Abstract
Geriatric medicine is a full-fledged speciality nowadays. Anaesthesia for geriatric patients is quite challenging. Elderly patients with serious cardiac problems are presenting for various surgeries, warranting the anaesthesiologist to formulate tailor-made peri-operative plan of management. We hereby present a case of an elderly male patient, posted for bilateral inguinal hernioplasty having a permanent pacemaker in situ in DDDR (dual-chamber rate-modulated) mode. The patient, on preoperative examination, was found to have a complete atrioventricular (AV) block on electrocardiogram (ECG) and electrophysiology study showed degenerative AV conduction disease and symptomatic complete AV (atrio-ventricular) block. The pacemaker mode changed to VOO (asynchronous ventricular pacing) mode preoperatively. Central neuraxial blockade was given. Beat-to-beat haemodynamic monitoring was instituted with invasive arterial catheter-transducer system. The patient tolerated the procedure of bilateral inguinal hernioplasty well and vital parameters were maintained throughout the operation. Phenylephrine infusion was given briefly to maintain the blood pressure (MAP > 65mmHg). After the operation, patient was shifted to the intensive care unit (ICU), pacemaker was reprogrammed to DDDR mode, and vigilant monitoring was done. The patient was shifted to the ward on the 2nd post-operative day. This case highlights that low-dose spinal anaesthesia along with vigilant monitoring is a reasonable choice for elderly patients with permanent pacemakers coming for elective surgeries.

Key words: Geriatric anaesthesia, Pacemaker mode, Central neuraxial block, Phenylephrine, Complete AV block