Interesting Case

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We had an interesting case in the OR last week (well, at least I thought it was interesting).

Patient with a pacemaker scheduled for a posterior C4-5 fusion. Since I know how we handled it... what would be your concerns and how would you handle the case??

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Was there any neuro (sensory/motor) monitoring being done ...

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I'd want to know why they have a PM, and if you turn it off temporarily, how will they handle it? And if your post. cervical, I'm assuming you're sitting, so I'd be concerned about VAE and all that goes along with it. Tell us more!

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what is the underlying rhythm, what type of pacer cont or on demand?. is it actually a pacer or an internal defib.

when was it implanted. was it due to an mi. if so when was the mi. where was the mi. what meds are they on.

put pacer pads on preoperatively. have an external pacer in the room.

is there a cardiology workup before hand.

echo? ef? significant cardiovasc. disease.

12 lead ekg.

d

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I'd want to know why they have a PM, and if you turn it off temporarily, how will they handle it? And if your post. cervical, I'm assuming you're sitting, so I'd be concerned about VAE and all that goes along with it. Tell us more!

Actually, I'd hope they're not sitting - most of these can be done prone.

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The case was indeed done prone.

No Neuro monitoring in place.

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The case was indeed done prone.

No Neuro monitoring in place.

The pacemaker issue doesn't bother me all that much. The type and why it's there are the main things I'd want to know. Depending on what it is it may need to be re-programmed preop/postop, and have a magnet available, etc., etc. We would insist on a recent cardiology workup / clearance before doing this case. I think having external pacing stuff available would be fine, but in all these years I don't think I've ever experienced a pacer failure in the OR, although I'm sure it does happen.

I'd be more worried about the reason for the fusion. HNP, fracture, is the neck stable or unstable, are there any neuro deficits preop? Interesting that they didn't use neuro monitoring, since that seems to be the trend with most of our neck cases. (my current pet peeve - trying to satisfy the SSEP techs who want 1/4 MAC, no N2O and minimal narcotics - hellllllooooo, we call that a MAC:chuckle )

If unstable neck, would have to consider awake FOB. If supposedly stable, I'd opt for a light wand or GlideScope (new favorite toy) for intubation. Other than that, I don't see any other big red flags popping up.

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our SSEP people don't want us to use gases...we use Remi/Propofol infusions...works nicely.

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our SSEP people don't want us to use gases...we use Remi/Propofol infusions...works nicely.

GASP - But then what good is the BIS? :rotfl:

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Interesting responses.

Besides everything you have all listed, we were also concerned about the pacemaker and the close proximity of the bovie. We elected to apply a magnet before hand, since the patient would be prone making access impossible after the beginning of the surgery.

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most places i have been don't use the bis.....:)

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GASP - But then what good is the BIS? :rotfl:

Propofol is an hypnotic and therefore you can still use your BIS monitor; in fact, we use it all the time. :)

skipaway

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