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Methods of Anesthesia II > Pacing & CIEDs > Flashcards

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

two placement options for transesophageal pacing

A

pill electrode swallowed

flexible catheter can be inserted

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5
Q

what does transesophageal pacing pace? atria? ventricle?

A

atria

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6
Q

what current does transesophageal pacing require

A

high current

>20mA

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7
Q

advantage to transesophageal

A

no need for xray or cath lab

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8
Q

disadvantage to transesophageal

A

uncomfortable and requires sedation

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9
Q

when is transvenous pacing indicated?

A

stable or transcutaneous isnt working (inability to capture)

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10
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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11
Q

how is transvenous pacing function controlled?

A

external pacemaker box

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12
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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13
Q

what is the energy requirement for capture for transvenous pacing

A

1.5-3mA

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14
Q

disadvantages to transvenous pacing 2

A

more time consuming to establish (cant in emergency)

requires expert placement

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15
Q

epicardial pacing

A

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

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16
Q

CIEDs

A

cardiovascular implantable electronic devices

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17
Q

what is a CIED

A

permanent pacemaker

placed into pocket by surgeon

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18
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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19
Q

3 types of CIEDs

A

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

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20
Q

two reasons for patients to receive a pacemaker

A

pace pts with slow heart rates

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

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21
Q

what is an ICD?

A

CIED with specialized pacing lead placed in right ventricle that has a built in shocking coil
shock and sense tachyarrhythmias

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22
Q

intravascular ICD

A

provide pacing, synchronized cardioversion and antitachycardia pacing (in addition to defib)

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23
Q

subcutaneous ICDs

A

only indicated for defib (cannot pace or sync cardioversion)

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24
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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25
Q

5 intravascular CIED placement method

A

1- skin 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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26
Q

capture

A

cardiac cells responding to pacemaker stimulation

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27
Q

pacing threshold

A

minimum current that capture is observed

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28
Q

transvenous/epicardial approach capture current

A

1.5-3mA

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29
Q

transcutaneous approach capture current

A

40-80mA

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30
Q

why do we want to avoid high voltages?

A

cause discomfort

myocardial damage

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31
Q

maintenance threshold

A

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

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32
Q

sensitivity threshold

A

how sensitive the pacemaker is to sensing electrical activity in heart

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33
Q

if the sensitivity is too high?

A

not pace as much as it should

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34
Q

intrinsic heart rate

A

HR set by SA node 60-100bpm

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35
Q

paced HR

A

HR that comes from battery operated pacemaker ~60bpm

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36
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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37
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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38
Q

two potential sources of heart beat in pt with pacemaker

A

SA node

pacemaker

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39
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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40
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
senses when intrinsic rate falls below a certain rate

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41
Q

what prevents mistimed beats and arrhythmias?

A

sensing by the pacemaker

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42
Q

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

A

be suppressed

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43
Q

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

A

be suppressed

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44
Q

effect of cautery on pacemaker

A

pacemakers sense surgical cautery and interpret it as electrical activity of the heart
(wont pace during cautery)

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45
Q

pacemaker dependent

A

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

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46
Q

asynchronous mode

A

pacemaker cannot sense anything and they start pacing constantly

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47
Q

advantage of asynchronous mode

A

pacemaker will not stop during cautery

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48
Q

problem with asynchronous mode

A

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

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49
Q

when is asynchonous mode safe?

A

when the intrinsic rate is slower than the paced rate

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50
Q

pacemakers should only be placed in asynchonous mode if

A

pacing rate is high

patients intrinsic HR is slow

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51
Q

pacing rate in asynchronous mode

A

programmed for pace rate to increase to 80-100 bpm

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52
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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53
Q

when should asynchronous mode be necessary?

A

pacemaker dependent pt is experiencing profound cautery induced bradycardia

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54
Q

how to convert pacemaker to asynchronous mode

A

place magnet over it

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55
Q

rate modulation

A

during exercise the pt moves and breaths more and it senses this and can increase the paced HR

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56
Q

antitachycardia pacing (ATP)

A

senses tachycardia and paces faster than intrinsic rate to suppress it

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57
Q

what rhythms can ATP be effective for

A

afib
aflutter
svt
monomorphic vtach

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58
Q

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

A

shock the heart

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59
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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60
Q

what pacemaker should be used for chronic sinus brady or SSS

A

atrial pacing

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61
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

62
Q

where is the ventricular lead placed

A

close to septum and causes left and right ventricles to contract

63
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

64
Q

how does dual chamber pacemaker fix complete heart block 2

A

atrial lead senses when atria contract

ventricular lead pace 120-200 msec after atria contracts

65
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

66
Q

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

A

no

67
Q

what are the 4 ecg that a dual chamber can have?

A

no pacing spikes (SAN is fast and AVN working)
atrial only pacing (SAN too slow and AVN working)
ventricle only pacing (SAN fast and complete heart block)
dual chamber pacing (SAN slow and complete heart block)

68
Q

in biventricular pacing what does having a lead in both ventricles improve?

A

in HF the R and L ventricles may be out of sync lowering CO

it improved the timing of ventricular beats

69
Q

what does improved timing of ventricular beats do?

A

increases SV and CO

decreases myocardial oxygen demand

70
Q

what does an ICD have?

A

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

71
Q

who are ICDs usually placed in?

A

CHF pts bc they are more prone to tachyarrhythmias

72
Q

what are ICDs capable of?

A

pacing and defibrillating

73
Q

S-ICD

A

CANNOT pace

only defibtrillate

74
Q

advantage to S-ICD

A

no need to replace fibrosed leads

just as effective as transvenous

75
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

76
Q

why are ICDs dangerous

A

can be inappropriately triggererd to shock whenever cautery is used

77
Q

what are ICDs programmed energy to shock

A

15-35 J

78
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

79
Q

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

A

15cm

80
Q

what are alternatives to unipolar cautery

A

bipolar or harmonic scalpel

81
Q

harmonic scalpel

A

cuts via vibration and seals tissue with protein denaturation

82
Q

advantages to harmonic scalpel

A

cuts thicker tissue than bovie
less smoke
less thermal damage

83
Q

disadvantages to harmonic scalpel

A

takes longer to cut and coagulate tissue

can only coagulate as it cuts

84
Q

magnet on ICD does what

A

diable the shock function only

85
Q

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

A

no

86
Q

can cautery induced bradycardia occur with magnet on ICD?

A

yes

87
Q

are magnets over a CIED predictable?

A

no some reports showed it didnt always work as it should

88
Q

at a surgical site below _____ the shock function of a CIED doesnt have to be disabled

A

umbilius

89
Q

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

A

no shock, possible brady or asystole

90
Q

pacemaker interrogation

A

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

91
Q

pacemaker checks are

A

scheduled at regular intervals over the pts life

recommended by doctor prior to elective procedure

92
Q

how often should pacemaker be checked

A

every year

93
Q

how often should ICDs be checked?

A

every 6mo

94
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

95
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?
96
Q

normal battery life

A

7-10 years

97
Q

adequate battery life for surgery

A

> 3-6mo

98
Q

intraoperative management supplies and drugs CEID

A

external pacemaker
magnet

atropine
epi

99
Q

postop management CEID

A

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

100
Q

first letter chamber classification

A

what chambers have pacing leads

101
Q

second letter chamber classification

A

what chambers can sense electrical activity

102
Q

third letter chamber classification

A

how pacemaker responds after it senses electrical activity

103
Q

fourth letter chamber classification

A

programmability

104
Q

fifth letter chamber classification

A

antitachyarrhythmia function

105
Q

options for first letter

A 
a= atria
v= ventricle
d= dual
106
Q

options for second letter

A 
a= atria
v= ventricle
d= dual
o= none
107
Q

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

A

it is in asynchronous mode

108
Q

options for third letter

A 
I= inhibits
T= triggered
D= Dual (t+i)
O= none
109
Q

pacemaker code for pt with sinus brady

A

AAI

110
Q

pacemaker code for pt with slow afib/aflutter

A

VVI

111
Q

pacemaker code for pt with av block, normal sinus node

A

DDD

112
Q

pacemaker code for pt with av block and sinus brady

A

DDD

113
Q

pacemaker code for pt with sinus brady and magnet on pacemaker

A

AOO

114
Q

AAI

A

single lead in RA for pts with sinus brady or SSS

115
Q

AOO

A

asynchronous pacing from RA activated by magnet

116
Q

VVI

A

single lead in RV for pts with afib

117
Q

VOO

A

asynchronous pacing with the lead in the RV activated by magnet

118
Q

DDD

A

leads in RA and RV for pts with complete heart block

119
Q

DOO

A

asynchonous pacing with leads in RA and RV activated by magnet

120
Q

VDD

A

specialized lead in RV that has a sensing portion in the RA indicated for pts with complete heart block and normal sinus node function

121
Q

can pt with pacemaker have MRI

A

NO

122
Q

CT scan and pacemaker

A

some ICDs receive interference

123
Q

are ICDs or pacemakers more sensitive to radiation therapy?

A

ICDs

124
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

125
Q

radiofrequency ablation

A

waves to ablate areas of the heart/terminate arrhythmias

acceptable with certain precautions

126
Q

emergency defibrillation for pt with pacemaker

A

place the defib pads away from pacemaker

127
Q

TENS

A

transcutaneous electrical nerve stimulation

used to relieve acute or chronic pain

128
Q

TENS and CIEDs

A

reported to interfere with ICDs to cause inappropriate shock

cautioned about use

129
Q

ECT

A

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

130
Q

how often is ECT performed

A

twice weekly for usually 3-4 weeks

131
Q

what is too short or too long of seizure?

A

<10 sec

>120 sec

132
Q

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

A

current delivered

133
Q

cardiovascular effects of ECT

A

initial parasympathetic discharge (brady and hypotension) then sympathetic response

134
Q

cerebral effects of ECT

A

cerebral oxygen consumption, blood flow, and iCP all increase

135
Q

what are the more popular induction agents for ECT

A

brevital or etomidate

136
Q

methohexital

A

pro convulsant
does not change duration
blunt sympathetic response

137
Q

etomidate

A

longest seizure duration but does not blunt the sympathetic response

138
Q

propofol

A

decreases seizure duration but does blunt the sympathetic response

139
Q

ketamine

A

longer seizure duration

ICP elevates

140
Q

airway management for ECT

A

usually not ETT unless indicated

hyperventilate to lower the threshold for seizure and prolong the duration

141
Q

neuromuscular blocking agents and ECT

A

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

142
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 deactivated
4 risks are low bc small amounts of electricity reach device

143
Q

ESWL

A

extracorporeal wave lithotripsy

transcutaneous ultrasonic shock waves breaks up kidney or ureteric stones

144
Q

synchronized litho shocks

A

triggered by the R wave and delivered in refractory period

145
Q

advantage to synchronized shock

A

carries lower risk of PVCs and arrhythmias

146
Q

disadvantage to synchronized shock

A

procedure is slower

147
Q

non synchronized litho shocks

A

shocks delivered at specific rate

148
Q

advantage of non synchronized litho shock

A

procedure is faster

149
Q

disadvantage to non synchronized litho shock

A

more likely to cause PVCs or arrhythmias

150
Q

ESWL and CIEDs

A

may interpret shocks same as cautery

magnets should be placed on ICD pt or pacemaker dependent pt

151
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

Methods of Anesthesia II (13 decks)

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