Anaesthetic management of a patient with permanent pacemaker posted for frontal lobe tumor excision

Introduction: Patients undergoing neuro-anaesthesia with cardiac co-morbidities pose a considerable challenge to anaesthesiologists. Management of patients with pacemaker in situ and anaesthetic implications are crucial. We report a successful anaesthetic management of a patient with pacemaker for frontal lobe tumor excision under general anaesthesia. Case Summary: 64 year old female with complaints of headache and irrelevant speech since 2 weeks, diagnosed to have frontal lobe tumor. Patient had history of syncope 5 years back and was diagnosed to have complete heart block. Thus a permanent pacemaker with VVI synchronised mode with heart rate 70/min was placed. On examination patient was moderately built, drowsy, heart rate was 68/min and rest vitals were within normal limits. Blood investigations were within normal limits. ECG showed pacemaker spikes just before QRS complexes and LVH. 2D Echo showed pacemaker lead in right ventricle and rest findings were normal. Patient accepted for surgery under ASA grade III with appropriate consent. Preoperatively central line was secured. Facility for temporary pacing and pacemaker technician were kept ready. Pacemaker settings were programmed from VVI mode to VVO mode. Patient was premedicated and induced with inj. thiopentone and inj. rocuronium, intubated and ventilated. Intraoperative vitals were maintained within normal limits. At the end of surgery patient was drowsy but maintained SpO2 100%. ET tube was kept in situ and patient was put on CPAP mode. VVO mode reprogrammed to VVI mode. Patient shifted to surgical ICU, all investigations were within normal limits. Patient was extubated in SICU 6 hours postoperatively. Conclusion: Neurosurgical patient with permanent pacemaker poses a real challenge to an anaesthetist. Thorough pre-op evaluation and team work of anaesthetists, physician and surgeon resulted in successful outcome.