Expert: Ronald Levy, M.D. - 7/23/2009

Question
Hello Doctor:

My 29-year-old son has just had surgery to insert a pacemaker (PM). The pacemaker was required to control symptomatic bradycardia & Mobitz II conduction block which both his Electrophysiology Cardiologist and General Cardiologist felt placed him in at the very least both Class I and Class II (a.) categories under the AHA indications for permanent pacemaker placement. He also has a long term underlying autoimmune disease (PAN vasculitis) for which he is treated with daily Avinza (90mg) and a small amount of hydromorphone (4-8mg) for associated breakthrough pain, of which his doctor was well aware.

My husband and I and my son all asked detailed questions about the "anesthesia" before the PM surgery and were told that he would be put into a "twilight sleep" along with local injections of "numbing" medications to keep him from feeling the surgery. We presumed that an anesthesiologist would be present, although this was NOT the case. The surgery was estimated to take around 40 minutes.

My son had had EP (electrophysiology) studies done in a cath lab at a local University hospital several weeks before and not only did they have an anesthesiologist present but the anesthetist insisted on giving him general anesthesia due to his debilitated condition and due to his tolerance to strong pain medications. (This despite the fact that none of us preferred general due to the extra dangers AND due to the fact that my son is a singer with the small risk of damage to the vocal cords.)

His Electrophysiology Cardiology specialist is extremely good (we got several "2nd" opinions & searched the entire LA area to find him). He is highly skilled in PM placement of which he performs at least 10 per week (±500 per year) or approximately ±6000 over the 12 years he has been in private practice.

During the actual surgery there was no anesthesiologist present and they began the surgery by giving him several successive doses of both Versed and Vicodin (IV equivalents), which failed to put him into any kind of sedation. They waited and waited for the drugs to work however my son failed to experience twilight sleep of any sort — in fact he apparently talked nonstop throughout the surgery. (He is a professional singer/songwriter/guitarist & is not hesitant to express himself verbally.)

Eventually he did tell his doctors that he felt "very relaxed" and so they tentatively began the surgery using local injections. The "40 minute" surgery began to take longer & longer as they had to keep stopping, give him more medication, and then wait to continue. Immediately following the surgery my husband and I were told by the amazed doctor that they had given him enough of the IV Versed/ Vicodan to “knock out a horse” and yet they were never able to get him into anything even closely resembling a “twilight sleep.” (Apparently this total dose was the equivalent of 20 Vicodin and 10 Versed but I never received a completely straight answer.)

My son swears he felt only minimal pain — during the injections, some discomfort as they were making a “pocket” in the Pectoral muscle, and also as they actually inserted the device. I asked my son if he had to go through PM surgery again if he would ask for a general or go forward with what he was given this time and he answered that he by far preferred having it done this way, disliking the recovery time and risks from a general. The only problem with this is that there was a fairly significant risk present that they may have had to stop the surgery or worse due to the lack of pain management planning with this method.

What is your take on this? Are there alternative drugs they could use when he needs surgery again (device replacement, etc)? My desire would be (as I expected to would be the case this time) to at least have a physician anesthetist specialist present throughout the surgery with some attempt to more definitively oversee my son’s pain management, including a pre-consult with him & family to discuss the anesthesia to be used.

Just because PM placement is considered “band-aid” surgery does not excuse the failure to consider the more complex pain management needs of a small but significant percentage of the patient population.

Thank you for taking time to read and consider this issue.  

Answer
It is not unusual to do a pacemaker without an anesthesiologist (in fact it is the usual). When you say they couldn't sedate him, that could mean several things. Sedation, in this respect, means that the person is comfortable, not moving and (hopefully) has some amnesia post procedure. Pain management is related to the narcotic he was given (I am surprised they used Vicodan which is long acting rather than Fentanyl which is short-acting). While talking is not desirable, it is also not necessarily harmful. The only additional medicine an anesthesiologist might use is Propofol and/or Ketamine, but if your son didn't mind the procedure, and the cardiologist didn't have a problem doing it, then sedation is probably better than general anesthesia.


Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston