European Journal of Molecular & Clinical Medicine

Anaesthesia for geriatric patients who are morbidly obese is quite challenging. Understanding anaesthetic care for such patients can be related to the description of fundamental alterations in physiology and changes in the pharmacokinetics and pharmacodynamics of anaesthetic medications. With advances in cardiology and cardiothoracic surgery, several newer implantable cardiac devices have become common in the surgical population. Cardiac pacemakers are generally required in patients with symptomatic bradycardia or severe conduction block. Many of the newer implantable cardiac electronic devices are targeted at managing heart failure. While managing such patients for non-cardiac surgeries, specific issues related to equipment characteristics and troubleshooting should be a priority for anaesthesiologists. There is a possibility of malfunction of the devices resulting in catastrophic outcomes. Intraoperative care of the pacemaker and understanding its anaesthetic implication is crucial in managing these high-risk patients. We present the anaesthetic management of a case of an elderly morbidly obese male patient, posted for inter-scapular non-healing ulcer debridement having a permanent pacemaker in situ in DDDR (dual-chamber rate-modulated) mode. The pacemaker was changed and inserted previously for complete atrioventricular (AV) block on electrocardiogram (ECG) and degenerative AV conduction disease with complete symptomatic AV (atrioventricular) block, on electrophysiology study. The pacemaker mode changed to asynchronous ventricular pacing mode preoperatively. Erector spinae block with field block was given. The patient tolerated the surgical procedure well, and vital parameters were maintained throughout the operation. After the operation, the patient was shifted to the intensive care unit (ICU), the pacemaker was reprogrammed to DDDR mode, and vigilant monitoring was done. Postoperatively patient developed iatrogenic pneumothorax which was managed successfully by the pulmonology team. The patient was then transferred to the ward on postoperative day 3 in stable condition. This case highlights that a good erector spinae plane block + field block along with vigilant monitoring and team effort is a reasonable choice for elderly obese patients with permanent pacemakers coming for elective surgeries

Background: This study compared the analgesic efficacy of the bilateral erector spinae plane
(ESP) with that of the bilateral transversus abdominis (TAP) postoperative delivery with
selected surgery.
Methods: Sixty mothers scheduled for caesarean section under random surgery were
randomly assigned to receive an ESP block or a TAP block. The ESP group received USG
guided block with 20 mL 0.2% of ropivacaine at the T9 level corresponding to T10 transverse
process e at the end of surgery. The TAP group received an ultrasound-guided TAP block
containing 20 mL of 0.2% ropivacaine at the end of delivery. The main effect was the
duration of analgesia achieved by each block. Measures of the second outcome were
postoperative pain severity, complete diclofenac use, patient satisfaction.
Results: The median duration (interquartile) block was longer in the ESP group than in the
TAP group (12 hours [10-14] vs 8 hours [8-10], p <0.0001). In the first 24 hours, the median
rate of analog pain observed at rest was lower in the ESP group. Intermediate diclofenac use
in the first 24 hours was significantly higher in the TAP group than in the ESP group (125 mg
[100-150] vs 100 mg [75-100, p = 0.003]).
Conclusion: Compared with the TAP block, ESP block provides effective pain relief, has a
long lasting analgesic action, increases duration of first analgesic need, is associated with
minimal diclofenac use, and can be used in multimodal analgesia and opioid -sparing
medication after surgery.