Transcript Perioperative Management of Patients with Cardiac Rhythm

Perioperative Care of Patients with
Cardiac Rhythm Management Devices
Jonathan Dubsky, M.D.
Staff Anesthesiologist
Southwest Division OAG
September 13, 2012
Objectives:
1.
2.
3.
4.
5.
To learn a brief history and basic knowledge of
Cardiovascular Implantable Electronic Devices
To understand preoperative evaluation and
preparation necessary for patients with these
devices
Intraoperative management of these patients and
devices including procedure specific
considerations and problems that can occur
Necessary postoperative evaluation and
management
To provide example CME/MOCA type exam
questions concerning these patients and devices
Pacemakers 101
1st implantable pacemaker placed in Sweden in 1958.
It lasted 3 hours before failing and was replaced. (The
replacement lasted 2 days.) The patient, Arne Larrson
ended up having 26 pacemakers placed and replaced
over the course of his lifetime, though he outlived
both the inventor and surgeon who performed his
first procedure.
1st implantable pacemaker: circa 1958
Arne Larrson (1915-2001) 1st implantable pacemaker
recipient
Pacemakers
Generic Pacemaker Code
Generic Pacemaker Codes
A Brief (Very Brief)
History of Implantable
Defibrillators
First implantable defibrillator placed in 1980 at
Johns Hopkins
To date, two defibrillators have been placed in
dogs with life-threatening arryhthmias
Table 2 Generic Defibrillator
Code
Famous people with implantable
defibrillators
In 2011, the American Society of Anesthesiologists
(ASA) and The Heart Rhythm Society (HRS) came
out with an expert consensus on the management of
patients with Cardiovascular Implantable
Electronic Devices (CIEDs)
This was published in Heart Rhythm 2011; 8: 11141152
The full article and recommendations are available
in this journal or on the websites of the ASA or the
HRS
This presentation is based on these
recommendations
How do they come up with an expert
consensus and what does this mean?
-The writing committee consisted of eight cardiac
electrophysiologists, four anesthesiologists(including
one from CCF), one CT surgeon, and one allied health
professional.
-The consensus is based on literature review, input from
a reference group, as well as the authors personal
experience treating patients.
-The literature reviewed consisted of case reports and
case series(small numbers). There were no randomized,
controlled studies even to be reviewed.
- Not everyone had to be in agreement (85% or greater)
Back in the olden days……
In the past, it was just generally accepted that
placing a magnet over the defibrillator or
pacemaker would be a one size fits all solution.
Until recently, this was even recommended on one
of the web sites of a manufacturer of CIEDs.
That’s no longer necessarily the case, so……
Before we can come up with a plan to manage these
patients, we need to understand what type of
problems can occur with CIEDs in the perioperative
period
EMI (electromagnetic interference) Patients are exposed to many
sources of EMI in the perioperative period, and EMI is well
documented to cause malfunction of CIEDs. But how this affects
management depends on many things including
- strength, duration and type of interference
- patient’s dependence on, indication for CIED and intrinsic rate
and rhythm
- built-in protective engineering of current devices
So… What is the most common
source of EMI and CIED interaction
in the operating room?????
Monopolar electrosurgery
Bipolar vs. monopolar electrosurgery
Bipolar – current flows between limbs of forceps
- only used for coagulation not dissection
- does not cause EMI unless applied
directly to the CIED
Monopolar – current flows from pen through patient’s
body to return surface electrode.
Most common form of EMI and CIED
interation in operating room
What types of problems can monopolar
electrosurgery/EMI cause to CIEDs?
1. Inhibition of pacing function due to oversensing (most
common)
2. Inappropriate ICD therapy/shocks (can cause sustained
ventricular arrhythmias though likely will do nothing more
than cause skeletal muscle contraction with shock if not using
muscle paralysis)
3. Triggering unnecessary antitachyarrhythmia therapy
4. Device reset (infrequent)
5. Pulse generator damage(uncommon as long as electrosurgery
current kept greater than 6 inches from generator)
6. Damage to the lead-myocardial interface(unlikely)
The last two are extremely unlikely unless energy applied
directly to the generator or leads
Risk mitigation
Risks of oversensing and other complications determined by site of
electrosurgery application, duration of electrosurgery, and
positioning of the return electrode
RECOMMENDATIONS
Keep electrosurgery current path as far away as possible from
generator
Limit electrosurgery usage to short bursts (4 to 5 seconds) if
possible
During surgeries close to generator (head, neck, shoulder, carotid
etc.) use bipolar electrosurgery if possible
Strategic positioning of return electrode so current path avoids
CIED
Risk mitigation continued
For surgery below the umbilicus in patients with upper chest implanted
generators, oversensing problems are unlikely. Surgeries above the
umbilicus pose more of a risk
RECOMMENDATIONS
For procedures below the umbilicus, the consensus group feels that it is
generally best to make a pacemaker asynchronous only if significant
inhibition is observed (even if the patient is pacemaker dependent)
For procedures below the umbilicus, the patient with ICD can have no
intervention or application of a magnet depending on comfort level of
anesthesia provider. Magnet application suspends arrhythmia detection
If nothing is done, a magnet should still be immediately available. If
ICD is deactivated, continuous monitoring for arrhythmia should be
performed and cardioversion/defibrillation equipment available
Special situations
Cardioversion- problems rarely observed with external
cardioversion. Use ant/post positioning of electrodes and >8cm
from ant lead to CIED. Occasionally CIED reset observed with
internal/direct cardioversion in OHS
RF ablation- can cause same problems as monopolar
electrosurgery and may be more problematic due to prolonged
exposure of current
Diagnostic radiation- generally does not cause problems
Therapeutic radiation- is type of EMI most likely to cause device
reset. Discuss with radiation oncologist shielding possibilities.
Calculation can be done to figure amount of radiation that will by
absorbed by device. If this exceeds manufacturers recommended
amount, CIED may need to be moved to different location.
Special situations continued
ECT- Hemodynamically significant inhibition
of pacing is unlikely due to stimulus being so
brief. Extreme sinus tachycardia that follows
seizure may be problematic though.
TURP- place return electrode on thigh or buttock
GI procedures- same precautions as monopolar electrosurgery if electrosurgery to be used
Tissue expanders- use expanders without magnets in patients with CIEDs
TENS and Spinal Cord Stimulators – In general TENS not recommended in pacemaker dependent
patients. There are specific recommendations available if felt treatment necessary and these
recommendations also apply to SCS
Lithotripsy – risk to CIED is low. Recommend continuous monitoring, terminate procedure is
arrhythmias occur, magnet if inhibition occurs, interrogation if complications occur
Table 2 / Summary
Preoperative evaluation of a patient with
a CIED
Many larger institutions have 24 hour access to a member of a CIED
team(cardiologist, electrophysiologist, device nurses, staff etc.)
The procedure team should advise the CIED team about the
anticipated surgical intervention and the CIED team should make
recommendations ( a prescription) for management of the device
perioperatively.
***** The consensus group feels that it is inappropriate to have
industry employed allied health professionals develop the
prescription/plan ******
Table 3
Preoperative recommendations
Table 4 Information given to the
CEID physician
Table 5
Table 6
Emergency Surgery Recommendations
Table 7 Intraoperative Monitoring
Tables 8 and 9
Postoperative evaluation
Notice that even though earlier they said
that cardioversion rarely causes
problems, that this is one of the three
situations that they recommend
absolutely be evauated prior to discharge
from telemetry.
Table 9 Indication for interrogation of CIEDs prior to patient discharge
or transfer from cariac telemetry environment
Question 1
Which Statement about a DVIR pacemaker is MOST likely true?
A.
B.
C.
D.
The atrium and ventricle are sensed
The paced rate may respond to increases in minute ventilation
The paced rate is not influenced by the patient’s intrinsic HR
Only the ventricle is paced
Answer
B
1st letter is chamber paced
2nd letter is chamber sensed
3rd letter is pacer’s response to the chamber whose rate is
sensed(I=inhibited)
4th letter is programmability for rate modulation (R) ex. Increasing the
paced rate as the paced detects an increase in motion, vibration or minute
ventilation
Question 2
Which of the following modes of temporary pacing would be
MOST appropriate to use in a patient with 3rd degree AV block
with a ventricular escape rate of 30 beats/min following mitral
valve replacement?
A.
B.
C.
D.
AAI
VOO
AOO
DDD
Answer
D.
Most commonly patients with AV nodal
dysfunction are paced with mode DDD following
cardiac surgery
Question 3
A patient has a pacemaker that detects an atrial
stimulus and responds by stimulating the atrium
only when the atrial rate is less than the lower
rate limit.
A)
AOO
B)
DOO
C)
VVI
D)
AAI
Answer
AAI
Question 4 (I made this one up)
Your patient has a CIED implanted in left upper
chest wall and presents to OR for Left forearm
surgery requiring extensive use of monopolar
cautery. Where should return electrode be placed?
A) Forehead of patient
B) Right on top of CIED generator
C) Left arm
D) Right arm
E) OR bed
Extra Credit Question #1
Who is this group of young lads?
Possibly the anesthesia team for the first
implantable pacemaker???
No, it’s Gerry and the
Pacemakers!
Also from Liverpool, England
1st three singles went to #1 in charts
in early 1960’s .
Most popular songs “You’ll never Walk Alone”, and “I
Like It”
Extra credit #2
What fine Northeast Ohio dining
establishment do we see in the photo?
Answer: Pacers
14600 Detroit Ave. Lakewood
References
:
Crossley GH,Poole JE, Rozner MA, Asrivatham SJ,Cheng A, Chung MK, Ferguson
TB, Gallagher JD, Gold MR, Hoyt RH, Irefin S, Kusumoto FM, Moorman LP,
Thompson A: The Heart Rhythm Society(HRS)/American Society of
Anesthesiologists (ASA) Expert Consensus Statement on the Perioperative
Management of Patients with Implantable Defibrillators, Pacemakers and
Arrhythmia Monitors: Facilities and Patient Management. Heart Rhythm.
2011;8:1114-1152.
ASA ACE continuing education program (various years 2006-2011)