Perioperative Care of Patients with Cardiac Rhythm Management Devices Perioperative Care of Patients with Cardiac Rhythm Management Devices Jonathan Dubsky, M.D. Staff Anesthesiologist Southwest Division OAG September 13, 2012 Perioperative Care of Patients with Cardiac Rhythm Management Devices Ohio Anesthesia Group

Objectives: 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 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: 1114-1152 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? 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? 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. AOO DOO VVI 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? Forehead of patient Right on top of CIED generator Left arm Right arm OR bed

Extra Credit Question #1 Who is this group of young lads 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 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)