Users Online: 228 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 

RSACP wishes to inform that it shall be discontinuing the dispatch of print copy of JOACP to it's Life members. The print copy of JOACP will be posted only to those life members who send us a written confirmation for continuation of print copy.
Kindly email your affirmation for print copies to preferably by 30th June 2019.


Table of Contents
Year : 2011  |  Volume : 27  |  Issue : 2  |  Page : 285-286

Sick sinus syndrome with Alzheimer's disease for bilateral hernia repair

Department of Anaesthesiology, Padmasshree Dr D.Y. Patil Medical College and Hospital, Nerul, Navi-Mumbai - 400 706, India

Date of Web Publication3-Jun-2011

Correspondence Address:
Rochana G Bakhshi
Department of Anaesthesiology, Padmasshree Dr D.Y. Patil Medical College and Hospital, Nerul, Navi-Mumbai - 400 706
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9185.81841

Rights and Permissions

How to cite this article:
Bakhshi RG, Patil SS, Kini P, Jagtap SR. Sick sinus syndrome with Alzheimer's disease for bilateral hernia repair. J Anaesthesiol Clin Pharmacol 2011;27:285-6

How to cite this URL:
Bakhshi RG, Patil SS, Kini P, Jagtap SR. Sick sinus syndrome with Alzheimer's disease for bilateral hernia repair. J Anaesthesiol Clin Pharmacol [serial online] 2011 [cited 2020 May 28];27:285-6. Available from:


There is paucity of literature on delivery of anesthesia to patients with coexisting sick sinus syndrome and Alzheimer's disease. We recently administered anesthesia to a 79-year-old, 34 kg, 148 cm male patient of Alzheimer's disease with thoracolumbar kyphosis for bilateral inguinal hernia repair. The patient was a known case of Sick Sinus syndrome and had a permanent pacemaker implanted 11 years back. He was diagnosed to have senile dementia with Alzheimer's disease 7 years back and was taking oral quetiapine 6.25 mg once a day and rivastigmine 1.5 mg twice a week.

The patient was irritable and uncooperative. Preoperative blood investigations were normal. ECG showed occasional premature ventricular beats with evidence of pacemaker spikes. 2D echocardiography revealed left ventricular ejection fraction of 62%, and pacemaker electrodes were visible at the apex of right ventricle. X-ray chest confirmed the electrode position, and the pacemaker pulse generator was seen in the right thorax. The pacemaker type was Regency SC + 2402L VVI as per the patient records. The patient was on regular cardiac checkup, and functioning of pacemaker along with battery check was done by cardiologist prior to surgery.

The patient received the morning dose of 6.25 mg of quetiapine. Routine monitors were attached and intravenous access was established. Supplemental Oxygen was administered at the rate of 2 L/min. Emergency cardiac drug tray and defibrillator were kept ready in the operation theater. The right internal jugular vein was cannulated for central venous pressure (CVP) monitoring and emergency insertion of temporary pacemaker leads, if needed. An arterial line was established for beat-to-beat monitoring of blood pressure. Epidural anesthesia was planned. As the patient was irritable, anxious, and uncooperative, titrated doses of midazolam 1.25 mg and fentanyl 50 μg were administered to sedate the patient. Epidural catheter was placed via the L3-L4 intervertebral space in the left lateral position. An initial test dose of 2 ml of 2% lignocaine was given. Two more topups of 4 mL 1.5% lignocaine each were given after confirming no adverse reaction to the test dose. Sensory block up to T7 level was achieved in 20 min. After 30 min, an epidural infusion of 0.5% bupivacaine with fentanyl 2 μg per mL was started at the rate of 5 mL/h, which provided adequate level of anesthesia. Additional supplemental doses of local anesthetic were not required. The surgery lasted for 2.5 h.

Hemodynamic parameters and oxygen saturation were maintained within normal limits. Hemostasis was achieved by conventional ligation of bleeders. A bipolar cautery was kept ready but its use was avoided. The patient was monitored in intensive care unit for 48 h and discharged on the 7 th postoperative day.

Sinus node dysfunction in the elderly can have many causes but is usually idiopathic. The sick sinus syndrome refers to a combination of symptoms (dizziness, confusion, fatigue, syncope, and congestive cardiac failure) caused by sinus dysfunction and manifested by marked sinus bradycardia, sinoatrial block, or sinus arrest. Permanent pacemakers are the mainstay of therapy for patients with symptomatic sinus node dysfunction. [1] Our patient had a VVI type rate adaptive demand pacemaker which automatically adjusts ventricular pacing rates to a sensed indicator of exertion.

Demand pacemakers can sense electrocautery, and inhibit pacemaker firing, leading to asystole. Using a bipolar rather than unipolar electrocautery is recommended. The electrocautery grounding pad should be placed as far away from the pulse generator as possible. It should be used at the lowest effective current and in short bursts with long pauses. To monitor perfusion, a Doppler detector or intraarterial line may be used. [2]

Alzheimer's disease is a common form of dementia, characterized by the degeneration of the basal forebrain cholinergic neurons innervating the cortex, amygdale, and hippocampus, with difficulty in sustaining attention and profound cognitive impairment, such as loss of memory and learning ability. [3] Most of the general anesthetic agents interact with both nicotinic and muscarinic receptors. They produce inhibition of central cholinergic transmission, which is already impaired because of age-related changes. [4] Anesthetists need to be aware of the possibility of unfavorable drug interactions, for example, cholinesterase inhibitor rivastigmine and its metabolites block acetylcholine hydrolysis and antagonize atracurium, whereas it accentuates the effects of succinyl choline.

We avoided General Anesthesia and planned regional anesthesia. Several studies have shown that analgesia levels obtained after subarachnoid block are approximately 3-4 spinal segments higher in elderly compared to young adults. [5] A paced heart cannot compensate for hypotension by tachycardia and hence spinal anesthesia should be cautiously used in such cases. The more gradual onset of sympathetic blockade after epidural anesthesia provides more time for compensatory function to take over. As our patient had thoracolumbar kyphosis, we avoided large bolus dose and gave titrated bolus doses local anesthetic and thereafter administered supplemental dose by infusion. This was sufficient to achieve the desired anesthetic level and we succeeded conducting this case uneventfully.

   References Top

1.Tomaselli GF. The Bradyarrhythmias: Harrison's Principles of Internal Medicine. 17 th ed. New York: McGraw-Hill; 2008. p. 1416-8.  Back to cited text no. 1
2.Rozner MA. Implantable Cardiac Pulse Generators: Pacemakers and Cardioverter-Defibrillators: Miller's Anaesthesia. 6 th ed. Amsterdam: Elsevier Inc; 2005. p. 1415-27.  Back to cited text no. 2
3.Fodale V, Qualtrone D, Trecoci C, Caminiti V, Santamaria LB. Alzheimer's disease and anesthesia: Implications for central cholinergic system. Br J Anaesth 2006;97:445-52.  Back to cited text no. 3
4.Ma J, Shen B, Stewart LS, Herrick IA, Leung LS. The septohippocampal system participates in general anesthesia. J Neurosci 2002;22:RC200.  Back to cited text no. 4
5.Racle JP, Benkhadra A, Poy JY, Gleizal B. Spinal anaesthesia with bupivacaine: influence of age. Br J Anaesth 1988 60:508-14.  Back to cited text no. 5


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article

 Article Access Statistics
    PDF Downloaded291    
    Comments [Add]    

Recommend this journal