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Inadvertent suppression of a fixed rate ventricular pacemaker using a peripheral nerve stimulator
D O'Flaherty1, M Wardill, A P Adams
1Department of Anaesthetics, United Medical School, Guy's Hospital, London.
Anaesthesia
|August 1, 1993
Summary
Electromagnetic interference from nerve stimulators can cause dangerous pacemaker complications. This case highlights a rare but fatal risk of cardiac arrest in patients with ventricular pacemakers.
Area of Science:
- Anesthesiology
- Biomedical Engineering
- Cardiology
Background:
- Pacemakers are crucial for cardiac rhythm management.
- Electromagnetic interference (EMI) poses a potential risk to pacemaker function.
- While typically minor, EMI can have severe consequences.
Observation:
- A patient with a fixed-rate ventricular pacemaker experienced cardiac arrest.
- The event was linked to the intraoperative use of a nerve stimulator.
- This represents an unusual anesthetic-related source of EMI.
Findings:
- Activation of a common nerve stimulator caused significant EMI.
- The EMI led to a critical malfunction of the patient's pacemaker.
- This resulted in a fatal cardiac arrest.
Implications:
- Anesthesiologists must be aware of potential EMI sources.
- Careful patient selection and monitoring are vital for pacemaker patients.
- This case underscores the need for vigilance regarding device interactions in anesthesia.