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• W2000551763 abstract "Englehardt et al. [1] report pacemaker ‘malfunction’ with the use of a peripheral nerve stimulator for placement and subsequent management of an interscalene catheter. They applied high-current output nerve stimulation across the chest and the lead system of a cardiac pacemaker, inducing a signal on the sensing circuit of the pacemaker. According to the pacemaker’s ‘rules’, this signal was interpreted as native ventricular activity leading to pacemaker output inhibition. The authors state: ‘…we do not think that we were putting the patient at a disproportionate risk when investigating the inhibitory effects of different current levels, as the bradycardia seen during pacemaker suppression did not cause any adverse effects and ceased immediately when the stimulator was turned off’. We disagree. This patient was placed at undue risk from the start of case. The application of electricity, in any form, to any patient with an implanted electrical generator (whether pacemaker, implanted defibrillator, thalamic stimulator, spinal cord stimulator and so forth) should always provoke the consideration that the energy could enter the device. According to the Axios Technical Manual (the authors have misidentified the generator as ‘Axion’, a product name never used by Biotronik), application of electrical sources such as transcutaneous electrical nerve stimulation should take place only after a detailed analysis of the advantages and risks, and the electrodes should be as close to each other and as far from the pulse generator and lead system as possible [2]. For any pacing system, energy entering the ventricular lead generally produces output inhibition, with the possibility of asystole. This feature has actually been used to arrest a paced heart during bypass surgery [3]. The fact that this patient had some underlying rhythm preoperatively before the administration of a variety of drugs in no way confers similar pacing nondependence postoperatively. In fact, the interval on their Figure 1C from the paced QRS to the native QRS is over 3 s, demonstrating an underlying heart rate of less than 20 bpm. Perhaps the authors, and especially the patient, were just lucky. Furthermore, energy entering the atrial lead in a dual chamber pacing system (in the DDD mode) or entering a generator with a minute ventilation sensor will likely lead to an increased paced ventricular rate, and energy entering on either lead in a system with atrial or ventricular defibrillation capability could lead to an inappropriate atrial or ventricular defibrillation discharge. These behaviours are ‘pseudomalfunctions’, not ‘malfunctions’, since the generator is performing appropriately. In this case, the authors should have placed the current return electrode (it is not a grounding electrode) from the nerve stimulator as close as possible to the stimulating electrode, or perhaps on the patient’s left arm, thus directing the current away from the pacing system. Placement over the apex of the heart is, quite frankly, an invitation to disaster in cases like this. The lowest possible energy should have been delivered to the patient. Aside from the greater likelihood of pacemaker inhibition, use of current and pulse duration in the ranges described in the postoperative care of this patient has been associated with intense motor response and severe discomfort in awake patients [4]. Because these high current and pulse duration levels can provoke stimulation at great distance between electrode tip and nerve, the usefulness of affirmative motor response under these conditions becomes questionable. Consideration of an alternative means of performing the block without use of a nerve stimulator did not receive discussion prior to conduct of the case, or in retrospect. Use of ultrasound guidance to locate the brachial plexus between the scalene muscles would have allowed the electrical issue to be avoided entirely. In a recent series of 140 patients [5] placement of interscalene catheters for shoulder surgery under ultrasound guidance, without stimulation, was successful in 98% of patients with only one complication (pneumothorax). The points made by the authors about the use of 0.5 Hz compared with 2 Hz, the filtering circuit of the generator, or the nature of unipolar ventricular sensing are irrelevant. While it is true that a stimulation frequency of 30 bpm (0.5 Hz) would inhibit only a small proportion of ventricular paced events, this patient could still have developed a ventricular rate of 30 bpm (see their Figure 1b) with haemodynamic compromise. In addition, the application of a 2 or 0.5 Hz signal to a patient with an ICD could also produce an inappropriate discharge, depending upon the ICD ‘detect’ rate, since it could possibly cause the ICD to add 30–60 bpm to the actual sensed rate. Since signal conditioning is a proprietary feature of each generator, there is no assurance that the filtering component in a different generator from Biotronik or from another company would accept or reject signals in the same manner. Finally, the discussion in this case report should have included some guidance for the use of electrical nerve stimulation so this problem can be avoided in the future. Much of the guidance below is adapted from published reviews [6, 7]: apply the current in such a fashion that it will not cross the generator/lead/chest (for a cardiac generator) system use the lowest possible energy apply continuous cardiac and peripheral pulse monitoring to ensure detection of abnormal cardiac rhythms periods of asystole, if they occur, should be limited any defibrillation system that might be affected should be disabled during the application of the external electrical signal consider checking the generator for proper function following the application of the external electrical signal and to clear any abnormal events that might have been stored in the generator memory, which might confound a future generator interrogation." @default.
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• W2000551763 date "2008-04-11" @default.
• W2000551763 modified "2023-10-14" @default.
• W2000551763 title "Preventing pacemaker problems with nerve stimulators" @default.
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• W2000551763 doi "https://doi.org/10.1111/j.1365-2044.2008.05530_1.x" @default.
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