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Misinterpreting Paced Heart Rhythms: A Case Report
Betty M Luan-Erfe1, BobbieJean Sweitzer1, Max O Soghikian1
1From the Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
A&A Practice
|January 11, 2021
Summary
Misinterpreting cardiac implantable electronic device (CIED) rhythms during surgery led to negative outcomes. Anesthesiologists must understand CIEDs to prevent complications and ensure patient safety.
Area of Science:
- Cardiology
- Anesthesiology
- Medical Device Management
Background:
- Cardiac implantable electronic devices (CIEDs) are common in surgical patients.
- Perioperative management of patients with CIEDs requires careful attention to device function.
- Anesthesiologists play a crucial role in patient care during surgery, even with implanted devices.
Observation:
- Two cases are presented where misinterpretation of paced heart rhythms in patients with CIEDs occurred during surgery.
- These errors happened despite experienced clinicians and adherence to standard perioperative recommendations.
Findings:
- Failure to correctly interpret CIED-paced rhythms resulted in adverse events.
- Consequences included unnecessary invasive procedures, surgical delays, and patient dissatisfaction.
Implications:
- This highlights the critical need for anesthesiologists to possess a thorough understanding of CIED functions and potential pitfalls.
- Enhanced knowledge can prevent adverse events and improve patient outcomes in surgical settings.
- Reinforces the importance of comprehensive training in device interpretation for perioperative care.
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