Expert: Ronald Levy, M.D. - 3/5/2010

Question
Dr. Doctor Levy,

I am writing a new post because I wasn't able to reply again to my other one about general anesthesia and my PTSD. I appreciate your encouragement, and my logical rational side completely agrees that it's best not to wait regarding my pacemaker situation. Unfortunately another part of me is screaming "NO!!!!" and will not back down. If I may I'd like to expand further one more time to provide more input.

Just a brief rundown of my history. I've had many surgeries (20+) that were done with local or regional. I agree with you about the overall risk issue; clearly I've had many surgeries already and I'm still walking around.
Many of those surgeries, however, were not without complications. The pacemaker ones are by far the worst offenders. The pacemaker fix you mentioned might be a moot point, but I also have a history of these surgeries getting more complicated each consecutive time. Things never go as planned, and even since the very first pacemaker implant surgery I've had complications. I have to consider that the surgery also has good chance of making things worse too. My body clearly doesn't want the machines and to keep doing more and more surgery only adds more insult to an already upset body.
That said, I'd like to briefly(?) mention other medical history.

Another pacemaker complication I didn't mention is my very symptomatic and chronic SVC syndrome because of my wires. My SVC is totally occluded. My body has developed more collaterals, but they are becoming obstructed too. My wonderful hemiazygos vein greatly expanded to compensate for the increased venous pressure, but last year I lost that too (it occluded--no pacemaker wires there). In sum, my venous return is compromised. Just a little exercise (or stress) can send me overheating in my head because my blood can't return to my heart fast enough. This cat and mouse game of gaining collaterals and then losing them has been going on for some time. Only just late last year did a doctor finally diagnose central venous DVT and suggest anticoagulation therapy (I've had a 4,000 d-dimer the whole time. The dimer was discovered when I had symptoms of a PE several years ago. A PE was never diagnosed, however, which I'm not surprised given how well I hide things). I never started the recommended anticoagulation because I knew with my need for regional anesthesia this could get messy. I was also told by other medical advice that the anticoagulation will probably not work. In effect, much of the medical advice I've had has not been encouraging.

Anyhow, to expand further, because of my venous issue, my head is always congested to some extent. This complicates other problems. One, I also have chronic laryngeal edema due to poorly controlled reflux despite high doses of a number of meds tried. Secondly, I also suffer from untreated OSA with a CPAP I find too difficult to use because my nasal passages are chronically swollen from the edema. (This pacemaker surgery would not deal with this problem). I also suffer from recurring URIs.
I suffer from reactive airway disease, so beta-blockers are out of the question for anything else (I react with the blockers). I also suffer from unstable angina that so far has mostly been controlled, but can break through needing higher doses of calcium channel blockers. I have migraines now that never before gave me stroke like symptoms. I suffer from documented hypoglycemic episodes (I'm not diabetic) that can be worsened with fasting. Also, the last time I fasted for a surgery the fasting sent me into a potassium deficiency.
Muscle relaxants have in the past induced arrhythmia in me so my regular docs stay away from them like the plague.
After many of my surgeries the staff had later questioned me about my blood pressure dropping.
Benzodiazepines make me paradoxical. I am having increasing adverse reactions to narcotics (severe itching, chills, nausea, etc) and the last time I had a narcotic, demerol, some time ago, for post op pain it didn't do squat for me. With my pacemaker migration I have been in terrible nerve pain for some time, so I've been presribed low dose percocet that I could only take very rarely (and half a pill because of side effects). With the percocet I believe I've also started having a reaction.

With my pacemaker surgery, I was told that I would have to be placed on backup pacing which to my knowledge is at a fixed rate. How can an anesthesiologist tell if I'm in distress if my heartrate won't change with my physiology? The pacemaker, I'm told, would also be placed back under the muscle where I had already had severe pain already. (My quality of life has sucked because of this).
Despite all these pacemaker issues, the original arrhythmia that was supposed to be treated with ablation still exists to this day.

And if this all seems like a lot already...I'm just getting started. I just don't know how I can possibly cover all this with an anesthesia consult. You're right, I will have to live with my decision, and I'm afraid I've come to a place where I believe I have to weigh quality of life vs life itself. It's pretty sad to say this because I'm only 38. I want to live, but frankly I'm not optimistic with the consult coming up. I am simply too concerned about the fact it's just too easy for someone to make a terrible mistake with me. I will give that consult doc a chance, but it's going to take a miracle to change my mind esp where general anesthesia is concerned. And my mind is saying no.
Thanks so much for your encouragement. You've been very kind. Again your feedback is appreciated. (I still want to live, so I am praying mightily about this).

Answer
While you do have a complicated history, you still could have the surgery. To touch on some of the points (and I'm sure the anesthesiologist will go over any and all of this with you), the backup pacemaker is an external pacemaker that is there only if your pacemaker fails. While it is on a fixed rate, that is better than no rate and we can adjust that rate should we fell you need a different rate. Usually the backup rate is more than enough and we don't need to adjust it. We have several ways to tell if you're in distress. Hear rate is only one of them. While I know your brain is screaming no surgery, I still believe that this surgery warrants the risk.


Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston