Following the Path of Least Resistance: The Road Most Traveled mm Following the Path of Least Resistance: The Road Most Traveled Avoiding Electromagnetic Interference with Implanted Cardiac Rythm Devices (CRMD) Marjorie Voltero, CGRN

GOALS and OBJECTIVES Expand knowledge of Cardiac Rhythm Management Devices (CRMD) Explore recent trends in chronic disease management leading to increased use of CRMD in the GI patient population Review current literature recommendations in management of electrocautery use in patients with an implanted electronic device. Identify conditions that may result in a higher risk of electromagnetic interference (EMI) Initiate individual plan of care for GI patient

Cardiac Rhythm Management Devices (CRMD) (A little History….) Pacemaker history 1950 -John Hopps; Canadian Electrical Engineer; researching effects of radio frequency in hypothermia Late 1950’s- Wilson Greatbatch; another engineer working on oscillator to record heart sounds. 1980’s pacemaker use more widely used

Cardiac Rhythm Management Devices (CRMD) (A little History….) Implanted Cardioverter-Defibrillator (ICD) history 1980: Dr. Levi Watkins Jr. First ICD implantation at John’s Hopkins Hospital 1990’s pacemaker and ICD Innovation continues….

If it seems complicated….. It’s only because it is!!!….. The Short Form of the NASPE/BPEG Defibrillator (NBD)Code: ICD-S = ICD with shock capability only ICD-B = ICD with bradycardia pacing as well as shock ICD-T = ICD with tachycardia (and bradycardia) pacing as well as shock

Indications and Device Programming Indication examples Programming examples Symptomatic bradycardia AV Block Maximize medical therapy for CAD Severe heart failure, cardiomyopathy (EF less than 35%) -reduces sudden cardiac death History of a lethal arrythmia (VT, VF) Non-lethal arrythmia override (PAF, SVT) Programming is set to the individual patient needs and the device capabilities May sense or pace ventricle, atria or both May be programmed to override a non lethal tachyarrythmia Sense or not sense AV pacing sensing and firing in both chambers CRT Cardiac Resynchronization Therapy (DCM patients) ability to pace both ventricles M agnet response individual

And it’s not just cardiac devices……. In addition to ICD and pacemakers: Neurostimulators *brain *gastric (under study) *spinal cord *urinary bladder stimulators Drug infusion pumps (pain, chemo) Auditory (cochlear)

Case Analysis Patient admitted to Endo Unit for EGD Patient admitted to pacemaker only Exam positive for gastric antral vascular ectasia (GAVE ) Treated with APC Patient’s ICD delivered a shock to the patient Patient’s cardiologist called. (also denied ICD) Electrophysiology Fellow consulted and interrogated device No damage done, no patient adverse effects

Momentum to Develop Unit Policy and Evidence Based Nursing Practice Guidelines Multidisciplinary team -Endoscopist -RN -Cardiac Anesthesia -Electrophysiology MD Multiple revisions/clarifications Unit policy developed and implemented “moving target” New information Individual MD practices vary

Literature Review 2005 American Society of Anesthesiologists (ASA) * Report on Perioperative Management of Patients with CRMDs 2005 Society of Gastroenterology Nurses and Associates (SGNA) * Current Issues 2007 American Society for Gastrointestinal Endoscopy (ASGE) * Technology Status Evaluation 2009 New York State Board for Nursing * Practice Alerts & Guidelines AICD/Pacemaker Interruptions with a Magnet during Colonscopy Procedures

More Risk Versus Less Risk of EMI * Relative Risk versus Absolute What is not in the literature Balance knowledge of device with knowledge of interventions required No absolute rules No absolute recommended standards of care. Suggestions based on current knowledge and experience “universal recommendations applying to all patients in all settings cannot be made at this time.” (ASGE, 2007) WHAT IS AVAILABLE Evolving technologies require constant reevaluation and assessment of risk The more information providers have the better we can plan for patient safety!

EMI: Possible Effects on Device Sense EMI as intrinsic cardiac electrical activity: **inhibiting pacemaker from firing (pacer dependant at risk) ** ICD may discharge a shock when not required Sense EMI as “noise” and revert to “noise suppression mode” (pacemaker-asynchronous) *repetitive short bursts of even low level cautery High levels of current may damage device, battery or surrounding tissue Electrical impulses conducted to ICD and cause firing

Electromagnetic Interference (EMI) During Electrocautery Use in Endo General consensus in literature: **use of cautery in remote sites is unlikely to cause EMI definition of remote sites varies: bellow the waist, further than 4 or six inches from the device generator and leads ** maintain electrical current flow away from device, generator and leads of device **bipolar cautery is preferable to monopolar return electrode is in the device and no grounding is necessary ** lower wattage and shorter duration of cautery reduces the risk for EMI (most GI procedures)

Which patients are at more risk during their GI procedure? Cautery applications within 6 inches of the device generator and /or leads. *depends on patient’s anatomy: possibly stomach, esophagus, splenic flexure or transverse colon Monopolar modalities that require sustained cautery application *(APC (GAVE), complicated polypectomies, EMR, RFA-Halo)

NURSING PRACTICE -”Current Issues” 2005 Boards of Registration: * No specific language in Massachusetts BORN re: magnet application… “RN needs the “knowledge, skills and abilities” to safely perform whatever the activity.” (framework for decision-making nursing practice activities) NY Board requires: * Physician order * RN education, knowledge and skills * Institution written policy and procedure * monitoring and emergency equipment w/defibrillator SGNA: -”Current Issues” 2005 SGNA Website: General Discussions *various settings *different practices Consistent with evidence currently available Sample of different approaches: Contact company Contact cardiologist Contact pacer lab RN Automatically apply magnet during cautery use

Device Response to Magnet Application PACEMAKER ICD Internal switch closes to magnet application Pacemaker will pace at a preset continuous rate Rate varies dependant on individual programming Does not shut off the pacemaker Performs the same as if being interrogated Internal switch closes to magnet application ICD is inhibited from sensing Does not sense; does not shock Does not shut off the ICD in majority of models (exception Guidant and Biotronik)

My patient has a cardiac rhythm device, now what? Medical decision for Endoscopist to make if magnet is required or not. May need to consult expert to determine what precautions to take Is the patient pacemaker dependant? (consider consult) What type of cautery is planned? (ie: APC vs Symmetry) How proximal is the site to device generator and leads? (ie:rectal vs esophageal) How is the device programmed to respond to magnet placement? Correct pad placement; grounding to prevent current from moving to device generator or leads. The more information you have the better you can plan for patient safety!

Safety Precautions To Take During Magnet Use Clear communication between MD and RN Magnet use as brief as possible Maintain continuous EKG monitoring (good quality) Manual defibrillator readily available with qualified users

When bad things happen……. Scenario: the magnet has been placed on the ICD and the pt. goes into sustained VT or VF FIRST: REMOVE THE MAGNET!! (at least 2-3 feet away) It may take up to 20 seconds for the ICD to analyze and shock. *Have defibrillator ready to manually shock if needed

Algorithm Example

REFERENCES Endoscopy in Patients with Implanted Devices, Technology Status Evaluation Report, 2007 American Society for Gastrointestinal Endoscopy. Vol. 65, No. 4. Practice Alerts and Guidelines; AICD/Pacemaker Interruptions with a Magnet during Colonoscopy Procedures. http://www.op.nysed.gov/nursepacemaker.htm Current Issues, 2005 Gastroenterology Nursing, vol.28 issue 3. Practice Advisory for the Perioperative Management of Patients with Cardiac Rhythm Management Devices: Pacemakers and Implantable Cardioverter-Defibrillators, Anesthiology, vol.103, (1) July 2005.