aicd/pacemaker

[gasmark]

So then the question is whether a magnet is sufficient or is reprogramming before and after best practice?

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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[BLADEMDA]

So then the question is whether a magnet is sufficient or is reprogramming before and after best practice?

Don't get confused over Pacemaker vs AICD/Pacemaker. They are 2 different animals when it comes to magnets.

"Best practice" as defined by the Heart Rhythm Society or the ASA? I typically follow the EP specialists' advice on these devices and not necessarily the ASA.

 

[BLADEMDA]

 

[BLADEMDA]

 

[gasmark]

So what would you do if monopolar is utilized within 15cm of a pacemaker (no AICD) in a patient that is pacemaker dependent?

 

[coffeebythelake]

i've had a circulating nurse place the dispersive electrode essentially over a PPM before. i wasn't in the room at the time. my resident tried to say something but apparently the nurse seemed to know what she was doing.

 

[BLADEMDA]

So what would you do if monopolar is utilized within 15cm of a pacemaker (no AICD) in a patient that is pacemaker dependent?

The pacemaker MUST be reprogrammed to the asynchronous mode. Failure to do this preop could have devastating consequences in the O.R. I have seen a CODE due to this failure at my shop.

 

[Robotic Wis-Hipple]

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.

I don’t think I’m being “super conservative”. You are attempting to apply your this works in my 5000 cases rhetoric to a case that clearly indicates reprogramming while at the same time stating “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”..... which is an exact description of the case in question. I don’t get every PPM reprogrammed, this is a decision based upon pacer dependency and location of surgery.

If it’s a belly surgery in a Pt who isn’t described as dependent I’m content just having the magnet available, I just think this is a topic people either take lightly or misunderstand and I don’t think we should tell residents etc to just have a magnet around or slap it on everything without understanding the why. I also think it’s an area we just do the easy way or because an N of 5000 says we’ll get away with it because of perioperative or surgeon planning inadequacies.

 

[BLADEMDA]

I don’t think I’m being “super conservative”. You are attempting to apply your this works in my 5000 cases rhetoric to a case that clearly indicates reprogramming while at the same time stating “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”..... which is an exact description of the case in question. I don’t get every PPM reprogrammed, this is a decision based upon pacer dependency and location of surgery.

If it’s a belly surgery in a Pt who isn’t described as dependent I’m content just having the magnet available, I just think this is a topic people either take lightly or misunderstand and I don’t think we should tell residents etc to just have a magnet around or slap it on everything without understanding the why. I also think it’s an area we just do the easy way or because an N of 5000 says we’ll get away with it because of perioperative or surgeon planning inadequacies.

I'm not looking to argue here. If a scheduled surgical case involves surgery within 15 cm of the pacemaker then the device needs to be reprogrammed to the asynchronous mode. If by mistake my posts imply anything else then I misunderstood the location of the surgery in relationship to the device. I have seen the consequences if this is not performed preoperatively.

My posts reflect real world experience over decades of taking care of patients with an average age of 70 plus. I see these devices daily in my practice. This gives me good feedback on how far a provider can push the envelope.

For the most part I agree with the Rhythm Society on the handling of all CIEDs especially AICDs.

I definitely agree one should just not slap a magnet over all devices and be done. I've never posted that and that's not how I roll.

 

[anes121508]

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?

ASA needs to do some teaching or spread the word on this topic. Still shocked that people don't understand what the magnet does and doesn't do in case of pacer/icd in patient dependent on pacer. Saw it again yesterday.

 

[nlax30]

Cardiac Rhythm device indentification
http://www.ianchristoph.com/physician-resources-2/device_id.pdf

A handy article to have available if you have to identify an unknown device from an CXR.

 

[fakin' the funk]

Since this thread is still going, somehow, just wanted to throw this out there:

It's not our effing problem that the pt has the device. The surgeon is the one who wants to do the surgery. The patient is the one with the cardiac disease. Some doc put the fackin thing in, and some surly rep somewhere is responsible for it.

There's really no excuse for not doing the right thing in elective cases with patients who have devices that actively keep them from dying.

 

[fakin' the funk]

My posts reflect real world experience over decades of taking care of patients with an average age of 70 plus. I see these devices daily in my practice. This gives me good feedback on how far a provider can push the envelope.

How do you get your 30 serratus plane blocks per day done when you're reprogramming all these devices?

 

[BLADEMDA]

How do you get your 30 serratus plane blocks per day done when you're reprogramming all these devices?

• Next Abstract >

Efficacy of Ultrasound-Guided Serratus Plane Block on Postoperative Quality of Recovery and Analgesia After Video-Assisted Thoracic Surgery: A Randomized, Triple-Blind, Placebo-Controlled Study
Kim Do-Hyeong MD; Oh, Young Jun MD, PhD; Lee, Jin Gu MD, PhD; Ha, Donghun MD; Chang, Young Jin MD, PhD; Kwak, Hyun Jeong MD, PhD
Anesthesia & Analgesia: Post Author Corrections: January 09, 2018
doi: 10.1213/ANE.0000000000002779
Research Report: PDF Only

• Abstract

BACKGROUND:

The optimal regional technique for analgesia and improved quality of recovery after video-assisted thoracic surgery (a procedure associated with considerable postoperative pain) has not been established. The main objective in this study was to compare quality of recovery in patients undergoing serratus plane block (SPB) with either ropivacaine or normal saline on the first postoperative day. Secondary outcomes were analgesic outcomes, including postoperative pain intensity and opioid consumption.

METHODS:

Ninety patients undergoing video-assisted thoracic surgery were randomized to receive ultrasound-guided SPB with 0.4 mL/kg of either 0.375% ropivacaine (SPB group) or normal saline (control group) after anesthetic induction. The primary outcome was the 40-item Quality of Recovery (QoR-40) score at 24 hours after surgery. The QoR-40 questionnaire was completed by patients the day before surgery and on postoperative days 1 and 2. Pain scores, opioid consumption, and adverse events were assessed for 2 days postoperatively.

RESULTS:

Eighty-five patients completed the study: 42 in the SPB group and 43 in the control group. The global QoR-40 scores on both postoperative days 1 and 2 were significantly higher in the SPB group than in the control group (estimated mean difference 8.5, 97.5% confidence interval [CI], 2.1–15.0, and P = .003; 8.5, 97.5% CI, 2.0–15.1, and P = .004, respectively). The overall mean difference between the SPB and control groups was 8.5 (95% CI, 3.3–13.8; P = .002). Pain scores at rest and opioid consumption were significantly lower up to 6 hours after surgery in the SPB group than in the control group. Cumulative opioid consumption was significantly lower up to 24 hours postoperatively in the SPB group.

CONCLUSIONS:

Single-injection SPB with ropivacaine enhanced the quality of recovery for 2 days postoperatively and improved postoperative analgesia during the early postoperative period in patients undergoing video-assisted thoracic surgery.