- Case report
- Open Access
Sudden onset pacemaker-induced diaphragmatic twitching during general anesthesia
© The Author(s) 2019
- Received: 6 March 2019
- Accepted: 27 May 2019
- Published: 3 June 2019
Involuntary muscle contraction caused by extracardiac stimulation is a rare complication induced by a pacemaker. We report a case who developed sudden onset diaphragmatic contractions during general anesthesia caused by a DDD mode pacemaker.
A 74-year-old woman with a permanent pacemaker was scheduled to undergo mastectomy. The pacing mode was switched from DDD to VOO intraoperatively to avoid electromagnetic interference. Immediately after returning the pacing mode to DDD after surgery, diaphragmatic contractions occurred, mimicking bucking type of movements. After switching the pacing to A-sense V-pace, the twitching ceased. Because no structural problems were noted, and the twitching disappeared after terminating atrial pacing, diaphragmatic contractions might be caused by stimulation of the right phrenic nerve located near the right appendage where the electrode was installed.
The potential risk of muscle twitching should be carefully evaluated preoperatively especially in patients with atypical position of pacemaker leads.
- Atrial pacing
- Diaphragmatic twitching
- General anesthesia
- Phrenic nerve
A 74-year-old woman (height, 146 cm; weight, 36 kg) with cancer of the right breast was scheduled to undergo mastectomy under general anesthesia. The patient’s medical history included permanent dual-chamber pacemaker implantation (Adapta L ADDRL1, Medtronic, Dublin, Ireland) for complete atrioventricular block at the age of 59. The pacemaker had been programmed in DDD mode at 60–120 beats/min with atrial output 1.5 V-0.4 ms, ventricular output 1.5 V-0.4 ms, atrial sensitivity 0.5 mV, and ventricular sensitivity 2.8 mV. The patient’s preoperative electrocardiogram showed A-sense V-pace with an intrinsic atrial rate of 84 beats/min.
In the operating room, general anesthesia was induced with fentanyl 100 μg, remifentanil 0.2 μg/kg/min, propofol 50 mg, and rocuronium 40 mg intravenously. After tracheal intubation, the pacemaker mode was switched to VVI mode. The patient was pacemaker dependent, and her intrinsic ventricular rate was less than 40 beats/min. The ventricular pacing threshold (0.6 V-0.4 ms) was confirmed. The pacing mode was changed to VOO at a fixed rate of 80 beats/min intraoperatively because the surgical site was very close to the generator, and we expected electromagnetic interference due to the use of unipolar electrocautery. General anesthesia was maintained with 3.5% desflurane and 0.2–0.4 μg/kg/min of remifentanil. The patient remained hemodynamically stable intraoperatively, and the surgical procedure was uneventful.
In the present case, VOO mode was selected to avoid electromagnetic interference due to the proximity of the generator to the surgical site. DDD mode is widely used intraoperatively if the surgical site is not close to the generator  and considered to be superior to VOO as it maintains the “atrial kick” and sequential atrioventricular contraction . If DDD mode is selected, caution should be exercised because muscle twitching can be induced by atrial pacing as occurred in this case. In patients with a dual-chamber pacemaker, atrial pacing should be tested to evaluate thresholds and the presence of twitching. If twitching is induced by atrial pacing, reprogramming of the pacemaker with appropriate anesthetic and hemodynamic management is required. The atrial rate may need to be maintained higher than the pacing range; alternatively, the lower limit of the pacing rate should be reduced during surgery to avoid sudden muscle twitching.
Sudden, unexpected bucking movement during general anesthesia can be hazardous. Anesthesiologists should be aware of the possibility of extracardiac stimulation especially in a patient with atypical positioning of the pacemaker leads. A careful, detailed preoperative evaluation, including meticulous interview of the patient regarding any symptoms related to the pacemaker, should be performed. Although the details about the pacemaker and information on the time of implantation may not always be available, every effort should be made to obtain such information to avoid sudden muscle twitching .
In summary, we describe a patient with a permanent pacemaker implanted for complete atrioventricular block who presented with sudden bucking-like diaphragmatic contraction during general anesthesia. The potential risk of muscle twitching should be carefully evaluated preoperatively especially in patients with atypical position of pacemaker leads. We recommend testing of atrial pacing prior to surgery in these patients.
KT and MK carried out the anesthetic management of the patient and drafted the manuscript. DN, KM, KI, and TM revised the manuscript critically for important intellectual content. All authors have read and approved the final manuscript.
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Consent for publication
Written informed consent for publication of this report was obtained from the patient.
The authors declare that they have no competing interests.
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