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Intraoperative Management/How should automatic defibrillators be handled?

QUESTION:

We currently have a policy in place and do ambulatory procedures on patients with implanted automatic defibrillators . We turn them off if any form of electrocautery is to be used. We otherwise leave them on.

Is it appropriate to do such patients in a free standing center and should they always be turned off? We are somewhat concerned in that an AICD may simply be a marker of patients with enough cardiac pathology such that it may be best to simply exclude them.

-- From B. Evans, M.D.

REPLY:

Pacemakers and ICDs are complex implanted devices that have significant implications for perioperative care. Patients need these devices for various reasons and often have coexisting cardiac or other problems. Patients with ICDs may obviously have severe cardiac problems including ongoing ischemic cardiac disease (with previous myocardial infarctions) or severe cardiomyopathy. Only "minor" procedures would seem reasonable in a freestanding center for these type of ASA 3 and 4 patients. Your rapid access to cardiology assistance would also be a factor.

When you have a patient with cardiac devices you should consider:

• Why does the patient have the device? How long has it been there?
• Does the patient have a "Device ID Card"? (Make, model, serial number)
• When was the last time the device was checked? Battery status?
• Is the device near its replacement time? Replace it before an elective procedure!
• For pacemakers - is patient hemodynamically dependent on device? Underlying cardiac rhythm?
• For ICDs - what is the "shock" history?
• What is the hemodynamic response to electrical pacing? (Do all pacing "spikes" on ECG cause peripheral pulses?)
• What are the programming parameters? (Printout from interrogation)
• Does the device have "rate modulation" biosensors? What about battery saving auto-search routines? (Turn them off, usually)
• What will happen when a donut magnet is applied? Is the response programmable? (Ignored, fixed rate, shuts off, for how long?)
• Should the device be re-programmed prior to procedure?
• What heart rate will be appropriate to meet metabolic demands for the procedure?
• Are a defibrillator and an external pacing device available in your facility? (they should be)
• Have you consulted a knowledgeable Cardiologist and the device manufacturer concerning recommendations?
• ALWAYS consult with a Cardiologist if the patient has a device for Long Q-T or Cardiomyopathy, or is a pediatric patient.
• Re-interrogate device after the procedure to ensure proper functioning and battery life if electromagnetic interference (EMI) was present.

Preoperatively, you need to be sure the device is in good working order. Interrogation before the anesthetic is the only way to do this.

The following comments address ICDs. Pacemakers have an even longer set of issues (see Rozner reference).

Turning off the ICD is essential when EMI is anticipated. This prevents EMI induced ICD shocks. Turning it off with a programming device is the only way to do this with some ICDs. A donut magnet may elicit auditory (some Guidant) or no (Medtronic and others) indication of the active status of the ICD. With Medtronic ICDs, a Smart Magnet® is the only way to know if temporary magnet suspension of the device has been achieved. However, magnets may encroach on the surgical site, or slip off during the case.

Patients who have procedures performed without the use of electrosurgical units (ESU) or other EMI, may have an ICD left in the "active" mode. HOWEVER, if a shock is delivered by the device, the patient may move suddenly. If a sudden movement could cause surgical injury during a procedure (e.g. during an eye or middle ear operation), then this is a plan with some risk.

After any case with EMI exposure, cardiac devices should be checked to ensure proper functioning before the patient leaves the facility. Check with the device manufacture about any new information. This is a rapidly changing area of medicine. Don't assume.

These patients take much more time to care for in the perioperative period. Only you can decide if this is worth it in your practice.

References:

1. Heart Rhythm Society (NASPE): http://www.hrsonline.org
2. American College of Cardiology: http://www.acc.org
3. Rozner MA. Intrathoracic Gadgets: Pacemakers and Defibrillators in the New Millennium. ASA Refresher Course Lectures 2004
4. ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices. Circulation 2002; 106:2145-61

-- From Scott R. Springman, M.D., Madison, WI

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