Perioperative Management of Patients with Cardiac Implantable - - PowerPoint PPT Presentation

Perioperative Management

• f Patients with Cardiac

Implantable Electronic Devices

Rachel Heise, BSN, RN, CCRN, SRNA Melissa Maxwell, BSN, RN, SRNA Rosalind Franklin University

We have no conflicts of interest to declare and will not be discussing any off label uses

• f these devices.

Objectives

Ø Review the indications for permanent cardiac

implantable electronic devices (CIED) implantation and their basic functions

Ø Discuss potential intraoperative complications

associated with CIEDs

Ø Outline current recommendations regarding

perioperative management of patients with CIEDs

Ø Discuss implementation of an evidence based change

project to enhance perioperative management of CIED

Why should we care?

Ø 40,700 deaths annually Ø ~One million patients receive

CIED each year

Ø Mismanagement = bad outcomes

& unhappy patients!

http://www.leiferreport.com/tag/healthcare-costs/

Before we can get into the details on management …

What are indications for implantation of a pacemaker? (select all that apply)

a)

Sick sinus syndrome

b)

Supraventricular Tachycardia

c)

AV nodal dysfunction - third degree or high grade second degree AV block

d)

Acute myocardial infarction

e)

First degree AV block

f)

Persistent symptomatic bradycardia

What are indications for implantation of a pacemaker? (select all that apply)

a)

Sick sinus syndrome

b)

Supraventricular Tachycardia

c)

AV nodal dysfunction - third degree or high grade second degree AV block

d)

Acute myocardial infarction

e)

First degree AV block

f)

Persistent symptomatic bradycardia

Pacemaker Dependent

Ø Inserted for bradyarrhythmias Ø Is my patient pacemaker dependent?

http://www.ekgstripsearch.com/SSS.htm

What are indications for implantation of an ICD? (select all that apply)

a)

History of ventricular tachycardia or ventricular fibrillation arrest

b)

High risk of cardiac arrest but no history of cardiac arrest event

c)

Supraventricular Tachycardia

d)

First degree AV block

e)

Sinus arrhythmia

What are indications for implantation of an ICD? (select all that apply)

a)

History of ventricular tachycardia or ventricular fibrillation arrest

b)

High risk of cardiac arrest but no history of cardiac arrest event

c)

Supraventricular Tachycardia

d)

First degree AV block

e)

Sinus arrhythmia

How our respondents answered…

Implantable Cardioverter Defibrillators

Ø Primary prevention

Vs

Ø Secondary prevention

https://academic.oup.com/europace/article/12/12/1673/431085

Literature

Updates out now!

You can view the updated practice advisory by visiting: https://www.asahq.org/standards- and-guidelines

Approach to CIED Patient Management

Expert consensus recommendations[1]

Ø Preoperative Evaluation Ø Preoperative Preparation Ø Intraoperative Management Ø Postoperative Management

Preoperative Evaluation & Preparation is key!

Ø Device type & function Ø DDD? VVI? Ø Pacemaker-dependent? Ø Look for recent

interrogation report*

Ø Document!

https://healthcare.utah.edu/cardiovascular/treatments/pacemakers-defibrillators.php

Interrogation

Ø How often should a

pacemaker be interrogated?

Ø What about an ICD?

a) Before any surgery b) 30 days c) 3 months d) 6 months e) 12 months

Interrogation recommendations

Ø Pacemaker every 12 months Ø ICD every 6 months

How did you measure up to our respondents?

Intraoperative Management

https://www.istockphoto.com/illustrations/anesthetist?sort=mostpopular&mediatype=illustration&phrase=anesthetist

Management Algorithm

Magnet Management

Ø Always have magnet available!

Ø Magnet removal will result in resuming

therapy in ~10-12 seconds

Ø CIED also stores data from shocks

delivered – can be useful

Ø Secure with tape; check position

throughout case

When a magnet is placed over an ICD, the following usually happens:

a) The pacemaker function is deactivated b) The anti-tachycardia (defibrillation) function

is deactivated; pacemaker function remains unchanged

c) The pacemaker paces at an asynchronous rate

• f 80-100 beats per minute

d) Nothing

When a magnet is placed over an ICD, the following usually happens:

a) The pacemaker function is deactivated b) The anti-tachycardia (defibrillation)

function is deactivated; pacemaker function remains unchanged

c) The pacemaker paces at an asynchronous rate

• f 80-100 beats per minute

d) Nothing

Our results

Magnet response will:

Ø Inhibit tachyarrhythmia pacing & detection in

ICDs

Ø NOT affect pacemaker function in an ICD –

reprogramming needed

Ø Asynchronously pace a pacemaker Ø (AOO, VOO, DOO)

POST-OP

Guidelines for interrogation prior to discharge

• r transfer from telemetry unit[1]

Ø If antitachycardia detection was disabled (ICD) Ø If procedure was hemodynamically challenging* Ø If patient experienced significant event* Ø Emergent surgery if EMI above umbilicus Ø Cardio-thoracic surgery Ø Certain procedures* Ø Patients who are unable to have device evaluation

within 1 month of procedure

Summary

Ø Know the device, settings, indication Ø EMI sources Ø Magnet response Ø Document your plan Ø Communicate

References

[1] Crossley, G. H., Poole, J. E., Rozner, M. A., Asirvatham, S. J., Cheng, A., Chung, M. K., … Thompson, A. (2011). The Heart Rhythm Society (HRS)/American Society of Anesthesiology (ASA) Expert Consensus Statement on the Perioperative Management of Patients with Implantable Defibrillators, Pacemakers and Arrhythmia Monitors: Facilities and Patient Management. Heart Rhythm, 8, 1114-

• 1154. doi:10.1016/j.hrthm.2010.12.023

[2] Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: Pacemakers and implantable cardioverter- defibrillators: An updated report by the american society of anesthesiologists task force on perioperative management of patients with cardiac implantable electronic devices. (2011). Anesthesiology, 114(2), 247-261. doi:10.1097/ALN.0b013e3181fbe7f6 [3] Neelankavil, J.P., Thompson, A., & Mahajan, A. (2013). Managing cardiovascular implantable electronic devices (CIEDs) during perioperative care. Anesthesia Patient Safety Foundation Newsletter, 28(2), 29-48

References

[4] Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R. Clinical

• Anesthesia. 8th ed. Philadelphia, PA: Wolters Kluwer

[5] Schulman, P. M., & Rozner, M. A. (2013). Use caution when applying magnets to pacemakers or defibrillators for surgery. Anesthesia and Analgesia, 117(2), 422-427. doi: 10.1213/ANE.0b013e31829003a1 [6] Rozner, M. A., Kahl, E. A., & Schulman, P. M. (2017). Inappropriate implantable cardioverter-defibrillator therapy during surgery: An important and preventable complication. Journal of Cardiothoracic and Vascular Anesthesia, 31(3), 1037-1041. doi:10.1053/j.jvca.2016.11.036

THANK YOU!!

Quick Review of Pacing & Defibrillator Modes

Table 1 - Generic pacemaker codes (NBG) Table 2 – Generic defibrillator codes (NBD)