympathetic response

192
Q

how long does initial parasympathetic discharge last in ECT?

193
Q

when does secondary sympathetic response peak in ECT?

194
Q

cerebral effects of ECT

A

incr cerebral oxygen consumption
incr blood flow
incr ICP

195
Q

what are the more popular induction agents for ECT

A

brevital or etomidate

196
Q

methohexital

A

pro convulsant
does not change duration
blunt sympathetic response

197
Q

etomidate

A

longest seizure duration
does not blunt the sympathetic response

198
Q

propofol

A

decreases seizure duration
does blunt the sympathetic response

199
Q

ketamine

A

longer seizure duration
incr ICP

ICP elevates

200
Q

airway management for ECT

A

usually not ETT unless indicated
mask ventilation

hyperventilate to lower the threshold for seizure and prolong the duration

201
Q

neuromuscular blocking agents and ECT

A

reduce muscular convulsions and decrease risk of serious injury (sux most common)

202
Q

CIED implications for ECT 4

A

1 skeletal muscle potentials during seizure may trigger pacemaker
2 regular demand should be asynchronous
3 shock function of ICD deactivated
4 risks are low bc small amounts of electricity reach device

203
Q

ESWL

A

extracorporeal wave lithotripsy

transcutaneous ultrasonic shock waves breaks up kidney or ureteric stones

204
Q

synchronized litho shocks

A

triggered by the R wave
delivered in refractory period

205
Q

advantage to synchronized shock

A

carries lower risk of PVCs and arrhythmias

206
Q

disadvantage to synchronized shock

A

procedure is slower

207
Q

non synchronized litho shocks

A

shocks delivered at specific rate

208
Q

advantage of non synchronized litho shock

A

procedure is faster

209
Q

disadvantage to non synchronized litho shock

A

more likely to cause PVCs or arrhythmias

210
Q

ESWL and CIEDs

A

may interpret shocks same as cautery

magnets should be placed on ICD pt or pacemaker dependent pt

211
Q

what can happen in atrially paced pts with ESWL?

A

the synchronized shock can read the atrial pace as the R wave and deliver a shock prior to the R wave causing arrhythmia

212
Q

atrially paced CIEDs during ESWL

A

avoid synchronized shocks

213
Q

regular demand pacemakers during ESWL

A

place in asynchronous mode if pt is pacemaker dependent

214
Q

ICD during ESWL

A

disable shock function

Fa: Methods 2 (16 decks)

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