**5.2 Preoperative evaluation**


#### **5.3 Anesthesia care**

The anesthesia team's performance is vital for the management of patients with multiple risk factors and older ages. The medical team must be prepared for potentially catastrophic events such as cardiac arrest, cardiac tamponade, and unstable arrhythmias. Therefore, make sure that surgical instruments and anesthesia support measures are ready for emergency sternotomy.

In these patients, the relationship between the EP physician and the anesthesiologist is crucial. The type of anesthesia is determined based on the patient's medical history and condition and might involve monitored anesthesia care (MAC),

#### *Pacemakers and Defibrillators Implantation DOI: http://dx.doi.org/10.5772/intechopen.101518*

sedation, regional anesthesia, or general anesthesia. The patient's position is usually supine so that the right or left shoulder (according to the surgeon's decision) is elevated by a pad. Also, the positions of the head and neck are very important and should be in a way that the patient feels comfortable. The patient's head is rotated to the opposite side of the surgical site for easier access to the subclavian vein. The airway should be easily accessible because of intravenous sedation. Most patients undergo local anesthesia with intravenous sedation by applying oxygen through a non-rebreather mask. The hands should be neutrally placed on either side. Standard vital signs monitoring is performed with ECG, pulse oximetry, non-invasive blood pressure monitoring (NIBP), and capnography.

The patient should be constantly monitored for airway obstruction and respiratory failure regardless of the anesthetic technique. In case of airway obstruction, the chin-lift and jaw-thrust maneuvers are immediately performed. Excessive restlessness, anxiety, and pain intolerance due to electric shock are the reasons for choosing general anesthesia with intravenous sedation. The arterial line should be established for patients with severe conditions.
