COURS EPS POUR RÉSIDENTS ANESTHÉSIE

ICM 2 nov 2016

Katia Dyrda MD FRCPC MSc Ing

Partie 1: Cardiostimulateur et défibrillateur implantable

• Definitions/modèles• Indications d’implant• Technique d'implant • Paramètres/tests• Gestion péri-opératoire des devices• Gestion péri-procédure de l’anesthésiste

Partie 2: Insertion de pacemaker temporaire en périop de chx

cardiaque• Sujets a risque de bradycardie et de bloc

péri-chirurgie cardiaque • Types de PM temporaire • Fonctions de base des cardiostimulateurs

Lignes directrices du CCS

La stimulation cardiaque

• La stimulation cardiaque pure: pacemaker (PM)

• Stimulation cardiaque et défibrillation: défibrillateur automatique implantable (DAI)

Pacemaker

• Sondes : 0,1, 2 ou 3• OD, VD, VG (sinus

coronaire)• Pacemaker = batterie• Connecteurs• Abord veineux (veine

céphalique, axillaire et/ou sous-clavière)

Position

Category

Letters Used

Manufacturers’Designation

Only

I II III

Chamber(s)Paced

Chamber(s)Sensed

Responseto Sensing

RateModulation

MultisitePacing

O = None

R = Ratemodulation

O = None

A = Atrium

V = Ventricle

D = Dual(A + V)

S = Single(A or V)

S = Single(A or V)

O = None

T = Triggered

I = Inhibited

D = Dual(T + I)

IV V

O = None

A = Atrium

V = Ventricle

D = Dual(A + V)

O = None

A = Atrium

V = Ventricle

D = Dual(A + V)

NASPE / BPEG Generic (NBG) Code

X-Ray

Abdominal ICD

Défibrillateur

Défibrillateur

X-Ray

Pectoral ICD

Défibrillateur sous-cutané

TherapyDetection

Arrhythmia is detected

Antitachycardia pacing(ATP) or Shock

How ICDs work ?

ICD therapies• ATP therapy :

Involves delivering a series of specifically timed pacing pulses in an attempt to interrupt re-entrant monomorphic ventricular tachycardia

ATP is highly effective in treating fast VTPainfree therapy = improvement in QoL

• Shock therapyPulse generator delivers truncated exponential shocks synchronous to a sensed event. Energy level and polarity of shocks can be programmed

High energy: Defibrillation / Low energy: Cardioversion The most efficient therapy but painful for the patient

Wathen, M. S. et al. Circulation 2001;104:796-801

ECG - ICD therapies

Raccordement sondes-boitier

tournevis

boitier

sondes

Enfouissement du boitier dans la loge

Techniques d’implantation

• Sous AL + sédation (propofol+narco)• Au bloc opératoire ou salle dédiée• Voie céphalique, axillaire et/ou sous-clavière• Incision: sous-claviculaire ou sillon delto-

pectoral• Logette pré ou rétro-pectorale • Rarement test par CEI +/- CEE en fin

d’intervention• 1 jour d’hospitalisation / 1nuit

Appareils traditionnels

• A droite: trajet plus droit pour les sondes et moins de contraintes, sauf si chasseur ou pb local

• A gauche: cœur pris « en sandwitch » pour la défibrillation

Seuil de défibrillation

Resynchronisation en insuffisance cardiaque

• Complications précoces- locales au site d’implantation : hématome,

infection, stimulation du muscle pectoral ou phrénique

- liées à la ponction de la veine : pneumothorax, phlébite ou embolie gazeuse

- cardiaques : perforation, hémopéricarde- déplacement de sonde

• Complications tardives- locales au site d’implantation : infection,

déplacement du boîtier, extériorisation du boîtier, phlébite

- liées aux sondes de stimulation : déplacement de sonde, anomalie de stimulation et de détection, fracture de l’isolant ou de sonde

Potential Perioperative Issues With CRDs

• Most widely appreciated potential complication with CRDs in operative setting is inappropriate sensing of electromagnetic interference (EMI) from electrocautery.

• Consequence depends on – type of CRD, patient characteristics, and device settings.

• In general, may observe: – No effect; – Inappropriate inhibition of pacing; – Inappropriate rapid pacing; or – Inappropriate sensing and triggering of ICD therapy (shock

or rapid pacing, ATP)

Effects on device function from anesthesia and surgery

1. Damage to or reprogramming of pacemaker2. Anatomical consequences associated with surgical

procedures 3. Physical damage to CRDs or leads through direct

trauma; device or lead infection associated with perioperative bacteremia;

4. Physical damage (burn) to tissue associated with EMI conduction through leads; and

5. Complications associated with the failure to return devices to preoperative settings.

6. Vagotonic manoeuvres or agents (rapidly acting narcotics) may enhance conduction blockade and this effect is likely more pronounced in patients with sinus or atrioventricular node dysfunction.

7. Alterations in fluid balance, acid base status, electrolyte disturbances, and altered medication schedules can have an impact on device function and propensity to arrhythmias.

Effects on device function from anesthesia and surgery

Likelihood of EMIEMI is more likely if: • surgery < 15 cm from CRD or leads (ie, intrathoracic,

shoulder, etc) or above the umbilicus;• monopolar cautery rather than bipolar cautery to be

used; • long (> 5 seconds) or frequent (< 5 seconds between)

bursts of cautery to be used;• CRD has unipolar leads or bipolar leads programmed

in unipolar mode or with very high sensitivity.

Minimizing EMI - electrocautery• Bipolar cautery if possible• If unipolar, direct current path away from CRD & leads; • Short (<5 sec) bursts, >5 sec between bursts; • Lowest acceptable cautery settings• No direct contact of cautery with CRD;

* Argon beam coagulation system– Same concerns as with cautery– Consider reprogramming if CRD-dependent patient since

short bursts not possible

Likelihood of CRD complications

• If PMP-dependent, risk of asystole if inappropriate inhibition of pacing from EMI

• Risk of inappropriate shocks or ATP if EMI results in inappropriate sensing

• PMP-dependent pts with a unipolar pacemaker on the same side as a surgery known to induce pneumothorax (ie, pneumonectomy, lobectomy, etc) are at risk of:– Asystole due to sudden increase in pacing impedance. – High defibrillation thresholds

What does a magnet do to an ICD?

Recommendations Pacemaker

• Operations with minimal or no electrocautery– No change to programming; – Have magnet available.

• Operations with significant or unavoidable electrocautery– Patient is pacemaker dependent

• Magnet if device accessible and device responds continuously to magnet placement,

• Device not accessible or does not respond continuously to magnet, then reprogram to asynchronous mode at the start of the procedure.

Recommendations Pacemaker

• Operations with significant or unavoidable electrocautery– Patient is not pacemaker dependent

• Device continuously accessible and responds continuously to magnet: have magnet available

• If device is not continuously accessible and operative circumstances require a more physiologic rate: consider reprogramming for the procedure.

• Consider suspending rate modulation

RecommendationsICD - Bradycardia

• Operations with minimal or no electrocautery– No change to pacemaker programming.

• Operations with significant or unavoidable electrocautery– Patient is pacemaker dependent

• Consider reprogramming device to asynchronous mode prior to procedure.

– Patient is not pacemaker dependent• Consider reprogramming to physiologically acceptable

rate in synchronous mode for the duration of the procedure.

RecommendationsICD - Tachycardia

• Operations with no electrocautery– No change to VT and/or VF programming; – Magnet available to suspend tachy functions PRN

• Operations with electrocautery– Device accessible and clear of operative field

• Magnet over device during surgical procedure– Device is not accessible or in operative field or

magnet cannot be securely affixed • Reprogram to disable tachyarrhythmia therapies• Apply external defibrillator pads• Ensure postoperative reprogramming monitoring.

Central lines• Subclavian venipuncture should be

avoided ipsilateral to an implanted device – Needle might tear the insulation of indwelling

leads, leading to device malfunction. – The ipsilateral venous system may be occluded– IJ venipuncture should be safe on either side.

• The metal guide-wire may trigger an inappropriate shock. – As such consideration should be given to either

avoid a metal guidewire or deactivate the ICD during central line placement.

ACLS• ACLS Protocols (even if they have an ICD)• Chest compressions should be continued

(even if they have an ICD)• If the ICD discharges some of the current

may enter the rescuer. – There has never been a reported case of

rescuer injury. – Minor discomfort may result (i.e. slight tingle)

• prevented by wearing latex gloves– If rescuers are uncomfortable the ICD can

be deactivated with a magnet

External pacing & cardioversion• Place external pads distant (>2.5cm) from the pulse generator and out of

the out of the shock vector (i.e. AP position is preferred)

• Clinically appropriate energy output should be used • Pts who receive external shock must have devices interrogated afterwards

– Pacing thresholds may rise after external energy delivery leading to loss of capture. – Defibrillation that affects the generator may cause total device failure.

Questions?

Partie 2: Insertion de pacemaker temporaire en périop de chx

cardiaque• Sujets a risque de bradycardie et de bloc

péri-chirurgie cardiaque • Types de PM temporaire • Fonctions de base des cardiostimulateurs

Indications

• Brady• SSS• BAV• Rythme jonctionel lent• Suppression de battements ectopiques• Dysfonction de PM permanent• Rx, E+ • Torsades sur QT long

Pacemaker temporaire

• Transcutané: PM externe (chariot code)• Endoveneux (accès jug ou fem)

– Swan pace– Sonde endocavitaire (vissante ou non)

• Épicardique– Fil suturé a/n A et/ou V

• (Transesophagien)

Principes de stimulation

• Modes les plus communs:– AAI– VVI– VOO– DDD– DOO

Absence de capture

• Causes– Énergie délivrée insuffisante– Batterie faible– Sonde déplacée, endomagée, tissu fibrotique– Désordre E+: acidose, hypoxémie, hypoK

• DANGER: diminution du débit

Solutions pour perte de capture

• Choisir une bande de rythme différente• Remplacer electrodes• Remplacer connecteurs• Augmenter l’output• Renverser la polarité

Problème de sensing

• Pacemaker pas assez sensible• Myocarde (ondes R trop petites)• Sonde déplacée, endomagée, tissu

fibrotique • Désordre électrolytique• Batterie faible• Dysfonction de pacemaker

• DANGER: R on T

Situations cliniques

• RVM• RVA• Pontages• Cardiopathies congénitales• FA

Retrait du PMT

• Site de l’introducteur– Hématome

• Au niveau du myocarde– Saignement

• Effusion péricardique/tamponnade– Arrythmie

Conclusion

• A temporary pacemaker to treat a bradyarrhythmia or tachyarrhythmia is used when the condition is temporary and when a permanent pacemaker is either not necessary or is not immediately available.

• Complications are not rare and include infection, local trauma, pneumothorax, arrhythmias and cardiac perforation.

Questions?

• Resources/références– Lignes directrices CCS– Shared web presentation– Dre Blandine Mondésert