In this MRCS Part B scenario you are the surgical registrar. The anaesthetist for today’s list has some questions for you.
What precautions should be taken in a patient with a pacemaker?
Preoperatively the patient should undergo a pacemaker check where a “passport” containing information on the device model, date of implant, and reason for implant should be available. They should have had a recent review by their pacemaker follow up clinic with information regarding degree of pacing dependency, extent of any heart failure and any particular safety advice communicated to the anaesthetic and surgical team.
The theatre should have cardio-pulmonary resuscitation and temporary pacing equipment available. The patient’s ECG should be monitored throughout from before induction, and an arterial line inserted to provide an alternative method of monitoring pulse in case the ECG picked up is actually the pacing spike, rather than the QRS (theoretically the patient could be in asystole despite a normal looking paced rhythm).
Intraoperatively the use of monoplolar should be strictly limited, and not used near the pacemaker device. Where its use is unavoidable, it should be limited to short bursts. The return electrode should be placed so that the current pathway is as far away from the pacemaker as possible.
Bipolar can be used, but should be used in short bursts, and only in areas distant from the pacemaker if possible.