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Sunday, January 15, 2023

Does what goes on behind the anesthesiologist drapes stay behind the drapes?

 At least some of what occurs behind the anesthesiologist drapes stays there not  being completely captured by the surgeons op note.  This is the case because the surgeon does not know what goes on in real time focused as he should be on the details of the procedure.

The story

I have a pacemaker, a dual chamber  in DDD mode with the right ventricular lead placed in close proximity to the Bundle of His.Typically this is referred to as non select His Bundle pacing, I was to have surgical procedure with the operative field to be within a few centimeters of the pacemaker .

It is common practice to deactivate the sensing function of the PM since the cautery typically used in surgery can emit electromagnetic energy  ( electromagnetic interference (EMI )) that can damage the PM or change its function with variable clinical consequences.

The sensing function of the PM can be disabled by the application of a magnet over the PM.This converts a  PM in DDD mode to one in D00 mode in which the atrium and ventricle are paced typically at a rate of 85. This is called asynchronous pacing and referred to as magnet mode .

This eliminates the risk of EMI but at the cost of limiting the heart ability to increase cardiac output and poses the risk of ventricular tachycardia or ventricular fibrillation if a pacing spike should occur at the vulnerable phase of repolarization. If the patient has a functioning sinus node and  intact electrical transmission  there will be two competing rhythms .  

The operative record include a series of Blood pressure recordings all of which in my case were normal.Yet the medication record includes levophed which would have only been used if the blood pressure has decreased significantly. So that fact must have stayed behind the drapes.

Could the presumed blood pressure drop be due to the magnet mode not allowing an intrinsic increase in cardiac output assuming there was a valid reason for the use of levophed?

 


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