Anesthesia Management of an Elderly Patient Having Permanent Pacemaker for Total Hip Replacement

Elderly patients with serious cardiac problems are presenting for major orthopedic surgeries. We present a case of an elderly male patient posted for total hip replacement having a permanent pacemaker in situ in ventricle paced, ventricle sensed, pacing inhibited (VVI) mode. The patient, on preoperative examination, was found to have a complete atrioventricular (AV) block on electrocardiogram (ECG) and electrophysiology study showed degenerative AV conduction disease and symptomatic complete AV block. The patient had seizure disorder and anemia, for which the patient was treated accordingly and optimized before surgery. The pacemaker mode changed to vesiculo‑vacuolar organelle (VVO). Combined spinal‑epidural was given. Arterial line was secured and the patient was monitored hemodynamically. The patient tolerated the procedure of total hip replacement well; vitals were maintained within 20% of the baseline. Phenylephrine infusion was given to maintain blood pressure. After operation was shifted to the intensive care unit (ICU), pacemaker was reprogrammed to VVI mode, and epidural infusion for pain and vigilant monitoring was done. The patient was shifted to the ward on the 3rd day and was discharged on the 5th day. To conclude, combined spinal‑epidural along with invasive cardiac monitoring is a reasonable choice for elderly patients with permanent pacemakers coming for major orthopedic surgeries.