Conquering Pacemaker Management
Susan Gaeta, MD*
M.D. Anderson Cancer Center
Houston, Texas, USA
Opportunities to manage patients with permanent pacemakers in the intensive care unit (ICU) exist regardless of what type of unit one practices in. Intensivists should not feel anxious about managing patients with pacemakers because collaboration with a cardiologist and/or electrophysiologist is recommended. Evaluating devices in the perioperative setting, dealing with infected devices, and determining whether the device is contributing to the patient’s critical illness are some of the management opportunities that intensivists may encounter.
First, it is important to determine what type of device the patient received. Most patients can present a card detailing the brand and its settings; if a card is not available, a chest radiograph may provide the device identification number. Determination of the type of device is essential to facilitate its interrogation, a necessary step in cases where the device may be contributing to the patient’s illness or in the perioperative setting. In the latter setting, the pacemaker ideally was evaluated extensively before the operation, but it should be interrogated again postoperatively to ensure that no electromagnetic interference occurred during the procedure or that the patient’s physiology didn't change as a result of the procedure.(1)
Electrolyte and metabolic abnormalities may lead to pacemaker malfunction during the perioperative and intensive care periods. These derangements may affect the threshold for pacing and result in device failure. Examples of these derangements are acidosis, alkalosis, hyperkalemia and severe hyperglycemia. Antiarrhythmic drugs, type 1 agents in particular, may increase the pacing threshold.(2)
The device itself may be the etiology of the malfunction. Battery depletion may cause the pacemaker to reprogram to a slower rate and/or a non physiologic pacing mode.(3) The device leads may fracture or the insulation may deteriorate, resulting in loss of capture. Fracture of the lead may be observed on a chest radiograph, but insulation deterioration may not be visible. Lead impedance noted during interrogation of the device may point to problems with the lead.(3)
As the number of implanted pacemakers increases, the incidence of infected pacemakers increases as well, with a reported range of 0.13% to 19.9%.(4) Infection can be attributed to the pulse-generator pocket or to bloodstream infection with or without device-related endocarditis. Mortality rates range from 31% to 66% if the device is not removed, 18% or less with the combined approach of device removal Conquering Pacemaker Management and antimicrobial treatment. Suggested guidelines on the management of pacemaker-related infections recommend obtaining at least two sets of blood cultures, as well as culture from generator tissue and lead tip. If the patient has positive blood culture results, or negative results but recent antibiotic treatment before culture, a transesophageal echocardiogram should be obtained to assess for device-related endocarditis.
Infection attributed to the generator pocket should be considered if the patient presents with pain, tenderness around the pocket, and/or erythema around the overlying skin. Ultrasound or palpation of the pocket may demonstrate an effusion. For the most part, patients present with only localized symptoms.(4) Those with lead involvement infections, on the other hand, may present with subacute symptoms; at times they may be septic or in shock. These patients also may present with pulmonary abnormalities, i.e., lung abscess and/or pulmonary emboli.(4) A generator pocket infection may present soon after initial device implantation or battery exchange, but it also can occur many months later due to a chronic, smoldering infection from contamination at the time of implantation. Lead infections may occur within the first three to six months after manipulation, and approximately two-thirds of the occurrences occur later.(5,6)
Duration of antibiotic treatment can be 10-14 days after removal of the device for a limited infection, up to 4 weeks for device-related endocarditis limited to the right heart.4 Decisions to remove the infected device are based on location and extent of the infection, infectious organism and age of the device. The risk of developing arrhythmias while awaiting reimplantation also must be considered, as must the patient’s overall condition and prognosis.
Another area to review is deactivation of the pacemaker as the transition is made to comfort care. A review of the literature on recommendations regarding the deactivation of permanent pacemakers (PPM) demonstrates a disagreement on whether it is ethically permissible to deactivate a PPM in a dying patient. This dispute is based on claims that a PPM neither prolongs the dying process nor causes discomfort.(7) Braun et al made the argument that deactivating a PPM may cause bradycardia, rate-related congestive heart failure and dyspnea, resulting in increased suffering(8); they concluded that decisions to deactivate a PPM should be made on an individual basis, and education should be provided to both the patient and family to alleviate anxiety associated with the deactivation decision.(8) Lastly, one must also remember to have PPM removed before cremation to decrease the risk of injury from an exploding device.
References:
1. Rozner M. Pacemaker misinformation in the perioperative period: programming around the problem. Anesth Analg. 2004;99:1582-1584.
2. Stone KR, et al. Assessment and management of patients with pacemakers and implantable cardioverter defibrillators. Crit Care Med. 2004;32(4 Suppl):S155-S165.
3. McPherson CA, et al. Permanent pacemakers and implantable defibrillators: considerations for intensivists. Am J Respir Crit Care Med. 2004;170:933-940.
4. Sohail MR, et al. Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol. 2007;49:1851-1859.
5. Cacoub P, et al. Pacemaker infective endocarditis. Am J Cardiol. 1998;82: 480-484.
6. Klug D, et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management. Circulation. 1997;95:2098-2107.
7. Mueller PS, et al. Deactivating implanted cardiac devices in terminally ill patients: practices and attitudes. Pacing Clin Electrophysiol. 2008;31:560-568.
8. Braun TC, et al. Cardiac pacemakers and implantable defibrillators in terminal care. J Pain Symptom Manage. 1999;18:126-131.
Disclosures:
* Author has no disclosures to report
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