72-year-old man for Lumbar Laminectomy
- L5/S1 synovial cyst resulting in a radiculopathy.
- Severely limited by pain, unable to drive.
- Hypertension and hypercholesterolaemia
- CVA 12 years ago, on lifelong clopidogrel. No residual symptoms
- Phone consult, anaesthetist requested an ECG preoperatively
- ECG reviewed at a later date and Trifasicular block noted
- Patient denied any symptoms
- ECG discussed with cardiologist and decision made to proceed due to lack of symptoms
- Patient unable to make it to hospital on day of surgery due to floods
- Collapsed at home 2 days later and required emergency pacemaker insertion
- Very interesting sequence of events!
- Perioperative assessment of distance patients via phone can present difficulties.
- In this case the ECG was viewed by a different anaesthetist at a later date but was still picked up and acted upon effectively.
- Patients may often have symptoms but are unaware or symptoms developed insidiously
- Discussion around risk of asymptomatic Bifasicular and Trifasicular block intraoperatively
- Majority of the opinion that there was significant risk of complete heart block
- AHA 2018 Guidelines on Bradycardia state; “In the setting of non-cardiac surgery, intraoperative bradycardia is most commonly attributable to SND and only rarely attributable to worsening atrioventricular conduction.”
- Recommendations do state that many anaesthetic drugs and surgical procedures can exacerbate existing bradycardia and should consider transcutaneous or Permanent pacing perioperatively
- AHA Management Algorithm for AV Block (2018)