Anaesthetic considerations in a

geriatric patient with pacemaker

scheduled for TURP
Post graduates:
Dr. Megha, Dr. Meenakshi,
Dr. Ram Subramaniam Chandramouli,
Dr. Monika K
Moderators:
Dr. Radhika Dhanpal
Dr. Sripada Mehandale
 75 YEAR OLD PATIENT WITH A
PERMANENT PACEMAKER INSITU
POSTED FOR TURP SURGERY
 WHAT ARE THE PHYSIOLOGICAL
CHANGES IN ELDERLY PEOPLE WHICH
HAVE A BEARING ON ANAESTHESIA?
GERIATRIC PATIENTS- CNS AND PNS
GERIATRIC PATIENTS- CVS
GERIATRIC PATIENTS- RS AND RENAL
WHAT IS A PACEMAKER AND ITS
COMPONENTS?
 PACEMAKER

Device that generates electrical impulses and delivers the

impulses via electrodes which helps in contraction of the
heart muscle and hence regulates the beating of the heart.
 COMPONENTS OF A PACEMAKER

Pulse generator
Electrode lead
Programmer
WHAT ARE THE TYPES OF
PACEMAKERS?
 TYPES OF PACEMAKERS

Temporary
Permanent
 TEMPORARY PACEMAKERS

Transvenous pacing
Transcutaneous pacing
Epicardial pacing
Transesophageal
 PERMANENT PACEMAKER

Implantable pulse generators with endocardial or myocardial

electrodes for long term or permanent use.
 BIVENTRICULAR PACEMAKER

Biventricular pacemakers (also called cardiac

resynchronization therapy or CRT) use three leads. They
are placed in the right atrium, right ventricle and left
ventricle.
It paces the septal and lateral wall of the left ventricle
simultaneously
Resynchronizes heart to contract in full synchrony.
Indication- dilated cardiomyopathy with LVEF <35%
NYHA 3/4 despite maximal medical therapy
WHAT ARE THE INDICATIONS FOR
PACEMAKER?
 INDICATIONS FOR PACEMAKER

Sinus node dysfunction Post cardiac

transplantation
Acquired Hypertrophic
Atrioventricular(AV) block cardiomyopathy
After acute phase of Pacing to detect and
myocardial infarction terminate tachycardia
Neurocardiogenic syncope and Cardiac resynchronization
hypersensitive carotid sinus therapy in patients with severe
syndrome systolic heart failure
WHAT ARE PACEMAKER CODES?
PACEMAKER CODES
 MODES OF PACING

1. Asynchronous pacing (AOO, VOO, DOO)

2. Single chamber demand pacing (AAI, VVI)
3. Dual chamber demand pacing (DDD)
AAI
DDD
 WHAT ARE THE IMPORTANT TERMS
RELATED TO PACEMAKER FUNCTION?
 IMPORTANT TERMS
REGARDING PACEMAKERS

Pacing- regular output of electric current, depolarizing the

cardiac tissue
Sensing- response of a pacemaker to intrinsic heartbeat
Pacing threshold- minimum amount of energy pacemaker sends
to initiate heartbeat
Capture- cardiac depolarization caused by pacemaker stimulus
 IMPORTANT TERMS REGARDING
PACEMAKERS

Rate response- sensors which will activate during patient

activities and adjust the rate.
Triggered pacing- pacemaker senses activity in one chamber
and delivers a pacing stimulus in the other chamber after a time
delay.
Inhibition of output- inhibits sensing if there is intrinsic
activity
SHOULD A MAGNET BE AVAILABLE
INTRAOPERATIVELY? IF SO, WHY?
 MAGNET APPLICATION OVER THE
PACEMAKER
Magnet is placed over the pulse generator to trigger the reed
switch resulting in a non sensing asynchronous mode with a
fixed pacing rate
It shuts down the demand function
The response varies with the model and manufacturer
HOW DO YOU EVALUATE THE
PATIENT PRE-OPERATIVELY?
 History and
physical
examination
Laboratory Reduce
and cardiac anxiety with
testing counselling
Goals of
preoperative
assessment
Control of Informed
perioperative
diseases consent

Formulate
anaesthetic
plan
GENERAL PHYSICAL EXAMINATION
HOW DO YOU OPTIMIZE/ PREPARE THIS
PATIENT PRIOR TO SURGERY?
IDENTIFY THE MODE OF PACING
WHAT SHOULD THE PACING BURDEN BE TO
CALL A PATIENT PACEMAKER DEPENDENT?
WHAT IS MANDATORY IN THE OT
WHEN THIS PATIENT IS BEING
ANAESTHETIZED?
 PREOPERATIVE
INVESTIGATIONS

UROLOGIC
 PREOPERATIVE INVESTIGATIONS

CBC, blood grouping and typing to

• Correct anaemia, if present
• Arrange for blood, if Hb% is low
• Rule out and treat infection, if present
• Adequacy of platelet count as there is a possibility of
coagulopathy during resection of prostate
Renal function tests including serum electrolytes to
• Rule out acute, chronic or acute on chronic renal failure
• Correct any electrolyte disturbances
• As a baseline value
• Blood sugar and HbA1C
• Diagnose, rule out or find out adequacy of control of diabetes
mellites
• If diabetic, morning blood sugar
• ECG
• Mostly elderly population have HT, IHD or atherosclerosis, hence
effect on the heart
• Possible arrythmias
• Conduction abnormalities
• look for LVH and pacing spikes followed by normal QRS
complex
•X-ray chest
• Elderly, COPD, asthma or other respiratory afflictions
• Chronic smokers
• Reference
•Echocardiography
• Especially, if effort tolerance not assessable
• Known comorbidities
• To know the cardiac reserve
•Prostate size (ultrasound)
•Amount tissue resected
•Have an idea about duration of resection (blood loss 2 to 4 ml/min of
resection)
•Estimate blood loss (20 to 50 ml x weight of the gland in grams)

•Coagulation studies for patients on anticoagulation

• PT (INR)
• aPTT
•Any other tests as per the condition of the patient
 PREOPERATIVE PREPARATION

Cardiologists opinion and availability of technician

Patient should be kept nil per oral for 6 hours prior to surgery.
 WHAT ARE THE
COMPONENTS OF
CONSENT?
 Consent:
Anaesthesia technique
Complications
Blood transfusion
Possible need for:
ICU stay
Postoperative ventilation
Central lines/tubes
Pacemaker interrogation, AICD,
etc.
 WHAT ARE THE
ANAESTHETIC GOALS?
 ANAESTHETIC GOALS
Optimize the condition
Familiarize with the implanted device
Avoid interference with implanted pacemaker
Maintain hemodynamic stability
Close monitoring
Recognize and treat complications early
Adequate pain relief
HOW TO PREMEDICATE
THESE PATIENTS?
• Sedative premedication is required. Meantime, benzodiazepines
are likely to cause confusion in them.
• Diazepam is known to have prolonged elimination half-life
among elderly, and hence better avoided
• Tab. Alprazolam 0.25 to 0.5 mg on the preoperative night
• Though not a standard recommendation, Ranitidine 150 mg in the
night and morning of surgery may be given
 WHAT ABOUT
CONTINUATION OF
MEDICATIONS?
Anti hypertensives
Anti diabetics – skipped on the morning of surgery
Antiarrhythmics
Anticoagulants & antiplatelets
To be stopped, bridging as per the medications
Risk of postoperative bleeding following TURP
Others
WHAT IS THE ANAESTHETIC
TECHNIQUE OF CHOICE FOR
TURP?
 TURP

• Neuraxial anaesthesia makes patient remain awake and may

hasten the diagnosis of bladder or prostatic capsule perforation
and the TURP syndrome and may also decrease blood loss
compared with general anaesthesia and poly pharmacy is
avoided
• However, if a regional technique is contraindicated, general
WHICH ONE IS BETTER
SPINAL OR EPIDURAL?
 SPINAL OVER EPIDURAL

•It is considered to be technically easier to perform in

elderly patients
•The incomplete block of the sacral nerves, which provide
sensory innervation to the prostate, bladder neck, and penis,
occasionally occurs with epidural anaesthesia and is
usually avoided over spinal anaesthesia
 SPINAL OVER EPIDURAL

• Epidural has
 Slow onset

 Segmental block

 Longer analgesia

 Less haemodynamic changes

WHAT IS THE LEVEL OF
BLOCK REQUIRED?
 LEVEL OF SPINAL ANAESTHESIA

• Sensory level of T10

 Urinary bladder sensation (T10-11)

 Prostate (Sacral)

 Urethra (sacral)
 LEVEL OF SPINAL ANAESTHESIA

• Higher sensory levels might mask the symptoms

(abdominal or shoulder pain and/or nausea and vomiting) of
accidental perforation of the bladder or prostatic capsule in
the awake patient
 WHAT IS THE DRUG-DOSE
COMBINATION SELECTED TO
PRODUCE SPINAL ANAESTHESIA FOR
TURP?
More precision needed in adjusting dose due to

Several age related changes in elderly

•Decreased CSF volume

•Increased fat content in the epidural space

•Decreased epidural space: calcifications and thickening of

ligaments and disc bulges

SPECIAL CONSIDERATIONS OF
CARDIAC PACEMAKER IN TURP
 CARDIAC PACEMAKER
Neuraxial block/ Regional anaesthesia
• Vasodilation may be poorly tolerated with fixed heart rate
• Avoid under hydration

General anaesthesia:
• TIVA is preferred when GA is used
• Volatile agents in general increase AV delay and pacing
threshold
 Use of either bipolar cautery or laser technique
for resection is advisable

•In a patient with implanted pacemaker or defibrillator monopolar

cautery elicit override pacing or defibrillation shocks due to the

electromagnetic interference of cautery

• In case of bipolar cautery, both the poles are within the loops of

resectoscope, preventing electricity entering the patient hence

implanted devices are relatively safe
 CARDIAC PACEMAKER IN TURP

•Anaesthesiologist should be ready with Temporary pacemaker &

external defibrillator before starting the surgery
• Cautery should be used in coagulation mode as it does not cause
electromagnetic interference
•Use cautery in short bursts
•Place grounding electrode 15 cm away from the pacemaker
Recently, the laser assisted surgery is becoming more popular since:

• involves either photo selective vaporisation of the prostate (PVP) or

enucleation of prostatic gland using either holmium or thulium laser
(HoLEP or ThuLEP)

• Do not use electrical energy /diathermy directly and hence, no direct

effect on the implanted devices

•Overall blood loss is minimal with these techniques

•Narrowing of the intervertebral foramina precluding leakage of

epidural drug through them.

•Increased sensitivity of neural tissue due to decreased number of

synapses and neurotransmitters

•Reduced blood supply

•Reduced cardiovascular and respiratory reserve

 WHAT ARE THE DIFFERENT
IRRIGATION SOLUTIONS USED
DURING TURP?
 IDEAL IRRIGATION FLUID

•Transparent •Non metabolised when

•Electrically non conductive rapidly absorbed

•Isotonic • Rapidly excreted

•Non toxic •Easy to sterilize

•Non haemolytic •Inexpensive

•Glycine (1.2% and 1.5%) is the most commonly used followed
by sterile tap water in some resource poor settings
Following fluids have also been used:
•Mannitol (3%)
•Glucose (2.5% to 4%)
•Cytal (a mixture of sorbitol 2.7% and mannitol 0.54%)
•Urea (1%) solutions are also occasionally used
WHAT MONITORING
YOU LIKE TO HAVE
FOR THIS CASE?
•ISA Standard monitors (ECG, SpO 2, NIBP, temperature)

•Direct neurologic assessment in patients under regional

anesthesia and measurement of hemodynamics
•Serum sodium concentration and osmolality in patients under
general anaesthesia
•If the cardiorespiratory reserve is poor, additional invasive blood
pressure monitoring
•Added advantage of ABG analysis for blood gases and
 WHAT ARE THE INTRA
OPERATIVE COMPLICATIONS
ANTICIPATED?
 COMPLICATIONS

•Arrythmias: bradycardia, tachycardia, ventricular fibrillation, cardiac

arrest

•Malfunctioning of pacemaker/defibrillator

•Myocardial ischaemia, infarction

 COMPLICATIONS

•Hypothermia

•Blood loss
• Complications associated with positioning
•TURP syndrome
WHAT IS TURP
SYNDROME?
•It is a systemic complication of transurethral resection of the
prostate or bladder tumours, caused by excessive absorption of
electrolyte-free irrigation fluid
•It is a complication characterised by symptoms changing from
an asymptomatic hyponatraemic state to convulsions, coma
and death
 WHAT ARE THE
MANIFESTATIONS OF
TURP SYNDROME?
Volume overload  Hyponatremia
Systolic hypertension Light headedness
Bradycardia Confusion/ restlessness
Dysrhythmias Altered sensorium
Breathlessness/tightness in the chest Convulsions
Cough Coma
Desaturation/cyanosis
Pulmonary oedema
Cardiovascular collapse
Haemolysis Ammonia toxicity
Haematuria Confusion
Hyperkalaemia Tremors
Drop in Hb% Coma
Renal failure
Other irrigation fluids
Glycine toxicity (sorbitol-mannitol mixture)
Blindness – bilateral without any new Hyperglycaemia
ophthalmic findings
Lactic acidosis
Loss of hearing
DIC (Impaired coagulation and clot
ST-T changes) ST depression and T stabilization)
wave inversions
HOW WILL YOU MANAGE
TURP SYNDROME?
 PREVENTION

•Optimisation of preoperative hyponatremia and hyperkalaemia

•Optimisation of fluid status

•Planning staged or alternative procedure for large gland

•Treat CCF preoperatively adequately

•Conservative treatment of BPH in critically ill (medical

therapy/balloon dilatation)
• Use of non conducting irrigant with bipolar diathermy
•Avoid overdistension of bladder
•Microdrip set for IV fluids in cardiac/renal patients
•Use of vasopressors to control regional anesthesia induced
hypotension instead of fluids
•Monitoring fluid absorption by comparing the amount instilled
with the amount removed
 AVOID EXCESSIVE FLUID
ABSORPTION

•Surgery should be less than 60mins

•Irrigation fluid should be at a maximum RULE OF

height of 60cm from the operating table 60
•Not remove more than 60g of prostate
 TREATMENT

•Ensure adequate oxygenation with face mask or nasal cannula

•Terminate surgery as soon as possible
•Auscultate the chest for pulmonary edema
•Obtain 12 lead ECG
•Collect blood for estimation of CBC, glucose, RFT, cardiac
enzymes, serum electrolytes, ABG
•
 CORRECTION OF HYPONATREMIA

If asymptomatic, (Na+ > 120 Correction rates:

mEq/L): Mild symptoms: 0.5 mEq/L/hr
Moderate symptoms: 1 mEq/L/hr
Fluid restriction with diuretics Severe symptoms: 1.5 mEq/L/hr
Choice of fluids:
If symptomatic hyponatremia: Isotonic saline for mild-moderate
Amount of Na+ required = TBW symptoms
3% saline (or 5%) if severe symptoms
(desired Na+ – present Na+)
or serum Na+ < 110 mEq/L
Estimated sodium deficit = (140- 
Stop hypertonic saline when symptoms
current serum sodium) x (body cease or Na+ > 120 mEq/L
weight in kg) x (0.6) 
Rate of 3% NaCL should be < 100 ml/hr.
 TREATMENT OF OTHER
COMPLICATIONS
Seizures:
Midazolam 2–4 mg IV
Diazepam: 3–5 mg IV
Thiopentone: 50–100 mg IV
Phenytoin: 15–20 mg/kg at ≤ 50 mg/ min
Pulmonary edema:
Diuretics
CPAP ventilation
Intubation and positive pressure ventilation
 HOW ARE YOU GOING TO
MANAGE THE PATIENT POST
OPERATIVELY?
 PAIN MANAGEMENT

•Paracetamol 15 mg/kg, 8 th hourly is a good option, unless any specific contraindication

exists

•NSAIDs are generally avoided for

•Old age

•Decreased renal reserve or may already have CKD

•May interfere with haemostasis by their antiplatelet action

• Non sedative analgesic like tramadol, if additional analgesia is
demanded
• Opioids produce sedation, respiratory depression and sometimes
confusion among elderly. Hence to be used with caution
•Keeping the company of a family member may decrease the incidence of
delirium in the postoperative period
 POST OP COMPLICATIONS
Related to TURP: Related to the pacemaker
•TURP Syndrome •Hypotension
•Glycine Toxicity •Tachydysarrhythmia
•Perforation of Prostate •Bradydysarrhythmia
•Transient Bacteraemia & •Myocardial Burns
septicemia
•Myocardial Ischemia
•Hemolysis
•Device Malfunction
•Hypothermia
•Bleeding and coagulopathy
 POSTOPERATIVE CARE OF
PACEMAKER
•Check pacemaker functions, if procedure involved
cardioversion and diathermy
•Monitor cardiac rate and rhythm continuously
•Back up pacing and cardioversion/ defibrillation capability
•Use cardiologist help
•Reprogram appropriate setting
 SUMMARY

•Adopting a multidisciplinary, approach that involves the surgeon,

anaesthetist, cardiologist and industry employed allied health
professional is ideal for safe peri-operative CIED management.
•Anaesthetic plan should be planned preoperatively according to
individual patients needs and depending on their current medical
status
 REFERENCES

•Cronin et al. / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) 10761089

•Ozmen S, Koşar A, Soyupek S, Armağan A, Hoşcan MB, Aydin C. The selection of regional anesthesia in

TURP operation.Int Urol Nephrol 2003;35:507-12

•Siva K. Mulpuru et al, Cardiac Pacemakers: Function, Troubleshooting, and Management: Part 1 of a 2-

Part Series, Journal of the American College of Cardiology,Volume 69,,2017,

https://doi.org/10.1016/j.jacc.2016.10.061

•https://zsfganesthesia.ucsf.edu/pacemaker

•https://www.amjmed.com/article/S0002-9343%2821%2900513-1/fulltext

•https://www.jcvaonline.com/article/S1053-0770%2819%2930971-1/pdf
THANK YOU
Q AND A