Cardioverter Defibrillator

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Annals of Cardiac Anaesthesia 2005; 8: 6163 Bukhari et al. Anaesthetic Management of Patients w ith AICD 61

Anaesthetic Management of Patients with Implantable

Cardioverter Defibrillator

Alta f Bukha ri, MD, Sheeta l Ga rg, MD, Yatin Mehta , MD, DNB, FRCA, FAMSDepartment of Anaesthesiology and Critical Care, Escorts Heart Institute and Research Centre,

Okhla Road, New Delhi

Address for Correspondence: Dr. Altaf Bukhari, Fellow in Cardiac

Anaesthesia, Dept. of An aesthesia, Escorts Heart Inst itu te and Research

Centre, Okhla Road, New Delhi -110025

Phone: 26825000, 26825001 Extn 4125, Tele-Fax: 51628442

Annals of Cardiac Anaesthesia 2005; 8: 6163

Key words:- Implantable cardioverter defibrillator, Peripheral vascular

surgery, Hernioplasty, Epidural anaesthesia

Case Report

The use of implan table cardioverter defibrillators(ICD) has significantly increased the lifeexpectancy of the patients with life threatening

arrhyth mias. Such p atients are being increasingly

subjected to noncardiac surgery. We describe the

anaesthetic management for popliteal to anteriortibial artery bypass grafting and hernioplasty in

two patients with ICD.

Case: 1

A 54-year-old diabetic male patient underwent

coronary artery bypass graft (CABG) surgery. Two

months later, he was admitted with severe pain in the

right leg and around the heel of the same side, which

was d iagnosed as diabetic foot. ICD was implanted two

weeks after the CABG because of recurrent episodes of

ventricular tachycardia (VT) poorly responsive to

amiodarone.

Echocardiography revealed left ventricular ejection

fraction (LVEF) of 45% with hypokinesia of

interventricular septum and apex. Peripheral angiogram

showed 100% occlusion of p opliteal artery and anterior

tibial artery was getting filled from the collaterals.

Patient had d eveloped fever and raised w hite cell counts

which was managed with appropriate antibiotics. The

patient was scheduled to undergo popliteal to anterior

tibial artery bypass graft. He was premedicated with

lorazepam 2 mg and ranitidine 150 mg at night and on

the morning of surgery, morphine sulphate 5 mg

intramu scularly (IM) and lorazepam 2 mg per oral were

administered 90 minutes before surgery. Monitoring

dur ing surgery inc luded con t inuous two l ead

electrocardiogram (lead II and V5), oxygen satu ration,

direct arterial pressure, arterial blood gas analysis,

central venous pressure through left external jugular

vein, and urine output. All monitoring lines were

inserted under local anaesthesia. An external pulse

generator and external pacing were kept ready in the

operating room (OR). External counter shock paddles

were checked and kept read y in the OR. A 16G epidu ralcatheter (Portex, Kent, UK) was inserted in the 3rd lumbar

interspace with the p atient in left lateral position. After

a 3 ml test dose of 2% lidocaine hy drochloride, 12 ml of

0.5% bup ivacaine hyd rochloride w as injected a nd a T10

sensory block w as obtained. Oxygen was given via n asal

prongs at 4 L/ min. The patient did not need any sedation

or anxiolysis as he continued to sleep following comp lete

pain relief.

An electrocautery ground ing pad was p laced beneath

the right bu ttock. The ICD was d isabled before the start

of surgery using a noninvasive programming device

(Medtronic Inc, Minneap olis, USA). Popliteal to anterior

tibial artery bypass grafting was performed and there was

no adverse event during the procedure. A range of

antiarrhythmic drugs and external pacing were kept

standby to treat any life threatening arrhythmia. After

completion of the procedure which lasted for about five

hours during which one top up dose of bupivacaine

(0.5%) was given, the ICD was enabled and the patient

was transferred to the intensive care unit (ICU) for

observation. The intraoperative period remained

uneventful and no arrhythm ias were noted. The patient

did not have any significant haemodynamic changes

during the procedure except that the systemic arterial

pressure stabilised to 120/ 70 to 140/ 90 mm Hg from 190/

100 mm Hg, after epidural administration of local

anaesthetic. Two units of blood were tranfused during

the procedure to optimise haemtocrit to 30%. Acid base

balance was checked after 15 min of release of vascular

clamps, which was within normal limits. Monitoring in

the ICU included continuous ECG, arterial pressure and

pu lse oximetry. An infusion of 0.125% bupivacaine w ith

50 g of fentanyl d iluted in 50 ml of 0.9% saline at 5 m l/

hour was continued via the epidural catheter, for the next

36 hours after ensuring that the patient could move his

lower limbs. Intraoperatively blood sugar levels

were measured thrice and were found to be less than 200

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62 Bukhari et al. Anaesthetic Management of Patients w ith AICD Annals of Cardiac Anaesthesia 2005; 8: 6163

mg/ dl each time. Preoperatively patient w as receiving a

total of 30 units of regular insulin per day. After 36 hours,150 g buprenorphine diluted in 10 ml norm al saline was

injected via the epidural catheter and the catheter was

removed. The patient had an uneventful recovery and

the management of diabetic foot was continued.

Case: 2

A 59-year-old male p atient with left ind irect ingu inal

hernia was admitted for left sided hernioplasty. The

patient had undergone CABG six months back and an

ICD was implanted 4 mon ths back because of recurrent

episodes of VT nonresponsive to amiod arone.

Echocardiograp hy r evealed , LVEF of 25% with trivialmitral regur gitation. The chest X-ray showed an ICD in

situ and enlarged cardiac size. The h aematological, liver

and kidney function tests were normal.

Patient was p remedicated with d iazepam 5 mg and

ranitidine 150 mg at night before surgery and on the

morning of surgery, morphine sulphate 5 mg IM with

lorazepam 2 mg per oral were administered 90 min

before surgery. The intraoperative monitoring and

management of ICD was similar to that in the first

patien t. An 18G epid ura l catheter (Portex, Kent, UK) was

introduced into the 4th lumbar interspace with the p atient

in left lateral position. After a 3 ml test dose of 2%

lidocaine hyd orchloride, 15 ml of 0.5% bupivacaine w asinjected and a T

10sensory block w as obtained. Oxygen

was adm inistered via nasal prongs at 4 L/ min and

midaz olam 2 mg was given intravenou sly for sedation.

Left inguinal herniorrhaphy was performed and there

was no adverse event during the procedure. Five

hundred ml of ringers solution was administered

intravenously and patient remained haemodyn amically

stable. After comp letion of the procedu re, which lasted

for 1 hour 15 min, the ICD was enabled an d th e patient

was transferred to the ICU. Monitoring in the ICU

included continuous ECG, arterial pressure and pulse

oximetry. An infusion of 0.125% bupivacaine with 50

g of fentanyl diluted in 50 ml 0.9% saline at 6 ml/ hou r

was continued via the epidu ral catheter for the next 24hour s. After 24 hours, 150 g bup renorph ine diluted in

10 ml normal saline was injected via the epidural

catheter and the epidural catheter was removed. The

recovery of the patient was uneventful and he was

discharged from the h ospital on the following day .

Discussion

The first ICD was im planted in India at Escorts

Heart Institute and Research Centre in 1996, in a

patient who suffered recurrent cardiac arrests

despite a trial of multiple antiarrhythmic drugs.1

ICD has significantly reduced the risk of sudden

card iac death in pat ien ts wi th known l i fe

threatening ventricular arrhythmias.2,3 The ability

of an ICD to provide therapy within 5 to 15 sec of

arrhyth mia detection allows d efibrillation su ccess

rate approaching 100%.4

An ICD system consists of a pulse generator

and leads fo r detect ion and therapy of

tachyarrhythm ias. It may provide antitachycardia,

antibradycardia pacing, synchronized or n on-

synchronized shocks, telemetry and diagnostic

storage. Many devices use adaptive rate pacing to

modify the pacing rate for changing metabolic

needs. The ICD batteries contain up to 20,000 J of

energy. Most ICD designs use two capacitors in

series to achieve maximum voltage for

defibri l lat ion.5 Card iovers ion wi th energy

exceeding 2 J results in skeletal and d iaphragm atic

mu scle depolar izat ion and i s painfu l to the

conscious patient. High energy discharges of 10-

40 J, delivered asynchronously are used to treat

ventr icular fibrillation (VF).5 ICDs terminate VF

successfully in 98% of cases.6 Supraventricular

tachycardia (SVT) remains the most commonaetiology of inappropriate shock therapy.7

According to one report, antitachycardia pacing

successfully term inated sp ontaneous VT in greater

than 90% of cases.8 Approximately 20% of ICD

patients require pacing for bradycardia and 80%

of these benefit from dual chamber pacing.9 A

neuraxial block in the form of epidural analgesia

can lead to sympathetic block, causing brad ycardia.

In pat ien ts , undergo ing vascu lar surgery ,

heparinisation also poses a risk of an epidural

haematoma.

Most patients with ICD have poor LVEF with

coexisting systemic disease. Primary m anagement

of the patient includ es evaluation and optimization

of coexisting disease.

For a pacemaker dependent patient the device

should be reprogrammed to an asynchronous

mode, i f electrocautery is to be used and

tachycardia sensing and adaptive rate pacing

should be programmed off. Alternative facilities



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Annals of Cardiac Anaesthesia 2005; 8: 6163 Bukhari et al. Anaesthetic Management of Patients w ith AICD 63

for pacing like transvenous or external pacing

should be available. The cautery grounding toolshould be placed as far as p ossible (at least 15 cm)

in such a way that the pu lse generator and th e leads

are not in the current pathw ay between it and the

electrocautery. Only the lowest p ossible energies

and short bursts of cautery should be used to

minimize adverse effects of electromagn etic

interference. If electrocautery is to be used within

15 cm of ICD, a compatible programming device

must be available in the OR as well as a pulse

generator should be accessible.10 If external

defibrillation is required the pads or paddles

should be placed 10 cm from the pulse generator

and implanted electrodes. Other things like use ofligatures instead of cautery or bipolar instead of

unipolar cautery can be emp loyed to minimise the

risk of ICD malfunction. A less desirable solution

that may have to be considered is lead disruption

and temporary explantation of pulse generator.10

In both cases we reprogrammed (deactivated)

the ICD before commencing surgery and

reactivated it after electrocautery was no more

required. In the first patient internal juglar vein

(IJV) was not cannulated, because the ICD was

placed recently and there is always a chance ofdisplacement of the freshly placed ICD leads. Left

external jugu lar vein was cannulated using a 16G

cannula (single lumen). The blood flow to the limb

has been r estored and his diabetic foot is healing.In the second case a central venous sheath 7.5 F

was placed in the r ight IJV for emergency

trasvenous pacing, as the ICD placement was not

recent. The surgical procedure was uneventful.

Transient metabolic and electrolyte imbalance as

well as drugs may increase pacing threshold. In

both these cases epidural anaesthesia was used as

the technique of choice which besides facilitating

surgery and postoperative analgesia, has been

shown to have beneficial effect on preload and

transmyocardial blood flow distribution.11

Although bu pivacaine is more cardiotoxic than

lignocaine, the toxicity is unlikely to occur with a

single epidural inject ion and low dose

postoperative infusion.12

To conclude, perioperative management of

patients with cardiac rhythm m anagement devices

is challenging. It has been a complex and constantly

evolving field of technology. An un derstand ing of

the basic principles of these devices as well as

making use of available resources and consulting

the hosp ital responsible for its follow u p or d evicemanufacturer is strongly encouraged to make

anaesthesia safer for these h igh risk cases.

1. Mehta Y, Dhole S, Kler TS. AICD implantation and its

implications for the anaesthesiologist. Ind Heart J1996;

48: 68-70

2. Rosen thal ME, Josephson ME. Cur ren t s ta tus o f

antitachcardia devices. Circulation 1990; 82: 1889-99

3. Kelly PA, Cannom DS, Garan H, et al. The automatic

implantable cardiover ter -def ibr i lator . Eff icacy,

complications and survival in patients with malignant

ventricular arrhythmias.J Am Coll Cardiol 1988; 11: 1278-

86

4. Michael H, Gollob, Seger JJ. Current s tatus of the

implantable cardioverter defibrillator. Chest 2001; 119:

1210-221

5. Groh WJ, Lynee D, Fore Doughlas PZ. Advances in the

treatment of arrhythmias; implantable cardioverter

defibrillator:Am Fam Physician 1998; 57: 297-307

6. Saksena S. The impact of implantable cardiover ter

defibrillator therapy on health care systems. Am Heart J

1994; 127: 1193-1200

7. Schum acher B, Tebbenjohanns J, Jung W, Korte T, Pfeiffer

D, Luderitz B. Radiofrequency catheter ablation of atrial

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9. Geelan P, Lorga Filho A, Chauvin M, Wellens F, Brugada

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10. Mehta Y, Swaminathan M, Juneja R, Saxena A, Trehan N.

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11. Bloomberg S, Emanu ellson H, Kvish H. Effects of epidu ral

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847

12. Reiz S, Nath S. Card iotoxicity of local anaesth etic agents.

Br J Anaesth 1996; 58: 736-746


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