1. Cautery (ELECTRO MAGNETIC INTERFERENCE) & cardiac devices in endoscopy

2. background Increasing aging population Advancements in technology
Implantable cardioverter/defibrillators primary therapeutic modality for patients at risk for sudden cardiac death
Endoscopy nurses now have patients with multiple comorbidities undergoing procedures

3. Identification of patients
Cardiac implantable electronic devices (CIED) include pacemakers and cardioverter/defibrillator devices (ICD)
Any patient with CIED is identified prior to undergoing endoscopy procedures
Special precautions need to be taken
Multiple co-morbidities?

4. Important considerations
Medical reason for the device
Type of device
Date when last interrogated
ICDs: has the device fired before?
Anti-coagulants?

7. Types of Electrocautery
Monopolar cautery (the ground is the patient)
Bipolar cautery (the ground is within the instrument)
Argon plasma coagulator (APC) (gas/laser)

8. Electrocautery
Electrocautery used during endoscopic procedures can cause CIEDs to inappropriately sense because of electromagnetic interference (EMI)
Devices can:
Inappropriately fire
Inappropriately be inhibited
Inappropriately trigger cardioversion or defibrillation

9. Pacemakers Several different types:
100% paced all of the time OR
Demand- only needed in certain circumstances (i.e. drop in heart rate)
Type of pacemaker patient receives depends on indication for pacemaker
Patients with pacemakers should have wallet card identifying type of pacemaker they have

10. 100% paced

11. Demand pacemaker- atrial fibrillation

12. Implanted Cardiac Defibrillators
Three functions:
Pacemaker
Overdrive pacing
Defibrillation
Treated differently than pacemakers

13. Overdrive pacing

16. Defibrillator function

17. Little research available to guide practice, most evidence anecdotal
Few guidelines and most associated with the OR
Guertin D, Osman F, et al (2007) Electromagnetic interference and Implanted and Implanted Cardiac Devices
Looked at 41 patients with ICDs
40 patients were (L) pectoral placements, 1 (L) abdominal
Devices programmed to detection but tachyarrhythmia therapies off

18. 41 patients – 52 endoscopies, 5 upper, 28 lower, 8 both, 2 repeat
18 required therapeutic intervention, of these 10 underwent unipolar electrocautery
Post procedure ICD interrogation did not document tachyarrhythmia detection or pacemaker inhibition
Limits to the study – no oesophageal intervention and small cohort

19. Our practice
Policy was developed with the head of our Electrophysiology Lab
Ideally patients are pre-identified
Pre-admission assessment also includes a section for this
Anti-coagulants?

20. Electrocautery & Pacemakers
Do not need cardiac monitoring - monitor heart rate with SaO2 probe
Should have magnet in room but does not have to be on patient
If cautery is used, the pacemaker may sense the cautery as a heartbeat and not pace when it should
Could result in bradycardia
If heart rate slows, place magnet over pacemaker- this puts the pacemaker briefly in asynchronous mode
When magnet is removed pacemaker resumes normal function

21. Electrocautery & ICDs More complicated
Patient must be on cardiac monitor for the duration of procedure
May require two nurses in procedure room
Magnet is placed over the device site during cautery only
Must be coordinated with physician
Magnet should not be held over the device for longer than 30 seconds

22. Assign an RN with prior cardiac nursing experience
Bipolar cautery is best but if monopolar is used, place grounding pad opposite to ICD site, preferably the thigh
Magnet is held over the device for the length of the cautery time- remind the physician less than 30 seconds
When magnet is not needed, it should be at least 2 ft. away from the device
Newer devices will beep if magnet is held too long- the patient will have to go to cardiac lab to have device interrogated

23. Where do we go from here?
More research needed as there are more types of therapy out there
Spinal or neuro transmitters
Cochlear devices
Phrenic nerve stimulators

24. References
American Society for Gastrointestinal Endoscopy (2007). Endoscopy in patients with implanted electronic devices. Gastrointestinal Endoscopy, 65(4),
Capital District Health Authority (2014). Cardiac Implantable Electronic Device (CIED)- Endoscopic Procedures Policy. Retrieved from pe=6&documentRender.GenericField=&documentRender.Id=49926
Guertin, D., Faheen, O., Ling, T., et al (2007). Electromagnetic interference (EMI) and arrhythmic events in ICD patients undergoing gastrointestinal procedure. Pacing and Clinical Electrophysiology, 30(6),
Jacob, S., Panaich, S., Maheshwari, R., et al (2011). Clinical applications of magnets on cardiac rhythm management devices. Europace, 13(9),
Tsai, A. (2017). Perioperative management of permanent pacemakers (PPMs) and automatic implantable cardioverter-defibrillators (AICDs). Retrieved from emedicine.Medscape.com/article/

25. Questions