Pacemakers and Anaesthesia in a Low Resource Setting: A Case Report

Cardiac implantable electronic devices such as pacemakers are increasingly encountered in patients presenting for non-cardiac surgery. Their presence poses significant anaesthetic challenges, particularly in low-resource settings where access to device specialists and advanced monitoring may be limited. Careful perioperative planning is therefore essential to minimize complications related to haemodynamic instability and electromagnetic interference. We report the successful anaesthetic management of an 81-year-old male with a permanent pacemaker programmed in DDDR mode who presented for right knee arthrotomy, synovectomy, and washout for septic arthritis. The patient had multiple comorbidities including hypertension, type 2 diabetes mellitus, end-stage renal disease on thrice-weekly haemodialysis, and retroviral disease on highly active antiretroviral therapy. Preoperative evaluation included cardiology consultation, echocardiography demonstrating borderline left ventricular systolic function (ejection fraction 45–52%), and perioperative coordination with a pacemaker technologist who reprogrammed the device to an asynchronous pacing mode. Anaesthesia was conducted using a combined spinal-epidural technique with a low-dose spinal block consisting of 7.5 mg of hyperbaric bupivacaine and 25 µg fentanyl. Standard ASA monitoring was employed, and special precautions were taken to minimize electromagnetic interference from electrocautery by appropriate placement of the diathermy grounding pad. Surgery lasted approximately one hour and was completed without haemodynamic instability, pacemaker malfunction, or other perioperative complications. Postoperative analgesia was provided via the epidural catheter, and the pacemaker was subsequently restored to its original programming. This case highlights the importance of multidisciplinary collaboration, thorough preoperative assessment, and adherence to perioperative safety precautions in managing geriatric patients with pacemakers. It also demonstrates that low-dose spinal anaesthesia can provide adequate surgical conditions with stable haemodynamics for lower limb surgery in selected patients with limited cardiac reserve in resource-constrained settings.