European Journal of Molecular & Clinical Medicine

Abstract

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