title: Anesthesia care for subcutaneous implantable cardioverter/defibrillator placement: a single-center experience.
abstract: BACKGROUND
  The recently approved subcutaneous implantable cardioverter/defibrillator (S-ICD) uses a single extrathoracic subcutaneous lead to treat life-threatening ventricular arrhythmias, such as ventricular tachycardia and ventricular fibrillation. This is different from conventional transvenous ICDs, which are typically implanted under sedation. Currently, there are no reports regarding the anesthetic management of patients undergoing S-ICD implantation.
  
  
  OBJECTIVE
  This study describes the anesthetic management and outcomes in patients undergoing S-ICD implantation and defibrillation threshold (DFT) testing.
  
  
  METHODS
  The study population consists of 73 patients who underwent S-ICD implantation. General anesthesia (n = 69, 95%) or conscious/deep sedation (n = 4, 5%) was used for device implantation.
  
  
  METHODS
  Systolic blood pressure (SBP) and heart rate were recorded periprocedurally for S-ICD implantation and DFTs. Major adverse events were SBP <90 mm Hg refractory to vasopressor agents, significant bradycardia (heart rate <45 beats per minute) requiring pharmacologic intervention and, "severe" pain at the lead tunneling site and the S-ICD generator insertion site based on patient perception.
  
  
  METHODS
  Of the 73 patients, 39 had SBP <90 mm Hg (53%), and intermittent boluses of vasopressors and inotropes were administered with recovery of SBP. In 2 patients, SBP did not respond, and the patients required vasopressor infusion in the intensive care unit.
  
  
  RESULTS
  Although the S-ICD procedure involved extensive tunneling and a mean of 2.5 ± 1.7 DFTs per patient, refractory hypotension was a major adverse event in only 2 patients. The mean baseline SBP was 132.5 ± 22.0 mm Hg, and the mean minimum SBP during the procedure was 97.3 ± 9.2 mm Hg (P < .01). There was also a mean 13-beats per minute decrease in heart rate (P < .01), but no pharmacologic intervention was required. Eight patients developed "severe" pain at the lead tunneling and generator insertion sites and were adequately managed with intravenous morphine.
  
  
  CONCLUSIONS
  Among a heterogeneous population, anesthesiologists can safely manage patients undergoing S-ICD implantation and repeated DFTs without wide swings in SBP and with minimal intermittent pharmacologic support.
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA. Electronic address: Michael.Essandoh@osumc.edu.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Essandoh
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Juan G
authors.initials: JG
authors.lastname: Portillo
authors.affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Raul
authors.initials: R
authors.lastname: Weiss
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Otey
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Alix N
authors.initials: AN
authors.lastname: Zuleta-Alarcon
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Michelle L
authors.initials: ML
authors.lastname: Humeidan
authors.affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Jose L
authors.initials: JL
authors.lastname: Torres
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Antolin S
authors.initials: AS
authors.lastname: Flores
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Karina
authors.initials: K
authors.lastname: Castellon-Larios
authors.affiliation: Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Abdel-Rasoul
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Andritsos
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: William J
authors.initials: WJ
authors.lastname: Perez
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Erica J
authors.initials: EJ
authors.lastname: Stein
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Katja R
authors.initials: KR
authors.lastname: Turner
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Galina T
authors.initials: GT
authors.lastname: Dimitrova
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Hamdy
authors.initials: H
authors.lastname: Awad
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Sujatha P
authors.initials: SP
authors.lastname: Bhandary
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Ravi S
authors.initials: RS
authors.lastname: Tripathi
authors.affiliation: Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Nicholas C
authors.initials: NC
authors.lastname: Joseph
authors.affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: John D
authors.initials: JD
authors.lastname: Hummel
authors.affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Ralph S
authors.initials: RS
authors.lastname: Augostini
authors.affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Kalbfleisch
authors.affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Jaret D
authors.initials: JD
authors.lastname: Tyler
authors.affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Houmsse
authors.affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus OH, USA.
authors.forename: Emile G
authors.initials: EG
authors.lastname: Daoud
mesh_terms: D000328:Adult; D000368:Aged; D000768:Anesthesia, General / Q000379:methods*; D001145:Arrhythmias, Cardiac / Q000503:physiopathology / Q000628:therapy*; D001794:Blood Pressure / Q000502:physiology; D001919:Bradycardia / Q000209:etiology; D016292:Procedural Sedation / Q000379:methods*; D017147:Defibrillators, Implantable; D004554:Electric Countershock / Q000009:adverse effects / Q000379:methods; D005260:Female; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D007022:Hypotension / Q000209:etiology; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000209:etiology; D019919:Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies
keywords: Defibrillation threshold testing; General anesthesia; Subcutaneous implantable cardioverter/defibrillator; Transvenous implantable cardioverter/defibrillator