1. Cardiac Implantable Electronic Devices
Angela DeLaria, MS, CRNA

2. Disclosure Statements
Conflict of Interest Disclosure Statement MoANA Fall Meeting 2018 I have no financial relationships with any commercial interest related to the content of this activity.

3. Objectives List the most common indications for CIED placement.
Identify essential pre-operative assessment information to acquire when caring for a patient with CIED.
Describe perioperative care of the patient with an existing CIED.
Explain the implications of placing a magnet over a CIED.
Describe how to differentiate a pacemaker from a defibrillator on a chest x-ray.
Review “2011 HRS/ASA Expert Consensus Statement on the Perioperative Management of Patients with CIEDs”

4. Case Reports Schulman and Rozner, 2013
Use Cation When Applying Magnets to Pacemakers or Defibrillators

5. Permanent Pacemakers Bradyarrhythmias System
Sinus Node Dysfunction (sick sinus syndrome)
Failure of impulse generation (complete heart block)
System
Impulse generator + leads
Send electrical impulses to heart chambers
So why do people end up with pacemakers in the first place? Pacemakers are placed to correct for bradyarrhythmias. The two arrhythmias being Sick Sinus Syndrome and Third Degree Heart Block.
The pacemaker is made of an impulse generator and leads.

6. Pacemakers can have a variety of functions to meet patient needs
Pacemakers can have a variety of functions to meet patient needs. Every pacemaker has the following functions and the letter assigned describes what that function does. Both chambers can be sensed and paced.

7. Implantable Cardioverter Defibrillator
Tachyarrhythmias
Sense, classify, shock, pace
Deliver sufficient energy to terminate VF/VT
Superior to drug therapy
The other implantable cardiac device used is the defibrillator. The defibrillator is used to treat tachyarrhythmias. The device should deliver enough energy to overcome and terminate VT/VF. It is considered superior to drug therapy.

8. Preoperative Assessment
Determining indication for and date of placement
Identifying the type (PM/ICD) and manufacturer
Determining the patient’s underlying rhythm and rate
Identifying the number and types of leads
Determining the last generator test date and battery status
Obtaining a history of generator events
Obtaining the current program information
Ensuring that generator discharges become mechanical systoles with adequate pacing safety margins (proper function)
Ensuring adequate safety margin for sensing events
Ensuring that magnet detection is enabled (behavior & rate?)
Determining whether the pacing parameter should be reprogrammed
Miller’s Anesthesia Ch 48, Appendix 48-2
So when you’re seeing patients preoperatively you may be tempted to glaze over the details. But I hope the case reports compel you to obtain a more thorough assessment of cardiac implantable devices. According to Miller’s Anesthesia we should be doing the following: determining the indication and date of placement, identifying the type and manufacturer, determine the patient’s underlying rhythm, status of the generator and battery, obtain an interrogation with a history of generator events and current program information, magnet function, and does the device need to be reprogrammed for surgery?

9. Who you gonna call? Medtronic Boston Scientific St Jude
1-800-CARDIAC ( )
St Jude
Fortunately, there’s always someone to call. Patient’s are often poor historian’s, the cardiologist is unavailable, there is no rep in house to perform an interrogation. In any case, just ask for the patient’s pacemaker card. It’s going to have the manufacturer and the number. They will be able to tell you nearly all the information asked for on the previous slide.

10. Intraoperative Care Monitor rhythm with plethysmography
Ie pulse oximeter or arterial waveform
Operate with bipolar electrosurgical unit if possible
If not possible…
Ask for cut instead of blend or coag
Use short bursts (<4 seconds)
Separate bursts by at least 2 seconds
Bovie Pad placement
So now that you have your device information what are you going to do with it?
Monitor the patient’s rhythm with an EKG and some sort of correlating waveform – ie a pulse oximeter or arterial line
Electromagnetic interference is most commonly caused by monopolar electrocautery – causes pacing inhibition, damage to the pulse generator (the device itself), and can initiate inappropriate tachytherapy
Known as oversensing, the PM may misinterpret EMI as intrinsic electrical activity and fail to pace or an ICD could interpret EMI as arrhythmia and defibrillate the patient. So ask your surgical colleages to use bipolar cautery and place the bovie pad in a manner that any electricity will not travel near or past the device.
If there is any concern about the device failing, you are unsure of it’s function, or otherwise, you need to be ready to back up a failed device. So place pacing/defibrillator pads on the patient if the surgery will allow. And if you have to you can perform transcutaneous pacing or defibrillation if necessary.

11. Magnets and CIEDs PACEMAKERS ICDs Variable response
May produce no change in pacing
Not all models from one company behave the same
Obtain an interrogation or CALL the manufacturer
ICDs
Most will suspend tachydysrhythmia detection
SOME IGNORE magnet placement
May require an interrogation/reprogramming post magnet placement
What do magnets really do if they are placed on a device? It depends!
PPM – magnet may have no response, some will pace asynchronously, rate depends on manufacturer and battery life left and the rate may not meet the physiologic demand
ICD – magnet will prevent pacing and defibrillation, in modern PM/AICD combos, reprogramming the device is best pre and post op

12. What about emergent procedures?
Make emergency pacing equipment readily available
Identifying PPM vs AICDs
CXR - Pacemakers have leads with consistent texture and thickness on radiographs but ICDs have shocking coils toward the distal tip of the lead which are brighter on radiograph and are thicker.
Let’s say an 80 year with dementia is found down at home by a neighbor with a fractured hip. Patient obviously needs to go to surgery but you have no means of a proper pre operative anesthesia assessment.
A chest x-ray can be extremely informative for patients coming for emergency surgery. A chest x-ray can identify the device type, leads, and manufacturer. From this x-ray, it is clear that the patient has 3 leads: a right atrial lead, a right ventricular lead, and a coronary sinus lead. In addition, the right ventricular lead is a shocking coil, which is identified by the thicker, denser distal portion of the lead. From this chest x-ray, it is clear that the patient has an ICD due to the shocking coil, and the coronary sinus lead suggests resynchronization therapy for low ejection fraction. It also possible to see the manufacturer name on the device and with that you can call the company and obtain more info.

13. 2011 HRS/ASA Expert Consensus Statement on the Perioperative Management of Patients with CIEDs
I want to draw your attention to this article from the Anesthesia Patient Safety Foundation. A lot of the information in this presentation came from this article. If you work with a large cardiac device population I highly recommend reading it. It outlines in detail all of the information we went through.

14. References
Schulman, P.M. and Rozner, M.A. (2013). Use Caution Wen Applying Magnets to Pacemakers. Anesthesia and Analgesia. 117(2);
Crossley, G.H., Poole, J.E., Rozner, M.A., Asirvatham, S.J., Cheng, A., Chung, M.K., Ferguson, T.B. …Thompson, A. (2011). The Heart Rhythm Society/American Society of Anesthiologists Expert Consensus Staement on the Perioperative Management of Patients with Implantable Defibrillators, PAcemakers and Arrhythmia Monitors: Facilities and Patient Management. Heart Rhythm Society.
Neelankavil, J.P., Thompson, A., and Mahajan, A. (2013). Managing Cardiovascular Implantable Electronic Devices (CIEDs) During Perioperative Care. APSF. 28(2):