Pacing-dependent ICD patient for neck surgery74-year-old man, 82 kg, for elective left thyroid lobectomy with monopolar diathermy

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 74-year-old, pacing-dependent, with an ICD, having neck surgery near his generator. Patient
   • At 74, with EF 30% and breathless after one flight, his reserve is small; I screen frailty and cognition.
   • Urgency: elective, so there is time to check and set up his device. Stem trigger
   • Active cardiac conditions? None: no decompensated failure, angina or uncontrolled arrhythmia. Disease
   • Risk score: heart failure plus coronary disease make RCRI 2, so elevated risk.
   • Functional capacity: breathless after one flight, under 4 METs.
   • Decision: test further only if it would change his care; otherwise proceed with a device plan.

2. Prepare

   How do you prepare his device?

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   • I need device type, maker, model, indication, dependence and magnet response. Disease
   • His ICD was last checked 9 months ago; ICDs need a check every 6 months.
   • Interrogate today: battery, leads and current settings.
   • Reprogram to asynchronous pacing; a magnet won't do that on his ICD.
   • Suspend tachy-therapies so diathermy noise isn't treated as VT.
   • External pads on before induction, since his ICD cannot shock. Crisis
   • Bipolar, or short irregular monopolar bursts at low energy; return pad away from the device. Surgery

3. Plan

   How do you monitor him during surgery?

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   • Watch the pulse oximeter or arterial trace for perfusion; diathermy can mask the ECG. Disease
   • If pacing looks disturbed, the surgeon stops diathermy until we find the cause.
   • Re-interrogate and restore therapies before he leaves recovery. After surgery
   • Pads and ECG stay on until therapies are back on.
   • Apixaban restarts only once haemostasis is secure; a neck haematoma can obstruct his airway. Airway

4. Crisis

   During diathermy the ECG shows no paced complexes and the pleth trace goes flat. What do you do?

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   • Adult arrest, non-shockable: no paced complexes and a flat pleth in a pacing-dependent man. (Crisis)
   • Diathermy off: a burst near the generator may have reset his device.
   • Call for help, start CPR, and pace through his pads at once.
   • CPR continues until the pads capture with a pulse; compressor changed every 2 minutes.
   • Non-shockable branch: give adrenaline 1 mg early, repeating it every 3–5 minutes.
   • Technician interrogates him; a reset device often falls back to VVI and must be reprogrammed.
   • Capture back but output poor: adrenaline 2–10 mcg/min as a bridge.

5. Crisis

   Later, with therapies suspended, he develops a broad-complex tachycardia at 190/min, BP 70/40. What now?

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   • Tachycardia algorithm: broad-complex at 190, BP 70/40, ICD off, so unstable VT. Crisis
   • Unstable with a pulse: synchronised cardioversion through the pads, starting at 100 J.
   • Pulse lost: arrest algorithm, shockable branch; defibrillate at once, then CPR.
   • Initial shocks have failed: adrenaline 1 mg, then every 3–5 minutes.
   • Still shockable after repeated shocks: amiodarone 300 mg, with 150 mg as the second dose.
   • Stable rhythm with a pulse: amiodarone 150 mg over 10 minutes.
   • Therapies re-enabled and device interrogated before he goes to the ward. After surgery