Intraoperative pacemaker dysfunction caused by the use of electrocautery during a total hip arthroplasty

The Journal of Arthroplasty Vol. 13 No. 5 1998

Case Report

Intraoperative Pacemaker Dysfunction Caused by the Use of Electrocautery During a Total Hip Arthroplasty O h a n n e s A. N e r c e s s i a n , M D , H o w a r d W u , M D , D a v i d N a z a r i a n , M D , a n d Faiq M a h m u d , MD

Abstract: Pacemaker dysfunction encountered during orthopedic procedures is a rare but potentially life-threatening complication. With an increasing n u m b e r of orthopedic procedures performed on the aging population, it is not u n c o m m o n to encounter patients with pacemakers requiring major orthopedic intervention. Most, if not all, major orthopedic procedures performed today require the use of electrocautery for hemostasis. In this article we review the literature for pacemaker complications and report a case of pacemaker failure after a single use of the unipolar electrocautery on a patient undergoing a total hip replacement. Key words: pacemaker failure, total hip arthroplasty, unipolar, bipolar, electrocautery.

Case Report

Anesthesia was induced without complications. The patient was subsequently placed in the lateral decubitus position, and grounding pad for the unipolar electrocautery was placed on the inner thigh of the contralateral leg. The extremity was prepared and draped in the usual sterile manner. A lateral thigh incision was made. Soon after the skin incision, the unipolar electrocautery, with the setting at 35, was used to achieve hemostasis. After one brief pulse of the electrocautery, the patient's cardiac monitor displayed a sharp drop in the heart rate to approximately 30 beats per minute (Fig. 2). It failed to return to the preoperative paced rhythm. The blood pressure also dropped precipitously. The procedure was immediately aborted and the wound covered with sterile dressing. Drapes were removed, and the patient was placed in the supine position. The patient became asystolic at this time, and complete pacemaker failure was suspected. Cardiopulmonary resuscitation was begun and transvenous pacemaker instituted. The cardiac surgeon who had initially placed the pacemaker was con-

A 76-year-old white man with a history of coronary artery disease, myocardial infarction, and implantation of a permanent pacemaker elected to undergo a total hip replacement for degenerative hip disease. This patient was permanently dependent on the pacemaker. Before the planned surgery, the patient had progressively increasing left hip pain and difficulty with ambulation. The hip pathology was also exacerbating the patient's low back pain. After medical clearance from the patient's cardiologist, he was admitted for a left total hip replacement. The preoperative electrocardiogram revealed a normally paced rate of 70 beats per minute (Fig. 1). From the Department of Orthopaedic Surgery, New York Orthopaedic Hospital, Columbia Uniw,rsity College of Physicians and Surgeons, New York, New York. Reprint requests: Ohannes Nercessian, MD, 161 Fort Washington Avenue, New York, NY 10032. Copyright © 1998 by Churchill Livingstone@ 0883-5403/1305-001953.00/0

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tacted and was able to arrive to the operating room momentarily. Complete failure was contributed to the use of electrocautery. The pacemaker pulse generator was replaced immediately, with resumption of paced r h y t h m (Fig. 3). Anesthesia was reversed, and the patient was taken to the intensive care unit. There were no sequelae from the pacemaker failure. The patient was brought back to the operating room 1 week later. He u n d e r w e n t a left total hip replacement using a bipolar electrocautery without any complications.

In 1992 Purday and Towey [1] reported a case in which the surgical team unwittingly placed a magnetic instrument on the body of the patient with an implanted pacemaker. The patient went into a short period of asystole. The surgery was aborted but resumed without incident w h e n the source of the magnetic field was removed. Similar problems were reported by Barold et al. [2] and by Fleming and Toler [31. Four reported cases of pacemaker failure were due to metabolic imbalance [4-7]. These included malfunction secondary to hyperkalemia, hypokalemia, disturbance in the acid-base balance, and procainamide toxicity [8]. Although not e n c o u n t e r e d during surgery, four reports in the literature describe a very interesting cause of failure of pacemakers: collection of air pockets a r o u n d the device [9-12]. According to S a n t o m a u r o et al. [ 11 ], a pacemaker pocket is a low resistance area in the thoracic cavity. In event of subcutaneous air (i.e., subcutaneous emphysema), a pocket of gas is created a r o u n d the pulse generator. This can lead to a sudden increase in pacemaker impedance and a decrease in the contact area b e t w e e n the body and the pacemaker. For unipolar pacemaker models, this can lead to malfunction. Cases of pacemaker failure were reported secondary to blunt trauma, n o n e to have occurred intraoperatively. The majority of these cases have been due to wire displacement or fracture caused by blunt a b d u c t i o n - h y p e r e x t e n s i o n injuries of the upper extremity, carrying a heavy weight on the shoulder, m o t o r vehicle accidents, and blunt trauma to the

Discussion Despite a growing n u m b e r of patients with implanted pacemakers for cardiac conditions, a review of the literature reveals only few reported cases of pacemaker dysfunction occurring intraoperatively. Some reported dysfunctions had been associated with biochemical changes in the patient. Others were caused by trauma or a change in the physical e n v i r o n m e n t a r o u n d the pulse generator. The cases reported in the literature fall into five main categories: 1. Inadvertent application of a magnetic field to the pulse generator 2. Metabolic changes in the patient 3. A change in the physical e n v i r o n m e n t around the pulse generator 4. Blunt trauma to the pulse generator 5. Dysfunction associated with use of electrocautery.

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Fig. 2. Intraoperafive rhythm strip showing unpaced rhythm of approximately 30 beats per minute.

Pacemaker Dysfunction During Surgery

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Fig. 3. Electrocardiogram after replacement of pulse generator demonstrating normally paced rhythm.

chest [ 13-21 ]. Of these, d a m a g e to the pulse generator itself has b e e n reported in four cases, two due to m o t o r vehicle accidents, one from a blow to the chest with a baseball bat, and the other from a blow with a lead pipe [13,14,17]. In one review of scattered cases of intraoperative p a c e m a k e r failure reported in the literature, use of electrocautery appears to be the most frequently reported cause of the p r o b l e m [22]. Heller reported [23] a case of a 71-year-old w o m a n with a history of pacemaker dependency secondary to heart block who u n d e r w e n t revision of an arteriovenous fistula [23]. The surgeon m a d e his a p p r o a c h with a unipolar cautery with the grounding pad over the sacrum. At this point, the p a c e m a k e r began firing at a rate of 140 beats per m i n u t e s with intermittent capture. The r h y t h m persisted despite cessation of cautery use. Placing a m a g n e t over the pulse generator had no effect. The pulse generator was then replaced and analyzed. It a p p e a r e d that the unipolar cautery used during the a p p r o a c h had established a circuit t h r o u g h the pulse generator. F u r t h e r m o r e , after working with the m a n u f a c t u r e r in analyzing the r e m o v e d pulse generator, the a u t h o r postulated the generator had b e c o m e m o r e susceptible to malfunction because the battery life was reaching the end. Other investigators [24-33] h a v e also reported similar cases of p a c e m a k e r malfunction secondary to electrocautery malfunction, particularly in transurethral use of electrocautery during transurethral resection of the prostate. To the best of our knowledge, this report is the first to describe p a c e m a k e r m a l f u n c t i o n during an orthopedic procedure in the orthopedic literature. As the population ages, a growing n u m b e r of the elderly will be needing orthopedic intervention. It is i m p o r t a n t for the surgeon to be a w a r e of this complication. The use of unipolar electrocautery has b e c o m e routine in most m a j o r orthopedic procedures, and caution m u s t be exercised w h e n using the cautery in the unipolar m o d e in patients with pacemakers, particularly if the p o w e r source of the pulse generator is low. The exact m e c h a n i s m by which use of the unipolar electrocautery leads to dysfunction of the pacem a k e r is not clear. In one report, it is postulated that the cautery can establish a circuit t h r o u g h the pulse

generator [23]. To decrease the likelihood, it has been r e c o m m e n d e d to place the grounding pad as far a w a y from the p a c e m a k e r as possible. In addition, it is i m p o r t a n t for the surgeon and the operation r o o m t e a m to recognize the type of device that is implanted in the patient and h o w it will react to well-established factors such as a magnetic field. The type of device also determines in part its reaction to changes in the body's biochemistry and the physiologic e n v i r o n m e n t a r o u n d the pacemaker. It is p r u d e n t to h a v e all patients with p a c e m a k e r s receive clearance from his or her cardiologist before a n y m a j o r orthopedic procedure. The physician m u s t be familiar with the type of pacemaker. Use of the unipolar electrocautery should be avoided if possible. The grounding pad should be far a w a y from the pacemaker, and t e m p o r a r y pacing devices should be readily available. It is advisable to h a v e old p a c e m a k e r units replaced before a n y m a j o r orthopedic procedures. Perhaps the best guard against such unpredictable and potentially fatal complication is awareness of the p r o b l e m and the experience of others.

References 1. Purday JP, Towey RM: Apparent pacemaker failure caused by activation of ventricular threshold test by a magnetic instrument pad during general anesthesia. Br J Anesth 69:645, 1992 2. Barold SS, Gaidula J J, Casfillo R: Unusual response of demand pacemakers to magnets. Br Heart J 35:353, 1973 3. Fleming WH, Toler JC: Degradation of pacemaker function due to electromagnetic interference. Circulation 50S3:111, 1974 4. Al-Abdulla HM, Lulu DJ: Hypokalemia and pacemaker failure. Am Surg 40:234, 1974 5. Bailey AG, Stuart RL: Intraoperative pacemaker failure in an infant. Can J Anesth 38:912, 1991 6. Hughes JC Jr, Tyers GE Torman HA: Effects of acidbase imbalance on myocardial pacing thresholds. J Thorac Card Surg 69:743, 1975 7. O'Reilly MV, Murnaghan DIE',Williams MB: Transvenous pacemaker failure induced by hyperkalemia. JAMA 228:336, 1974

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8. Gay RJ, Brown DF: Pacemaker failure due to procainamide toxicity. Circulation 50:111, 1974 9. Kries DJ, Li Calzi L, Shaw RK: Air entrapment as a cause of transient pacemaker malfunction. Pace 2:64, 1979 10. Lasala AE Fieldman A, Diana DJ et al: Gas pocket causing pacemaker malfunction. Pace 2:183, 1979 11. Santomauro M, Ferraro S, Maddalena G et al: Pacemaker malfunction due to subcutaneous emphysema: a case report. Anesthesiology 43:873, 1992 12. Sermasi S: Air entrapment as a cause of transient cardiac pacemaker malfunction. Rev Eur Technol Biomed i2:99, 1990 13. Brown KR, Carter W, Lombardi GE et al: Blunt trauma induced pacemaker failure. A n n Emerg Med 20:905, 1991 14. Gould L, Betzu R, Taddeo M e t al: Pulse generator failure due to blunt trauma. Clin Card 11:581, 1988 15. Grieco JG, Scanlon PJ, Pifarre R: Pacing lead fracture after a decelerating injury. A n n Thorac Surg 47:453, 1989 16. Kronzon I, Mehta S: Broken pacemaker wire in multiple trauma. J Trauma 14:82, 1974 17. McAnn W J: Pacemaker malfunction associated with blunt trauma. NY State J Med 78:645, 1989 18. Ohm OJ: Displacement and fracture of pacemaker electrode during physical exertion. Acta Med Scand 192:33, 1972 19. Tegmeyer CJ, Bezirdjian DR, Irani FA et al: Cardiac pacemaker failure: a complication of trauma. South Med J 74:378, 1981 20. Lasky IL: Pacemaker failure from automobile accident. JAMA 211:1700, i970 21. Uppal SC, Mosterd WL: Dislocatee Van Een Pace-

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