Pacemaker Insertion

Anesthesia Implications

Position: Supine, arms tucked
Time: 30-60 min (short)
Blood Loss: Low (10-50 ml)
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: No
Lead: Yes

Approach – Light sedation (fentanyl + versed) is typically all that is required for a pacemaker insertion. In some cases the surgeon can complete the case with only localization at the insertion site.

Airway fire risk – Consider using face mask, blended O2, suction near the oxygen, or leaving at room air.

Monitor the heart – These patients are at a high risk for cardiac arrhythmias. Keep a close eye on the ECG.

ETCO2 – End tidal CO2 monitoring is required as the patient may be positioned out of your reach with their head covered by surgical drapes. Oxygen provided by nasal cannula or simple face mask is typically sufficient.

Leads – Position the leads out of the way. Usually the black lead will go on the shoulder, and you can position the red lead perhaps a little lower.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

Fluoroscopy / Xray (general considerations): Have lead aprons and thyroid shields available. Alternatively, distancing yourself 3 to 6 feet will reduce scatter radiation to 0.1% to 0.025% respectively. Occupational maximum exposure to radiation should be limited to a maximum average of 20 Sv (joules per kilogram – otherwise known as the Sievert/Sv) per year over a 5 year period. Limits should never exceed 50 Sv in a single year.

Airway Fire Risk (general considerations): Keep the inspired oxygen concentration (FIO2) below 30% in the breathing circuit to prevent airway fires. It is crucial to note that even after adjusting to the “safe” FIO2 range, the expiratory oxygen concentration can remain above 30% for a considerable amount of time, presenting an ongoing risk of airway fire. The inspired and expired oxygen concentrations in the circuit are influenced by various factors including the circuit’s length, the fresh gas flow rate, and the starting oxygen concentration, potentially taking several minutes to decrease to below 30%.

Patients who require a pacemaker are already at risk for cardiac arrhythmias (bradycardia, ventricular tachycardia, ventricular fibrillation), the anesthesia provider should always be prepared for the treatment of any arrhythmia, keep Atropine, Epinephrine, Lidocaine, and vasopressors available.

These patients also typically have multiple comorbidities (obesity, diabetes, vascular disease, lung disease).

Positioning for a pacemaker insertion requires the patient to lay flat on a hard surface. Many patients will be highly uncomfortable and may require more sedation and/or pain medication.