Perioperative Management of 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 of 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 http://www.leiferreport.com/tag/healthcare-costs/ Ø Mismanagement = bad outcomes & unhappy patients!
Before we can get into the details on management …
What are indications for implantation of a pacemaker? (select all that apply) Sick sinus syndrome a) Supraventricular Tachycardia b) AV nodal dysfunction - third degree or high grade c) second degree AV block Acute myocardial infarction d) First degree AV block e) Persistent symptomatic bradycardia f)
What are indications for implantation of a pacemaker? (select all that apply) Sick sinus syndrome a) Supraventricular Tachycardia b) AV nodal dysfunction - third degree or high c) grade second degree AV block Acute myocardial infarction d) First degree AV block e) Persistent symptomatic bradycardia f)
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) History of ventricular tachycardia or ventricular a) fibrillation arrest High risk of cardiac arrest but no history of cardiac b) arrest event Supraventricular Tachycardia c) First degree AV block d) Sinus arrhythmia e)
What are indications for implantation of an ICD? (select all that apply) History of ventricular tachycardia or a) ventricular fibrillation arrest High risk of cardiac arrest but no history of b) cardiac arrest event Supraventricular Tachycardia c) First degree AV block d) Sinus arrhythmia e)
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 a) Before any surgery b) 30 days interrogated? c) 3 months d) 6 months e) 12 months Ø What about an ICD ?
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 of 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 of 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 or 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)
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