AICD and outpatient surgery

[GaseousClay]

Whats your policy with patients with AICDs scheduled for outpatient surgery? Have had a few patients who are very stable (not pacer dependent, normal EF, etc)get general anesthesia at the outpatient center. Usually with cases without cautery or where cautery is not a factor. Whats your all's policy?

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[OTCAwesome]

Soo, our department doesn't have any official policy... What most of us do though is:
1) Cautery used - place pads on pt, place magnet on AICD when in OR, interrogate prior to d/c from PACU.
2) Cautery not used - place pads on pt, proceed as per usual.
Some of my colleagues say if the site of cautery is >15 cm away from the pacer and the grounding pad is appropriately placed, they won't place the magnet... Since I'm a noob, I err on the side of medicolegal caution and throw it in asynchronous even if they are using cautery on the toe.

 

[aneftp]

Also depends on unipolar and bipolar bovie along with the location of the surgical site.

Play it safe and arrange for device rep to examine device post procedure before outpatient discharge.

 

[Noyac]

Soo, our department doesn't have any official policy... What most of us do though is:
1) Cautery used - place pads on pt, place magnet on AICD when in OR, interrogate prior to d/c from PACU.
2) Cautery not used - place pads on pt, proceed as per usual.
Some of my colleagues say if the site of cautery is >15 cm away from the pacer and the grounding pad is appropriately placed, they won't place the magnet... Since I'm a noob, I err on the side of medicolegal caution and throw it in asynchronous even if they are using cautery on the toe.

Why are you placing pads?

 

[Robotic Wis-Hipple]

Soo, our department doesn't have any official policy... What most of us do though is:
1) Cautery used - place pads on pt, place magnet on AICD when in OR, interrogate prior to d/c from PACU.
2) Cautery not used - place pads on pt, proceed as per usual.
Some of my colleagues say if the site of cautery is >15 cm away from the pacer and the grounding pad is appropriately placed, they won't place the magnet... Since I'm a noob, I err on the side of medicolegal caution and throw it in asynchronous even if they are using cautery on the toe.

It's unclear from this if you're just putting a magnet on or getting devices reprogrammed for the OR, but just in case; placing a magnet on a combined AICD/PPM does not place the PPM into asynchronous mode. The important distinction is whether pt is pacemaker dependent. If you place a magnet on a pacer that has a magnet response and therefore put it in an asynchronous mode, and that asynchronous rate is LESS than the patient's intrinsic rate you are actually increasing the risk of arrhythmia and R on T.

 

[OTCAwesome]

Why are you placing pads?

In case anything goes fubar and I need to defibrillate

 

[Robotic Wis-Hipple]

In case anything goes fubar and I need to defibrillate

I think he's saying that A.) if you place a magnet and patient arrests you can just remove magnet. Or B.) you are working infraumbilical or without bovie and you don't magnet the device will do its thing.

 

[OTCAwesome]

I think he's saying that A.) if you place a magnet and patient arrests you can just remove magnet. Or B.) you are working infraumbilical or without bovie and you don't magnet the device will do its thing.

I see what your saying, some brands of AICD don't reactivate automatically when you take the magnet off though so I would feel more comfortable proceeding with pads in place

 

[Robotic Wis-Hipple]

I know this thread is geared towards private practice where EP or device reps aren't just standing around ready to assist in reprogramming and re-evaluating ICD's but here's the HRS document that discusses periop management of ICDs.

http://www.hrsonline.org/content/download/1432/20125/file/2011-HRS-ASA-Perioperative-Management.pdf

 

[pgg]

I see what your saying, some brands of AICD don't reactivate automatically when you take the magnet off though so I would feel more comfortable proceeding with pads in place

The other caveat to magnet use is they will NOT put an AICD's pacing function in asynchronous mode. If that's important, the only option is reprogramming.

More broadly speaking, unpredictable behavior with magnets is - I am assured by device reps, though always off the record - essentially a thing of the past. While St Jude and Boston Scientific devices have the capability of being programmed to ignore a magnet, there's really no reason to do so and their device reps say (quietly) it's totally safe to just assume the device will revert to its prior state when a magnet is removed. Medtronic devices don't have the magnet-off capability. The really old devices that had persistent on/off switches controlled by a magnet don't exist any more, those patients are long dead and if they're not the devices are long since replaced by now.


Anyway - AICD management is easy, even at 2 AM for an urgent case. Call the company and ask what the magnet does. Then use a magnet. Place pads if you like ... but honestly, you can probably deliver a faster shock just by grabbing the magnet and letting the device do it. Postop: monitored bed, the device can get interrogated later before leaving telemetry. Easy.

The only hitch to that is that if they're pacer dependent, and it's an AICD, and the surgical site is close to the device, it should be reprogrammed to therapy off + asynchronous pacing for the duration of surgery.



To answer the original question (AICD, not pacer dependent, normal EF, surgicenter, electrocautery isn't a factor), I'd just do the case and leave the device alone IF (per the guidelines) the device had been interrogated within the previous 12 months (pacer) or 6 months (AICD). If not, it gets interrogated first, then the case gets done like any other. Postop, no interrogation necessary.

 

[jwk]

Outpatient surgery OK - outpatient surgery center except for cataracts not OK.

 

[Noyac]

To answer the original question (AICD, not pacer dependent, normal EF, surgicenter, electrocautery isn't a factor), I'd just do the case and leave the device alone IF (per the guidelines) the device had been interrogated within the previous 12 months (pacer) or 6 months (AICD). If not, it gets interrogated first, then the case gets done like any other. Postop, no interrogation necessary.

Bingo!!!!

 

[Noyac]

In case anything goes fubar and I need to defibrillate

When is the last time you had to do this? Or better yet, the last time you know someone that had to do this?

 

[Noyac]

I see what your saying, some brands of AICD don't reactivate automatically when you take the magnet off though so I would feel more comfortable proceeding with pads in place

Shouldn't you know the brand you are dealing with and what it does before just slapping pads on the pt and calling it good?

 

[Plead the Fifth]

Whats your policy with patients with AICDs scheduled for outpatient surgery? Have had a few patients who are very stable (not pacer dependent, normal EF, etc)get general anesthesia at the outpatient center. Usually with cases without cautery or where cautery is not a factor. Whats your all's policy?

Cautery below umbilicus - we do nothing provided there is an interrogation report within past 6 months (12 months for PM)

Cautery above umbilicus - depends if the patient is PM dependent. If not then we just place a magnet over ICD to turn off defibrillation function. If patient is PM dependent we reprogram to asynchronous mode (or rather the rep does it). We rarely place pads on the patient.

 

[GaseousClay]

Outpatient surgery OK - outpatient surgery center except for cataracts not OK.

So patient is overall healthy, AICD placed for episodes of v-tach in past no shocks from AICD in last 7 years. Not being paced. . Interrogated 3 months ago. Having surgery that does not require cautery but general anesthesia. I would still do this at outpatient surgical center

 

[sethco]

Cautery below umbilicus - we do nothing provided there is an interrogation report within past 6 months (12 months for PM)

Cautery above umbilicus - depends if the patient is PM dependent. If not then we just place a magnet over ICD to turn off defibrillation function. If patient is PM dependent we reprogram to asynchronous mode (or rather the rep does it). We rarely place pads on the patient.

Tread carefully.

I had a patient a couple months ago where the magnet did not deactivate the ICD function. Long story, but Had to stop mid surgery and have device rep come in.

 

[pgg]

Tread carefully.

I had a patient a couple months ago where the magnet did not deactivate the ICD function. Long story, but Had to stop mid surgery and have device rep come in.

What was the rest of the story?

It was programmed to ignore the magnet? Or the device was not functioning properly?

 

[Skip2myLou]

I feel that in the many times I've used a magnet for AiCD or PPM, It does not always shut off AiCd and place ppm into synchronous mode.


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[pgg]

I feel that in the many times I've used a magnet for AiCD or PPM, It does not always shut off AiCd and place ppm into synchronous mode.

A magnet will never put an ICD into asynchronous mode ...

 

[AdmiralChz]

Tread carefully.

I had a patient a couple months ago where the magnet did not deactivate the ICD function. Long story, but Had to stop mid surgery and have device rep come in.

Our cardiac attendings and fellows are trained to interrogate the major brands of ICD/PPMs for this very reason. Honestly, I don't think one needs to be a sub-specialist if they want to do this. There is always the question of responsibility and who assumes it in such a case (e.g. does the attending who turned off the ICD function need to stick around 8 hours until the neck dissection is done at 10 PM?), but in an emergency this can be very, very helpful as device reps aren't always available at the drop of a hat and are frequently at other hospitals participating in ICD/PPM placements.

 

[Robotic Wis-Hipple]

Honestly, and I'm aware this is an overly rigid only feasible in a big center viewpoint, but ideally, you really shouldn't be relying on a magnet. Magnets are more for emergencies and short term procedures. Most ICDs have no obvious indicator to tell you that placement of said magnet successfully deactivated tachyarrhythmia functions. And even if the model ICD does give an audible beep to signify this they don't have any indicator that tells you they've been reactivated (either by purposeful removal after the case or by shifting under the ioban/tape/miscellaneous stabilizer of choice).

Of course, in just a few months when I'm out in PP land I'll be doing the same thing so it is what it is. But I think this thread documents pretty clearly how much misinformation is prevalent regarding magnet actions in isolated AICDs vs PPMs vs combined AICD/PPMs as myself and others have noted multiple times that a magnet will not place the PPM of a combined CIED into asynchronous mode.

 

[facted]

Marc Rozner of MD Anderson gives a great talk at the PGA every year on device management. MD Anderson policy on interrogation is "every device, every time".

Our institution recently got rid of cardiology on call and we're moving to a magnet first algorithm on off-hours. The problem is three fold:

1) You will never know a magnet response. You can take an educated guess that you'll convert a PPM to asyncrhonous, but that's a an educated guess. Devices can be programmed to all sorts of settings and though that's not often done, it CAN be done. And you could be up a creek...Magnet might also turn the AICD off, but again, that's only the "standard" response which can be programmed otherwise. SUPER important to note, as others have above, that a magnet will do nothing for an AICD pacemaker function. Tread lightly if you're patient is paced with an AICD.

2) What if DOO or DDO 60 isn't enough? What if they need higher cardiac output in the middle of the case when the **** hits and the fan and you've got a bleeder?

3) You know nothing about the device fidelity. Failing battery? Failing leads with poor contact? Granted, this isn't common, but with the the follow-up that a lot of my patients have, I wouldn't take this one for granted.

 

[sethco]

What was the rest of the story?

It was programmed to ignore the magnet? Or the device was not functioning properly?

Probably not functioning properly. I copy and pasted from previous thread on this subject...

I had a case a couple months ago with a patient with an ICD for CABG. Couldn't figure out the manufacturer and patient didn't know. Called both STJ and Medtronic to no avail. Decided to put a magnet on it. ICD discharged several times while taking down the LIMA. Medtronic rep informed us that his Cardiologist usually puts in Biotronik devices, so we called them and they deactivated the device before going on pump. I always make an effort to figure out who makes the ICD and have them come in. I would rather not depend on the magnet for many reasons, including the one above