Perioperative anaesthetic Mx of patients with cardiac pacema
Patients with cardiac disease presenting for non-cardiac surgery pose a considerable challenge to the anaesthesiologists. Care of the pacemaker during surgery as well as understanding its anaesthetic implication is crucial in management of these patients. Published in the Gujarat Medical Journal, the authors present a case of 60yr old female with permanent cardiac pacemaker posted for modified radical mastectomy.

A 61yr old, female weighing 55kg was scheduled for Modified Radical Mastectomy. She had undergone permanent pacemaker implantation 10 years back for symptomatic bradycardia & syncope. She had medical history of Hypothyroidism since 7 yrs. and taking tablet Thyroxine50 ug once daily regularly.

ECG showed pacemaker rhythm and echocardiography was normal. Chest X-ray showed pacemaker with impulse generator. Thorough interrogation with competent authority was carried out for obtaining pacemaker details like when it was implanted, battery life, mode, effect of magnet, baseline rate etc. Our patient base line heart rate of 70/min and on VVI-R mode. After taking informed consent for general anaesthesia patient was premedicated with Tab. Lorazepam and kept nil per oral overnight.

On day of surgery pacemaker was set to asynchronous mode (VVI to VOO) and baseline heart rate was reset from 70/min to 90/min. Monitors in the form of ECG, Pulse oxymetry, Non-invasive blood pressure, Capnography and Temperature were applied. After pre-oxygenation for 3min with 100% oxygen,

Anaesthesia was induced with Injection Glycopyrollate 4μg/kg, Inj. Fentanyl 2μg/kg, Inj. Thiopentone Sodium 5mg/kg, Inj. Vecuronium 0.1mg/kg and intermittent positive pressure was given for 3 mins. Patient was intubated with cuffed portex tube no 7 and was mechanically ventilated. Anaesthesia was maintained with O + N O+ Isoflurane and Inj. Vecuronium bromide. During intraoperative period care was taken to maintain normotension, normocapnea and normal temperature.

A monopolar cautery was used with return pad kept below Left Scapula.Following completion of surgery patient was reversed with Inj. Glycopyrollate 10μg/kg and Inj. Neostigmine 0.04mg/kg. Patient was extubated after having adequate tone, power andconsciousness. Then she was shifted to I.C.U where her heart rate was reset to 80beats/ min.Analgesia in form of Diclofenac sodium was given and care was taken to prevent shivering. On I post-operative day mode and heart rate were reset to pre-operative settings.

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