Insertion of pacemaker or ICD

Insertion of pacemaker or ICD

Anesthesia type	MAC
Airway	Natural
Lines and access	1-2 PIV
Monitors	5 lead EKG
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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Pacemaker or ICD placement is a minimally invasive procedure were a small incision below the clavicle is created and a cardiac pacemaker or ICD is placed. Through this pocket the cardiologist will insert a wire into the RV of the heart. Once the device is tested and functional, the pocket is closed and local is typically injected in the field.

Preoperative management

Patient evaluation

System	Considerations
Neurologic
Cardiovascular	Consider etiology requiring pacemaker/ICD insertion. Symptomatic bradycardia, high degree heart blocks, sick sinus syndrome, syncope, HF are some of the common causes.
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Intraoperative management

Monitoring and access

1-2 PIVs are typically required

Standard ASA monitoring

Induction and airway management

Natural airway typically utilized. If concerns for obstruction or other considerations, LMA or ETT can be considered.

Positioning

Supine

Maintenance and surgical considerations

There is very little stimulation after pocket is made. Due to length of procedure, consider at propofol infusion (25-100 mcg/kg/min) and precedex infusion (0.6-1 mcg/kg/hr). After pocket creation, propofol infusion can slowly be weaned off.

Postoperative management

Disposition

PACU

Pain management

Minimally invasive with local injection in field.

Potential complications

Arrhythmias, pneumothorax, heart perforation, bleeding

Later complications include pericarditis, lead dislodgement, device migration, venous thrombosis, hematoma

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications