I have a surgi-ctr practice in an office bldg, with no EP/cath lab etc nearby. My surgeons have been spoiled by us doing most of their PS3 and PS3+ patients without much drama. We cannot do PS4 in an ASC in my state(hence 3+). WHen a pt comes with an AICD and electrocautry is needed, I get a good Hx on why they have the device etc. , I apply the magnet , remove magnet once hemostasis is achieved and call the rep who has been notified, the previous day at least , that we may need them in Pacu to verify defib has been enabled again. There are 4-5 other ASC's in a 30 mi radius of mine. The Medtronic guy barked that they only come to mine. I know the Guidant switch story and am very cautious with the Guidant. The Medtr. guy insisted no interrogation is needed on theirs after magnet placemnt to suspend defib. to verify enabled again. He did admit in the hospitals there are reps floating around daily to interrrogate in the pacu. ...Do you folks do this or would you not do the AICD Pt in an ASC ? MAybe that's why the other ASC's do not call the rep. I see mostly Medtronic> Guidant> St Judes. Couldn't find position statement from ASA regarding this. ....thanks
AICD - Magnet - ? verify enabled?
- Thread starter Dirtball
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When they tell us that we say, "Great! Can you fax that in writing to place in the patient's chart?" They won't.
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recent thread
http://forums.studentdoctor.net/showthread.php?t=761816
ASA practice advisory from 2005. may be something more recent.
http://journals.lww.com/anesthesiol...sory_for_the_Perioperative_Management.27.aspx
ASA comment
http://www.asahq.org/Knowledge-Base...ASA/Informing-the-Misinformed-About-ICDs.aspx
http://forums.studentdoctor.net/showthread.php?t=761816
ASA practice advisory from 2005. may be something more recent.
http://journals.lww.com/anesthesiol...sory_for_the_Perioperative_Management.27.aspx
ASA comment
http://www.asahq.org/Knowledge-Base...ASA/Informing-the-Misinformed-About-ICDs.aspx
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That one was updated just this year:
http://www.asahq.org/For-Members/Pr...arameters/CardiacRhythmManagementDevices.ashx
From a quick glance it doesn't look like they address the ASC vs. hospital setting. However, here's a quote from the advisory:
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Have the reps get you the devices to interrogate them yourself and then bill for it.
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Although I am happy to re-program for the OR and subsequently return the settings to the preoperative state, there is no way that I am going to take on the liability for sending someone out on the street afterwards. The rep can come in and verify the settings. That is what they are paid for.
I am not worried that something that I do will be wrong, but if there is a pre-existing problem with the programming of the device, and I am not aware of the problem, I believe that I would be liable as the last person to interrogate/ adjust the device.
I am not even sure how I would bill for it. I suspect the insurance companies would look at my bill and laugh before denying it 50 ways from Sunday.
- pod
I am not worried that something that I do will be wrong, but if there is a pre-existing problem with the programming of the device, and I am not aware of the problem, I believe that I would be liable as the last person to interrogate/ adjust the device.
I am not even sure how I would bill for it. I suspect the insurance companies would look at my bill and laugh before denying it 50 ways from Sunday.
- pod
Medtronic AICD's are safe to use a magnet on without reprogramming afterwards. We never have a rep see them afterwards.
There is one version of medtronic pacemaker that you cannot use a magnet on.
Guidant devices are hit or miss and we call the company directly for every one of them. Some need to be turned off, others can safely be magneted.
Having a rep do the work is sort of iffy. They are legally forbidden from doing anything other than discussing how a product works and approved indications for it. They cannot offer medical advice nor can they prescribe courses of treatment. If a rep turned the device off and then back on for you and there was a problem, it would be problematic for you.
There is one version of medtronic pacemaker that you cannot use a magnet on.
Guidant devices are hit or miss and we call the company directly for every one of them. Some need to be turned off, others can safely be magneted.
Having a rep do the work is sort of iffy. They are legally forbidden from doing anything other than discussing how a product works and approved indications for it. They cannot offer medical advice nor can they prescribe courses of treatment. If a rep turned the device off and then back on for you and there was a problem, it would be problematic for you.
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I think you could make a pretty good case for not doing AICD patients in ASC's for anything but things like cataracts. Any case requiring a bovie heads to the big house.
Our cardiology service manages our patients with pacers and AICD's. MMan is right about the reps - you're the one telling them to turn the device off and on, etc. It's your ass, not theirs - they're just following your directions.
Our cardiology service manages our patients with pacers and AICD's. MMan is right about the reps - you're the one telling them to turn the device off and on, etc. It's your ass, not theirs - they're just following your directions.
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yeah all our AICD patients come to the main hospital
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I wouldn't do an AICD patient in an ASC. They're the very definition of a 4 - they wouldn't have the device if there wasn't a constant lethal threat lurking in their hearts. I don't know how I'd defend an event or adverse outcome, even one totally unrelated to the surgery or anesthetic.
What's this 3+ you speak of? 😕
It reminds me of a phenomenon I thought was exclusive to certain militant CRNAs. At some military hospitals, CRNAs are essentially "independent" but are required to consult an anesthesiologist for ASA 3 & 4 patients. At the hosptial I left a couple years ago, they did their own preop assessments, so some of them just made everyone a 2 in order to avoid having to talk to a physician. I'm not sure that fudging your 4s into some made-up 3+ class to skirt state law is such a great idea, but of course the whole system is sort of subjective and I'm not really casting stones at your ASC go/no-go decision process. It just seems weird, that's all.
Dirtball said:
What's this 3+ you speak of? 😕
It reminds me of a phenomenon I thought was exclusive to certain militant CRNAs. At some military hospitals, CRNAs are essentially "independent" but are required to consult an anesthesiologist for ASA 3 & 4 patients. At the hosptial I left a couple years ago, they did their own preop assessments, so some of them just made everyone a 2 in order to avoid having to talk to a physician. I'm not sure that fudging your 4s into some made-up 3+ class to skirt state law is such a great idea, but of course the whole system is sort of subjective and I'm not really casting stones at your ASC go/no-go decision process. It just seems weird, that's all.
I never ask them to disable defib funct. pre-op, I apply magnet if Bovie is needed during the case. Sometimes for skin but typically TURVNC and TURBT. Good fast Urologist. Sometimes we've done ESWL and Greenlight Laser Prostatectomy. I remove magnet after good hemostasis, keep EKG on Pt. in Pacu til rep arrives to verify defib is still enabled and they go home. ......If everyone agrees that the Pt with AICD is PS4 then I can avoid the issue entirely, I am not reckless, but 25,000 cases done 1:1 can breed confidence. I don't take risks to send bills. I have a very nice pre-op eval process that prevents alot of mayhem and I do refuse admission to the theatre regularly. ....I really can't argue they are not PS4's and they surely are once you tape that magnet on., keep the comments coming 3 or 4 ???
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follow up question...do you put the R2's on if you put the magnet on? i feel obligated to put the R2's on if i put the magnet on if for no other reason than i'd be a sitting liable duck if something happened, no matter how unlikely that something may be...
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The interrogation pays $45 by Medicare. Probably not worth it, but then it only takes 5 minutes. I agree ICD = ASA 4 and anything going wrong in an ASC would be indefensible.
I do not put patches on, I watch EKG and would remove magnet if needed for defib. Hopefully device would analyze and administer therapy. If it is an old Guidant with the problematic switch, and wouldn't reset, then I guess I'd be greasing up the paddles. ....Please keep your votes coming for PS3 vs 4. .............The 3+ I speak of is in my head, I do not write it down.
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In our hospital, the written policy requires us to call the rep and have him turn it off preop and then turn it back on postop. However, what I have been doing is the same as Dirtball: I place the magnet on the device to turn it off, and then, after I remove it, have the rep interrogate it to make sure everything is the way it was supposed to be before discharging the patient from the recovery room.
Regarding Guidant, I have talked many times with their tech support, and within the last year they have told me that nowadays the chances of finding a device programmed the old way, that is, as a toggle switch instead of magnet dependent, are minimal, because they don't program them like that any longer. However, I don't want to find in the middle of the operation that the device was programmed the old way, so I call them, even though you can tell by the beep. When you give them the serial number by phone, they tell you exactly how that particular device is programmed, when it was interrogated last, and the results of that interrogation.
I cannot remember which brand it was, a few months ago, when I called them, they told me that this device was at the end of its battery life and that it had to be changed before we could operate electively on that patient. So we rescheduled the surgeries, first the generator change and then the surgery the patient was to have originally, a few weeks apart.
Regarding Guidant, I have talked many times with their tech support, and within the last year they have told me that nowadays the chances of finding a device programmed the old way, that is, as a toggle switch instead of magnet dependent, are minimal, because they don't program them like that any longer. However, I don't want to find in the middle of the operation that the device was programmed the old way, so I call them, even though you can tell by the beep. When you give them the serial number by phone, they tell you exactly how that particular device is programmed, when it was interrogated last, and the results of that interrogation.
I cannot remember which brand it was, a few months ago, when I called them, they told me that this device was at the end of its battery life and that it had to be changed before we could operate electively on that patient. So we rescheduled the surgeries, first the generator change and then the surgery the patient was to have originally, a few weeks apart.
More votes please, Is the Pt with an AICD PS3 or PS4 ? I had another one booked for the ASC today. Surely anyone on here in practice has an opinion and maybe some policy from your place to add to the discussion.....thanks
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ASA 4.
We have the rep come and interrogate the device pre and post procedure. I wouldn't feel comfortable sending a patient anywhere unmonitored until I'm sure the device has returnedt to it's pre surgery settings.
We have the rep come and interrogate the device pre and post procedure. I wouldn't feel comfortable sending a patient anywhere unmonitored until I'm sure the device has returnedt to it's pre surgery settings.
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Re: ASA3 vs. ASA4 for an AICD:
I can't see how you could argue that a condition requiring an AICD is not a "constant threat to life" and therefore makes someone an ASA4. I mean, theoretically everyone with an AICD either has survived, or is at risk for, a life-threatening event.
I can't see how you could argue that a condition requiring an AICD is not a "constant threat to life" and therefore makes someone an ASA4. I mean, theoretically everyone with an AICD either has survived, or is at risk for, a life-threatening event.
An EF < 35% is an indication for an AICD. In fact, it's probably the indication most commonly used to place one. Is someone with an EF of 30% without an AICD also an ASA 4? I don't think they necessarily are. They are definitely at least a 3. But if they've been stable for some time and compliant with meds, I'd probably call them a 3 and not a 4.
I make all dialysis patients a 4.
I don't make all AICD patients a 4, though many are.
