aicd/pacemaker

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izzygoer

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some questions related to aicd pacemaker.

say a patient presenting for nasal polyp removal requires general. aicd/pacemaker put in 1 year ago. interrogated 5 months ago, functioning properly pacemaker dependent on ekg. 1 aicd shock recorded 2 months ago

surgeon says he can use bipolar

1) have pacemaker switched to async by cardio.. pre-op pads on for the case. re-interrogated after

2) place magnet on before take off after..no further intervention

3) place magnet on before take off after..(interrogate after)

4) no intervention required as bipolar is low risk for emi


surgeon says he needs monopolar

1) have pacemaker switched to async by cardio.. pre-op pads on for the case. re-interrogated after

2) place magnet on before take off after..no further intervention

3) place magnet on before take off after..(interrogate after)

thanks
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Call rep, document a discussion that placing a magnet deactivates anti-tachy therapy without affecting pacing function, and that removing the magnet restores anti-tachy therapy.

Then do the case with a magnet.

They shouldn't need to come interrogate after for a modern device but I do think documentation of that discussion with them is important.
 
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I was wondering the same thing the other day. I know the "board answer", but in PP when you're doing your own cases and you barely see the patient except for minutes before heading back to the OR, do you really call the rep still?

I always get as much information regarding the AICD from the patient as possible, and make sure it was interrogated within the last 6months-1 year, however, if I had to call the rep every time, it would undoubtedly delay surgery. It's not like we have a preop clinic that screens these patients and addresses the issue prior to their arrival to the OR. So unless you are preopping patients well in advance (day before or early the morning of), I don't see how it would not delay surgery (maybe in a care team model you can address the issue while running around doing other things?). Not saying it's not the RIGHT thing to do if time allows, but in a PP rapid pace practice, it would get some moans and groans. I suppose the surgeon could flag those patients prior to scheduling them, but I highly doubt they would ha.
 
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If it’s an ICD AND patient is pacer dependent AND surgical site with cautery is above the waistline, you MUST have device set to asynchronous mode.
 
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My response was dependent on bipolar cautery- if monopolar is planned, it depends on how much cautery use is anticipated. If he's gonna be buzzing away like a steel welder then yeah you gotta asynch it. If it's just gonna be seldom short bursts you can get away without it.

So it all depends on your surgeon, the procedure, and how trustworthy your surgeon's report of the plan is.
 
caligas said:
If it’s an ICD AND patient is pacer dependent AND surgical site is above the waistline, you MUST have device set to asynchronous mode.
Click to expand...

Yes, especially if monopolar is used but one can argue for bipolar as well given proximity.

Side note - pacemaker dependent with ICD in place, this guy might have chronic heart failure and overall poor health. Be sure his cardiologist has him tuned up or at least stable prior to surgery or your ICU might “win” a 5 day CHF exacerbation postop. There’s no rush to be a hero for nasal polyps here, do the patient right.
 
I agree with the poster above. This is a no-brainer. Either have to call the pacer nurse during normal hours or call the rep after hours. Its an elective surgery...not your fault if the case gets delayed.
 
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Why not place the magnet, putting the patient in asynchronous pacing and deactivating the AICD. Then have pads available if patient goes into VF/VT. Am I missing something? Obviously a rep interrogation is always optimal, but this would seem fine to me...

Edit: missed that the surgery is close to heart and pacemaker would pick up cautery,i.e. wouldn’t pace.
 
agammaglobulin said:
Why not place the magnet, putting the patient in asynchronous pacing and deactivating the AICD. Then have pads available if patient goes into VF/VT. Am I missing something? Obviously a rep interrogation is always optimal, but this would seem fine to me...
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Because placing a magnet on a pacer/AICD has no effect on the pacing function. All it does is switch off the ICD.

If the patient is pacer dependent, EMI can fool the device into thinking it's sensing intrinsic heart activity at an acceptable rate ... so it won't pace, and the patient may become bradycardic.

For patients who are not pacer dependent, most would agree that in modern days the magnet is just fine with the plan you outlined. But the ultra conservative answer is that there's no ironclad 100% guarantee that removing the magnet will return the AICD to its original function, so one should check with the device rep and/or interrogate it postop.
 
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where i trained people routinely used magnets. at my current hospital the policy is for elective cases it should be interrogated before hand and
magnets only if emergent cases because of unknowm effects of magnets

specifically to the issue of bipolar...all of the literature says this is low risk for emi..equivalent to any other electrical device in the OR. unless there are a series of case reports i am missing from bipolar causing problems..couldn't one reasonably proceed with the case without any intervention?
 
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With bipolar the current flows between the two bovey tips. Should be no need to reprogram regardless of surgery location.
 
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I'm gonna suggest something CRAZY:

I was talking to the rep for St.Jude the other day (obv cause she was cute), but it turns out the AICD and pacemakers are fairly easy to reprogram if one has the right machine. She walked me through it, once for the AICD, once for the pacemaker. it's 100% doable and learnable if you have 30 mins.

What would be the liability/legality if the reps left one of those machines with the ORs and we just reprogram the AICD to off and everything to DOO or VOO?
 
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dchz said:
I'm gonna suggest something CRAZY:

I was talking to the rep for St.Jude the other day (obv cause she was cute), but it turns out the AICD and pacemakers are fairly easy to reprogram if one has the right machine. She walked me through it, once for the AICD, once for the pacemaker. it's 100% doable and learnable if you have 30 mins.

What would be the liability/legality if the reps left one of those machines with the ORs and we just reprogram the AICD to off and everything to DOO or VOO?
Click to expand...
This is very institution dependent. I trained at a place where I did all the perioperative reprogramming myself. It's not difficult.

In the real world of private practice, now you're talking about a rep whose income depends on doing this stuff, and they are far less likely to hand this kind of control over to you. In some places, where you establish a relationship with these reps, it may be possible once they trust you.

It exposes you to nontrivial liability, so if you're going to do this stuff yourself you better be damn sure you do it right. But yeah, it isn't hard.
 
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pgg said:
Because placing a magnet on a pacer/AICD has no effect on the pacing function. All it does is switch off the ICD.

If the patient is pacer dependent, EMI can fool the device into thinking it's sensing intrinsic heart activity at an acceptable rate ... so it won't pace, and the patient may become bradycardic.

For patients who are not pacer dependent, most would agree that in modern days the magnet is just fine with the plan you outlined. But the ultra conservative answer is that there's no ironclad 100% guarantee that removing the magnet will return the AICD to its original function, so one should check with the device rep and/or interrogate it postop.
Click to expand...
this is why i always have them interrogate after the magnet. sure the rep will tell you one thing but God forbid that bad boy malfunctions for some reason. i've definitely heard stories of people thinking a ICD turned back on after a magnet removal only to have the patient go into VT in PACU. Let that rep earn their money and check the ICD
 
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facted said:
Still not necessary for BIPOLAR.

"Bipolar electrocautery is not a concern for CIEDs since the current is small and energy travels between the 2 poles of the pen or stylus."

Managing Cardiovascular Implantable Electronic Devices (CIEDs) During Perioperative Care
Click to expand...

My last year of residency we had at least two AICDs go off during spine surgery when we left it alone bc the surgeon used bipolar. Magnets are hard because the person is prone (in one of the cases the magnet fell off and no one noticed, then boom!) so deactivating the antitachy function should be strongly considered for thoracic spines.
 
Why do people think it's ok to randomly put a magnet on an unknown icd when there is a lot of guidelines saying not to do this.

Especially not in an elective case.

The magnet in many manufacturers cases is put there as a last resort, not a first option
 
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Newtwo said:
Why do people think it's ok to randomly put a magnet on an unknown icd when there is a lot of guidelines saying not to do this.

Especially not in an elective case.

The magnet in many manufacturers cases is put there as a last resort, not a first option
Click to expand...
Because you only follows guidelines when it's convenient!

Though I worked at place where we had EP come program every device and they decided to get rid of that service and just tell us to put a magnet on everyone, and that was after a lot of higher level discussions.
 
dchz said:
I'm gonna suggest something CRAZY:

I was talking to the rep for St.Jude the other day (obv cause she was cute), but it turns out the AICD and pacemakers are fairly easy to reprogram if one has the right machine. She walked me through it, once for the AICD, once for the pacemaker. it's 100% doable and learnable if you have 30 mins.

What would be the liability/legality if the reps left one of those machines with the ORs and we just reprogram the AICD to off and everything to DOO or VOO?
Click to expand...

Yeah I like this idea and I pitched it a couple years ago. Here’s the flip side - what if you get relieved from the case and it’s late with no cardiac/AICD trained peeps around? You going to come back in to turn it back on? Might be hard to reach the rep after 5, maybe call Cardiology? Wait until the morning?

No perfect answer, but something to consider and chew on.
 
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pgg said:
Because placing a magnet on a pacer/AICD has no effect on the pacing function. All it does is switch off the ICD.

If the patient is pacer dependent, EMI can fool the device into thinking it's sensing intrinsic heart activity at an acceptable rate ... so it won't pace, and the patient may become bradycardic.

For patients who are not pacer dependent, most would agree that in modern days the magnet is just fine with the plan you outlined. But the ultra conservative answer is that there's no ironclad 100% guarantee that removing the magnet will return the AICD to its original function, so one should check with the device rep and/or interrogate it postop.
Click to expand...

As I have posted before this has actually occurred to one of my patients. I've seen this up close and personal. The patient may have no intrinsic heart rate without the pacemaker. This leads to massive hypotension and a near arrest situation.

If the patient is pacemaker dependent and the surgery is above the umbilicus then the use of a monopolar cautery device requires the pacemaker be set to an aynchronous mode. If you skip this step then the bovie may cause the pacemaker to think it's sensing heart activity and not pace. The patient must then rely on his/her instrinsic rate to maintain perfusion and BP. One of former partners told me his view was just to ask the surgeon to be quick or not use the bovie much. He didn't believe my "theory" was true so that provider simply placed the magnet over the AICD every single time no matter what.
 
dchz said:
I'm gonna suggest something CRAZY:

I was talking to the rep for St.Jude the other day (obv cause she was cute), but it turns out the AICD and pacemakers are fairly easy to reprogram if one has the right machine. She walked me through it, once for the AICD, once for the pacemaker. it's 100% doable and learnable if you have 30 mins.

What would be the liability/legality if the reps left one of those machines with the ORs and we just reprogram the AICD to off and everything to DOO or VOO?
Click to expand...

I've heard of a patient considering legal action against his Anesthesiologist for improper discharge of his AICD during surgery. The claim was the battery was run down prematurely due to negligence on the part of the provider. This led to "pain and Suffering" because a new AICD had to be placed prematurely.

If you monkey with the AICD then you own it intraop and postop as well.
 
Newtwo said:
Why do people think it's ok to randomly put a magnet on an unknown icd when there is a lot of guidelines saying not to do this.

Especially not in an elective case.

The magnet in many manufacturers cases is put there as a last resort, not a first option
Click to expand...

There a lot of guidelines where one only needs a magnet. In fact, most of the time all you need is a magnet for a new, modern AICD. But most of the time does not mean ALL of the time.
 
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BLADEMDA said:
There a lot of guidelines where one only needs a magnet. In fact, most of the time all you need is a magnet for a new, modern AICD. But most of the time does not mean ALL of the time.
Click to expand...
Well i totally agree. If the manufacturer says a magnet is ok, then its ok!

facted said:
Because you only follows guidelines when it's convenient!

Though I worked at place where we had EP come program every device and they decided to get rid of that service and just tell us to put a magnet on everyone, and that was after a lot of higher level discussions.
Click to expand...
Thats also excellent. If someone up on high wants to put their neck on the line and sign a decree like that im good with that. Hell i'll put the MRI magnet on their pacemaker is someone writes it down...

But you can sing it that i am not touching an unknown ICD with a magnet unless i have to. I am not an amateur cardiologist nor a tech. Thats someone elses job
 
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Newtwo said:
Why do people think it's ok to randomly put a magnet on an unknown icd when there is a lot of guidelines saying not to do this.

Especially not in an elective case.
Click to expand...

Uhhh who's doing that? :eek:

There shouldn't be anyone doing elective cases on patients with "unknown" ICDs. Standard of care is to have all device info and interrogation within last 6-12 months.

In my experience, understanding of CIEDs is pretty low/poor in our field because, well, they're complicated. But they're becoming more and more common...
 
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fakin' the funk said:
Uhhh who's doing that? :eek:

There shouldn't be anyone doing elective cases on patients with "unknown" ICDs. Standard of care is to have all device info and interrogation within last 6-12 months.

In my experience, understanding of CIEDs is pretty low/poor in our field because, well, they're complicated. But they're becoming more and more common...
Click to expand...
At my old place, patients ROUTINELY came with no info about their devices and certainly not checked recently. I used to have EP come and interrogate the device, but hospital policy became to just put a magnet on the device, which I strongly disagreed with, but I'd end up cancelling all these cases which clearly wouldn't fly.

Agree that the standard should be you know what device and settings before putting a magnet on it.
 
fakin' the funk said:
Uhhh who's doing that? :eek:

There shouldn't be anyone doing elective cases on patients with "unknown" ICDs. Standard of care is to have all device info and interrogation within last 6-12 months.

In my experience, understanding of CIEDs is pretty low/poor in our field because, well, they're complicated. But they're becoming more and more common...
Click to expand...
We have guys who think they can confidently identify the icd from a chest x-ray...

Some residents even!
 
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AdmiralChz said:
My last year of residency we had at least two AICDs go off during spine surgery when we left it alone bc the surgeon used bipolar. Magnets are hard because the person is prone (in one of the cases the magnet fell off and no one noticed, then boom!) so deactivating the antitachy function should be strongly considered for thoracic spines.
Click to expand...

How do you tell the AICD shocked during general anesthesia?
 
I can identify AICD vs. PPM from CXR, but I usually get that information from a patient discussion or looking through the chart :)
 
AdmiralChz said:
My last year of residency we had at least two AICDs go off during spine surgery when we left it alone bc the surgeon used bipolar. Magnets are hard because the person is prone (in one of the cases the magnet fell off and no one noticed, then boom!) so deactivating the antitachy function should be strongly considered for thoracic spines.
Click to expand...
Bipolar is not an absolute guarantee against a device discharging.
 
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Newtwo said:
How do you id a manufacturer from a cxr?
Click to expand...
You read it. The device has a radio opaque manufacturer label on it. A pacer dependent ICD patient gets a rep for interrogation, defib disable and v/doo for cases above the umbilicus bipolar bovie or not. What's the big deal?
 
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Bumping for a recent case. Pacemaker dependent patient going for a complete gastrectomy, may involve GE junction and require thoracotomy. Pacemaker placed for symptomatic severe bradycardia, no AICD. Monopolar will be utilized. Is magnet placement to switch the pacemaker to asynchronous mode sufficient or does it need to be reprogrammed?
 
gasmark said:
Bumping for a recent case. Pacemaker dependent patient going for a complete gastrectomy, may involve GE junction and require thoracotomy. Pacemaker placed for symptomatic severe bradycardia, no AICD. Monopolar will be utilized. Is magnet placement to switch the pacemaker to asynchronous mode sufficient or does it need to be reprogrammed?
Click to expand...

If the pacer site is accessible during the case, just have a magnet handy.
 
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drmwvr said:
If the pacer site is accessible during the case, just have a magnet handy.
Click to expand...

The Pt is pacemaker dependent, I would argue just having the magnet available is not enough. If you are sure you can place the magnet and have it secured in the proper place for the duration of the case that’s acceptable, otherwise get it reprogrammed into an asynchronous mode. I would get it placed in an asynchronous mode (if Pt truly is dependent).

This is one of my pet peeves, surgeons booking these big a$$ cases and not bothering to set this kind of stuff up.
 
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gasmark said:
Bumping for a recent case. Pacemaker dependent patient going for a complete gastrectomy, may involve GE junction and require thoracotomy. Pacemaker placed for symptomatic severe bradycardia, no AICD. Monopolar will be utilized. Is magnet placement to switch the pacemaker to asynchronous mode sufficient or does it need to be reprogrammed?
Click to expand...

Pacemakers these days are resilient to interference from bovie/cautery (monpolar). At my gig if the pacemaker is fairly recent (less than 5 years) and the battery has been checked within the past 6 months we simply do the case. A magnet won't be needed but should be available in the room.

If it's an AICD and the patient is pacemaker dependent then reprogramming is required prior to the start of the case because the surgery is above the umbilicus.

The Oral Board answer to your question is to reprogram the pacemaker but that is NOT what we do and our N is well over 5,000.
 
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The decision on the need for CIED check and reprogramming before operating depends on the nature of the procedure (having identified possible EMI sources), type of CIED and the patient’s pacing burden. CIED reprogramming is indicated in ICD patients, procedures with potential EMI and patients who are pacing dependent (i.e. pacing burden ≥ 40%). For such cases, device reprogramming may entail switching off ICD antitachycardia therapies (i.e. antitachycardia pacing and defibrillation), converting the pacing mode to an asynchronous one (i.e. VOO, DOO) and/or deactivating rate modulation features. Patients who do not fulfil the listed criteria generally do not require preoperative CIED reprogramming and the procedure can proceed with a cardiac device magnet on standby.

A practical approach to perioperative management of cardiac implantable electronic devices
 
BLADEMDA said:
Pacemakers these days are resilient to interference from bovie/cautery (monpolar). At my gig if the pacemaker is fairly recent (less than 5 years) and the battery has been checked within the past 6 months we simply do the case. A magnet won't be needed.

If it's an AICD and the patient is pacemaker dependent then reprogramming is required prior to the start of the case because the surgery is above the umbilicus.

The Oral Board answer to your question is to reprogram the pacemaker but that is NOT what we do and our N is well over 5,000.
Click to expand...

Are you saying you do this with pt’s who are pacemaker dependent or those that are paced ~10% of the time?
 
The pacemakers may be resilient to damage or corruption of programming from bovie, but this is entirely different from saying they don’t interpret EMI as intrinsic electrical activity and therefore sense and inhibit pacing function.
 
Robotic Wis-Hipple said:
Are you saying you do this with pt’s who are pacemaker dependent or those that are paced ~10% of the time?
Click to expand...

I fully understand the conservative nature of our specialty. But, What I'm saying is that for modern pacemakers (NOT AICDs) many providers follow outdated and overkill guidelines.

The modern pacemaker is quite resilient to EMI and as long as the surgery itself (monopolar is more than 15 cm/ I use 30 cm just to be safe) is far enough away from the pacemaker then no reprogramming is typically needed. This applies for pacemaker dependent patients but not those who are pacer dependent with an AICD component.

I can see being extra cautious in pacemaker dependent patients and deactivating the rate responsive mode but in my extensive experience it isn't necessary. That said, if the surgery and monoplar device will be close to the pacemaker then the EMI will INTERFERE with the device; that means reprogramming will absolutely be required.
 
Robotic Wis-Hipple said:
The pacemakers may be resilient to damage or corruption of programming from bovie, but this is entirely different from saying they don’t interpret EMI as intrinsic electrical activity and therefore sense and inhibit pacing function.
Click to expand...

How many patients have you done without a magnet or reprogramming of the device? I have seen thousands come through surgery safely and without any issues. The pacemaker will function just fine. There was one case where the pacemaker itself got reprogrammed from the monoplar cautery and had to have the device reset by the Rep in the PACU.

Also, the EMI will stop the pacemaker from functioning properly if the cautery is too close to the device. I've seen this happen to other providers several times.
 
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I’m well aware I’m a n00b and you’re an old vet......

But, this surgery is within your 15-30cm window, the patient as described is pacemaker dependent, and there are literally guidelines that you yourself copy and pasted from the HRS saying this Pt should be reprogrammed. That’s not rookie conservatism, that’s good practice.

And to answer your question, I’m not even 1 year out, and I’ve already seen multiple cases of “oh we’ll just have the magnet around” turn into trying to place a magnet under the drapes and secure it so the patient can actually create a systole during bovie use.

With respect, I think it’s lazy, and dictated by our constant desire to not delay our precious surgeons who have no idea what a CIED is and not best practice.
 
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Robotic Wis-Hipple said:
And to answer your question, I’m not even 1 year out, and I’ve already seen multiple cases of “oh we’ll just have the magnet around” turn into trying to place a magnet under the drapes and secure it so the patient can actually create a systole during bovie use.
Click to expand...


I do keep a magnet in the room but I’ve never placed a magnet on a pacemaker to set it to asynchronous mode and never had to in over 25 years. ICDs are a different story.
 
Robotic Wis-Hipple said:
I’m well aware I’m a n00b and you’re an old vet......

But, this surgery is within your 15-30cm window, the patient as described is pacemaker dependent, and there are literally guidelines that you yourself copy and pasted from the HRS saying this Pt should be reprogrammed. That’s not rookie conservatism, that’s good practice.

And to answer your question, I’m not even 1 year out, and I’ve already seen multiple cases of “oh we’ll just have the magnet around” turn into trying to place a magnet under the drapes and secure it so the patient can actually create a systole during bovie use.

With respect, I think it’s lazy, and dictated by our constant desire to not delay our precious surgeons who have no idea what a CIED is and not best practice.
Click to expand...

No problem. I think that my method works just fine. We can agree to disagree here. I don't have any issues with your being ultra conservative with CIEDs.

As for doing surgery close to the device that is a problem. If the surgery (with monopolar) is within 15 cm of the pacemaker the device will likely malfunction and not pace the patient. So, the pacemaker would need to be reprogrammed to an asynchronous mode or the case will likely get cancelled rather quickly intraop.
 
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