P025: PERCUSSION PACING REVISITED
Jordan Miller, MD, Ilan Keidan, MD, Chris Giordano, MD; University of Florida
Introduction: Anesthesiologists frequently encounter acute, vagally mediated bradycardia in the perioperative setting. Percussion pacing has been suggested as an alternative to treat those events. Percussion pacing involves using one's fist to repeatedly strike a patient's left lower chest in a rhythmic manner resulting in increased left ventricular pressure and subsequent depolarization and contraction of the myocardium (1). The approach to acute bradycardia in the perioperative setting has been recognized as an entity requiring a separate algorithm (Anesthesia advanced circulatory life support(A-ACLS) 4 ).While the ACLS and A-ACLS differ in the initial approach, differential diagnosis and treatment, both do not include percussion pacing in the 2015 treatment algorithm (2,3).
Case Presentation: Our patient was a 63 year old male who sustained multiple bone/rib fractures and a complete T6 spinal cord injury from a motor vehicle accident 10 days prior, and was scheduled for an insertion of a gastric feeding tube. The patient arrived to the operating room intubated and ventilated. When reconnected to the anesthesia ventilator on spontaneous ventilation with semi-closed pop-off valve creating high CPAP, his heart rate dropped to 30 BPM and a corresponding decrease of end-tidal carbon dioxide to 15 mmHg was noted. While commencing mechanical ventilation, administering atropine 0.5 mg, and calling for a transcutaneous pacer, we performed percussion pacing at a rate of 80 percussions per minute. Our monitor showed that each of these fist percussions resulted in ventricular depolarization as evident on continuous electrocardiogram, which was further confirmed by the re-emergence of a waveform on plethysmography, arterial line waveform tracing, and lastly a return of EtCO2 values in the 30-40mmHg range. The patient returned to normal sinus rhythm after 120 seconds of percussive pacing, and the fist pacing was subsequently discontinued. Surgery was completed and the patient fully recovered with no adverse sequelae.
Discussion: Reports on the use of this technique in the perioperative period are limited, and the specific use in cases of vagally mediated bradycardia under anesthesia is rare. One report has described percussive pacing treatment of acute bradycardia under spinal anesthesia (3) and another described its utility secondary to an oculocardiac reflex during strabismus repair surgery (1). This case demonstrates the utility of percussion pacing as an adjunct to medical management for bradycardia during general anesthesia.This is an immediately available tool that can be used as part of the anesthesiologist's armamentarium. The AHA states that there is insufficient evidence to recommend this technique during cardiac arrest. While this practice is not recommended as part of the AHA ACLS guidelines, it can be considered in A-ACLS.