ICD question/Case tomorrow

[DrOwnage]

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Have a 73 y/o lady who’s coming tomorrow for completely elective ORIF hip. She is 95kg, a fib, EF<20% on echo 2 years ago, no significant structural disease besides severely reduced LVEF and a well functioning MVR. Last cath 2 years ago showed 60% left circ disease. She has a BIV ICD and is pacemaker depedent (100% paced). Cleared by cards (of course).

Anterior replacement, supine. Appears to be on lovenox bridge per chart.

You guys getting a rep to come and disable the device? I’m not sure of the magnet response. Would you put a spinal in this patient?

 

[coffeebythelake]

Have a 73 y/o lady who’s coming tomorrow for completely elective ORIF hip. She is 95kg, a fib, EF<20% on echo 2 years ago, no significant structural disease besides severely reduced LVEF and a well functioning MVR. Last cath 2 years ago showed 60% left circ disease. She has a BIV ICD and is pacemaker depedent (100% paced). Cleared by cards (of course).

Anterior replacement, supine. Appears to be on lovenox bridge per chart.

You guys getting a rep to come and disable the device? I’m not sure of the magnet response. Would you put a spinal in this patient?

Why would the ICD need to be disabled? Surgery is below the umbilicus, far enough away to not be an issue. Basically all modern ICDs are standardized to respond to magnet. So have a magnet in the room just in caee. if necessary will deactivate shock but doesn't change the pacing function of the ICD.

I would be cautious placing a spinal on a patient with such low EF along with MVR. They would be more sensitive to changes in preload. Art line wouldn't be a bad idea.

 

[DrOwnage]

Yeah I understand it’s “technically” not within EMI distance but pretty close. In these hips they bovi a crap ton and for long bursts. I don’t know if it’s for sure a thing she won’t be shocked mid-case if I do spinal MAC. It’s a well functioning mitral valve replacement. Was thinking of placing an A line then isobaric spinal MAC. Honestly though I dont think I’ve ever A lined prior to a spinal, always done general.

 

[coffeebythelake]

Yeah I understand it’s “technically” not within EMI distance but pretty close. In these hips they bovi a crap ton and for long bursts. I don’t know if it’s for sure a thing she won’t be shocked mid-case if I do spinal MAC.

Then if you are worried throw a magnet on to deactivate the shock function and put external pads on.

 

[DrOwnage]

I thought it was poor form to place a magnet on an AICD pacemaker dependent patient, remove it Postop, and expect everything to revert back to normal for discharge.

 

[coffeebythelake]

I thought it was poor form to place a magnet on an AICD pacemaker dependent patient, remove it Postop, and expect everything to revert back to normal for discharge.

It is protocolized at my institution. Unless you plan to reprogram the pacing function of the ICD, no need to call. When you read the official lit they say better to reprogram the device and that magnet should be used in urgent or emergent situations only. In practice that is not done. Having spoken to several EP cardiologists, putting on a magnet to deactivate the shock function is fine.

 

[DrOwnage]

It is protocolized at my institution. Unless you plan to reprogram the pacing function of the ICD, no need to call. When you read the official lit they say better to reprogram the device and that magnet should be used in urgent or emergent situations only. In practice that is not done. Having spoken to several EP cardiologists, putting on a magnet to deactivate the shock function is fine.

Curious do you place the magnet in preop first to see the effect or you usually take them back to the OR and do it?

 

[med2010]

We had a THA patient whose device charged multiple times during the procedure, despite being distal to the umbilicus. The charge timings corresponded with the patient being in the OR. Evidently each charge significantly reduces battery life. N=1, but it was an issue.

 

[coffeebythelake]

Curious do you place the magnet in preop first to see the effect or you usually take them back to the OR and do it?

I would try to figure out the type of ICD the patient has. Some ICDs may emit a tone when the magnet is applied, some do not.

 

[zizzer]

I would be concerned about the patient's ability to lie flat with HFrEF. Spinal and decreased preload may not be tolerated too well with ICM. My approach would probably be general anesthesia with preinduction arterial line and whatever vasopressor push doses and gtts ready. Magnet on preinduction with pads available. Monitors on to confirm no change in BiV pacing when I place the magnet (which there shouldn't be).

I'm not saying spinal anesthesia is necessarily wrong btw. It may be the way to go, but I don't know why you would hesitate to place an arterial line. They're painless, quick, and help a ton.

 

[dannyboy1]

Why pads? If patient goes into a rhythm that needs to be shocked just remove the magnet. ..

 

[narcotics999]

Put the bovie pad on the ipsilateral leg. 95Kg should give you enough leg surface area.

 

[deleted1111114]

Even though it is an inch or two below the umbilicus, they bovie excessively and You can see the intereference in ekg, bis and sometimes pulse ox. I’d get it reprogrammed if you have the time, since she is dependent, it should be asynchronous. Place pads if only because it sounds better that you did.

Definitely not a spinal. Could you? Yes, but why?

 

[DrN2O]

100% VP =/= pacemaker dependent. 100% pacing is likely the result of CRT (cardiac resynchronization) due to a widen QRS in the native conduction for someone with a low EF, but I don't have all the information for this patient. One needs a lot more information on this device: history, indication for ICD/CRT, underlying rhythm, and programming, which should be all available on a recent interrogation report. If you are not sure, call the rep (that's their job) or ask the in-house EP.

Then again, it's a hip and it's 2022, you are PROBABLY ok if you don't do anything about the device. But since you asked...

 

[Hork Bajir]

Great thread. This topic is a nerdy interest of mine- as with most things, there's a lot more subtlety than meets the eye...

1) Surgery below the umbilicus does NOT guarantee freedom from EMI, especially for ICDs (the sensitivity on the ICD can be set higher (lower threshold) than the sensitivity on pacing leads in order to detect fine VF, and there is inter-patient variability on this. There are PLENTY of case reports now where ICDs were not de-activated, and surgery below the umbilicus resulted in unintentional ICD shocks. Even more of a concern if your institution uses Megadyne return pads. See this example of ICD discharge during a total knee replacement: Unintended Discharge of an ICD in a Patient Undergoing Total Knee Replacement

2) If the patient is truly PPM dependent (which isn't totally clear from the above info, as @DrN20 correctly pointed out) then the device should be re-programmed to an asynchronous mode. Magnet obviously won't do anything for this. If you don't reprogram. the risk is inappropriate device inhibition and bradycardia during long bursts of electrocautery

3) This patient probably should have a CRT-D if they don't already. Easy to figure out by looking at a CXR (look for a coronary sinus lead). If they don't have one, why not? If they do, you want to make sure that they stay V-paced as much as possible (bi-V paced beats at least in theory will have a greater stroke volume than native QRS beats in someone with a bundle branch block and low EF- sometimes this difference can be quite dramatic)

4) Device interrogation and reprogramming doesn't take more than 5 minutes. If you communicate with the device rep ahead of time, don't schedule these patients as first case starts, and have them come in a little bit earlier, adding this to the workflow should not cause any delays... And if it does delay things for five minutes, big deal. These patients are sick and there are certain things we shouldn't rush

TL😀R: I'd get a rep to come in and reprogram to asynchronous mode. Since they're re-programming anyway, have them de-activate the ICD and you should put pads on. Then don't let them leave PACU until the rep has restored initial device settings. This is hands down the safest way to handle the scenario presented IMO... Less preferable second option would be use a magnet, and when they start using bovie, watch carefully to make sure it's not inhibiting the pacer

 

[vector2]

Great thread. This topic is a nerdy interest of mine- as with most things, there's a lot more subtlety than meets the eye...

1) Surgery below the umbilicus does NOT guarantee freedom from EMI, especially for ICDs (the sensitivity on the ICD can be set higher (lower threshold) than the sensitivity on pacing leads in order to detect fine VF, and there is inter-patient variability on this. There are PLENTY of case reports now where ICDs were not de-activated, and surgery below the umbilicus resulted in unintentional ICD shocks. Even more of a concern if your institution uses Megadyne return pads. See this example of ICD discharge during a total knee replacement: Unintended Discharge of an ICD in a Patient Undergoing Total Knee Replacement

2) If the patient is truly PPM dependent (which isn't totally clear from the above info, as @DrN20 correctly pointed out) then the device should be re-programmed to an asynchronous mode. Magnet obviously won't do anything for this. If you don't reprogram. the risk is inappropriate device inhibition and bradycardia during long bursts of electrocautery

3) This patient probably should have a CRT-D if they don't already. Easy to figure out by looking at a CXR (look for a coronary sinus lead). If they don't have one, why not? If they do, you want to make sure that they stay V-paced as much as possible (bi-V paced beats at least in theory will have a greater stroke volume than native QRS beats in someone with a bundle branch block and low EF- sometimes this difference can be quite dramatic)

4) Device interrogation and reprogramming doesn't take more than 5 minutes. If you communicate with the device rep ahead of time, don't schedule these patients as first case starts, and have them come in a little bit earlier, adding this to the workflow should not cause any delays... And if it does delay things for five minutes, big deal. These patients are sick and there are certain things we shouldn't rush

TL😀R: I'd get a rep to come in and reprogram to asynchronous mode. Since they're re-programming anyway, have them de-activate the ICD and you should put pads on. Then don't let them leave PACU until the rep has restored initial device settings. This is hands down the safest way to handle the scenario presented IMO... Less preferable second option would be use a magnet, and when they start using bovie, watch carefully to make sure it's not inhibiting the pacer

Agree with your recommendation to get the device reprogrammed in this case. I would also make sure their asynchronous rate is on the high side (90-100 bpm) to maintain CO given their function.

One correction though for what you wrote in 2). Magnets absolutely do change PPMs to asynchronous modes, although in the case of someone with a BiV CRT and ICD I wouldn't necessarily trust the magnet to do exactly what I had in mind for all the functions that need changed.

 

[hiyaman]

What's your definition of ppm dependence? Or what do you look for? I never really got a good answer other than "they are dependent if they have excessive bradycardia without pacing". Is there a good way to see on chart review. If I'm lucky their ep has a follow up note with their history and indication for device but a lot of times there's just interrogation notes which will just say everything is good.

 

[Hork Bajir]

Agree with your recommendation to get the device reprogrammed in this case. I would also make sure their asynchronous rate is on the high side (90-100 bpm) to maintain CO given their function.

One correction though for what you wrote in 2). Magnets absolutely do change PPMs to asynchronous modes, although in the case of someone with a BiV CRT and ICD I wouldn't necessarily trust the magnet to do exactly what I had in mind for all the functions that need changed.

View attachment 352435

Magnets will switch pacemakers to asynchronous mode, but if the device is an ICD, magnets won’t change the pacing mode- they will only inhibit the tachytherapies

With certain manufacturers the devices can also be programmed to ignore a magnet, but this happens rarely enough that it’s not worth talking about

 

[Hork Bajir]

 

[BobLoblaw78]

To paraphrase arthur wallace, "if a patients life depended on a machine/computer, would you push a button on the machine to see what happens?"

The magnet is essentially pushing a button and you don't know what that button does. For someone that has more than the basic ICD this is even more suspect action to take. Call the rep. Push this case back and the others up. Get it worked in today if at all possible.

You state you always do general (I assume you mean for THA and not art lines). If you do general for THA's then continue doing general for THA's. I like the isobaric idea, but you could probably make a case for general regardless.

 

[BobLoblaw78]

Let us know what you did and how it went.

 

[coffeebythelake]

We had a THA patient whose device charged multiple times during the procedure, despite being distal to the umbilicus. The charge timings corresponded with the patient being in the OR. Evidently each charge significantly reduces battery life. N=1, but it was an issue.

So charged but no shock delivered? That's interesting to say the least. And presumably a magnet over the device would have prevented this.

 

[coffeebythelake]

The magnet is essentially pushing a button and you don't know what that button does. For someone that has more than the basic ICD this is even more suspect action to take. Call the rep. Push this case back and the others up. Get it worked in today if at all possible.

But you know exactly what the magnet does. For an IVD it inhibits shock function and leaves pacing function unchanged. The topic of reproprogramming or setting the pacing function to asynchronous mode is interesting but unclear whether it is necessary in this case. Lot of new generation devices have good filters against EMI. Good to remember that asynchronous pacing while immune to sensing EMI also may put patient at risk for R on T.

 

[anbuitachi]

this type of patient is pretty common. these hip fractures are usually old/sick, and not uncommon for them to have PPM dependence with icd, low EF

we just did a case similar to this last week. 91 yr old, ICD/PPM dependent. CAD with 2 stents, severe pHTN, Tricuspid regurg. CHF ef 20%. interrogate and reprogram pacemaker. put a spinal in if not anticoagulated w some pressors in background.

 

[Guillemot]

Just wanted to chime in that the ASA guidelines and the HRS guidelines that are also endorsed by the ASA have a major discrepancy regarding utilizing magnets vs reprogramming. Really bizarre that this discrepancy exists.

2011 HRS/ASA Expert Consensus Statement on the Perioperative Management of Patients with Implantable Defibrillators, Pacemakers, and Arrhythmia Monitors: Facilities and Patient Management - HRS

Developed as a joint project with the American Society of Anesthesiologists (ASA) and in collaboration with the American Heart Association (AHA) and the Society of Thoracic Surgeons (STS), a diverse panel of experts in pacemaker and defibrillator management focused on medical procedures that...

www.hrsonline.org

Practice Advisory for the Perioperative Management of... : Anesthesiology

An abstract is unavailable.

pubs.asahq.org

The HRS guidelines is what is practiced in the “real world.” The ASA is what is practiced in academic centers.

 

[zizzer]

What's your definition of ppm dependence? Or what do you look for? I never really got a good answer other than "they are dependent if they have excessive bradycardia without pacing". Is there a good way to see on chart review. If I'm lucky their ep has a follow up note with their history and indication for device but a lot of times there's just interrogation notes which will just say everything is good.

I'm not sure on exact definitions, but I factor in the percentage of time they're paced from the report. Besides bradycardia, I would consider somebody with BiV (aka CRT) pacing for HFrEF to be dependent as well.

 

[Hork Bajir]

So charged but no shock delivered? That's interesting to say the least. And presumably a magnet over the device would have prevented this.

Most ICDs will look at the R-R interval, and if there are more than a predetermined number of “beats” above a certain heart rate, it will count as a “detection” for an arrhythmia (If you look at the interrogation report you’ll often see different heart rate zones to discriminate the detection of slow VT, fast VT, and VF, with different therapy/shock algorithms in response to each). Once the device thinks it has detected an arrhythmia, it will charge the capacitor, which takes a few seconds… Then after it is finished charging, it will take a moment to sense on the ventricular channel again in order to make sure that the patient is still in VF/VT before shocking. If VF or VT is no longer detected, The device will dissipate the charge without shocking.

So it’s actually not uncommon to see a scenario where the surgeon bovies for long enough that the device thinks it detects VT, charges the capacitor… and in the second or two it takes for the capacitor to charge, the surgeon has stopped using electrocautery, so when the device re-checks the rhythm prior to shocking it thinks the “arrhythmia” has spontaneously broken. If you look at a subsequent interrogation report you’ll see that the number of detections counted is higher than the number of shocks delivered when this happens.

The real reason it matters is because every charge shaves tons of time off of the battery life- three or four false detections could require the patient to get a generator change YEARS before it otherwise would’ve been necessary, even if they never actually got any inappropriate shocks

(I did say this was a nerdy interest of mine lol)

 

[coffeebythelake]

Most ICDs will look at the R-R interval, and if there are more than a predetermined number of “beats” above a certain heart rate, it will count as a “detection” for an arrhythmia (If you look at the interrogation report you’ll often see different heart rate zones to discriminate the detection of slow VT, fast VT, and VF, with different therapy/shock algorithms in response to each). Once the device thinks it has detected an arrhythmia, it will charge the capacitor, which takes a few seconds… Then after it is finished charging, it will take a moment to sense on the ventricular channel again in order to make sure that the patient is still in VF/VT before shocking. If VF or VT is no longer detected, The device will dissipate the charge without shocking.

So it’s actually not uncommon to see a scenario where the surgeon bovies for long enough that the device thinks it detects VT, charges the capacitor… and in the second or two it takes for the capacitor to charge, the surgeon has stopped using electrocautery, so when the device re-checks the rhythm prior to shocking it thinks the “arrhythmia” has spontaneously broken. If you look at a subsequent interrogation report you’ll see that the number of detections counted is higher than the number of shocks delivered when this happens.

The real reason it matters is because every charge shaves tons of time off of the battery life- three or four false detections could require the patient to get a generator change YEARS before it otherwise would’ve been necessary, even if they never actually got any inappropriate shocks

(I did say this was a nerdy interest of mine lol)

So even with a magnet on to deactivate the shock function ... it still charges and wastes battery life?? That seems odd it would be designed that way.

 

[Hork Bajir]

So even with a magnet on to deactivate the shock function ... it still charges and wastes battery life?? That seems odd it would be designed that way.

Nope- putting a magnet disables tachytherapies, so the ICD will not charge (eliminates concerns about battery drainage and inappropriate shocks). The scenario I just I described above is what can happen if you do NOT place a magnet or reprogram

 

[DrOwnage]

Just did the case. Turns out there was better information than I was given in the EMR. That echo with 20% was from 2 years prior, patient had a more recent echo with function improving to 45%. BiV paced at 70 in preop. Biotronik device. Called cardiologist who said magnet would work fine, expressed my other concerns, however he just responded with she will be fine. Given her relatively normalish EF I was comfortable proceeding with magnet placement only with pads placed appropriately given CIED.

Had enoxaparin 90mg yesterday at 730AM as part of her bridge(24 hours prior). She had some supratherapeutic INRs in the recent past (3.7, 4.1), stopped warfarin on Wednesday. However no one ordered a day of surgery INR. Decided on general because I didn't want to delay case for INR draw.

Surgeon bovied long and heavy, some break through sinus beats through the V pacing, nothing out of the ordinary, no shocks. Patient did fine. I think if the patient's EF had still been depressed <20 I would have delayed and called a rep. I was more comfortable with the new echo.

Thanks for all the input so far, really good discussion.

 

[BobLoblaw78]

But you know exactly what the magnet does. For an IVD it inhibits shock function and leaves pacing function unchanged. The topic of reproprogramming or setting the pacing function to asynchronous mode is interesting but unclear whether it is necessary in this case. Lot of new generation devices have good filters against EMI. Good to remember that asynchronous pacing while immune to sensing EMI also may put patient at risk for R on T.

You know exactly what the magnet does if they haven't changed the programming. The magnet can activate different things when programmed to do it. You could look to see what the most recent interrogation says regarding this. Or you could interrogate it yourself. It is not hard to do. We keep some machines to do exactly this for PM/ICD's. Although the report can read like a bad EMR that is 20 pages long.

 

[nimbus]

Just did the case. Turns out there was better information than I was given in the EMR. That echo with 20% was from 2 years prior, patient had a more recent echo with function improving to 45%. BiV paced at 70 in preop. Biotronik device. Called cardiologist who said magnet would work fine, expressed my other concerns, however he just responded with she will be fine. Given her relatively normalish EF I was comfortable proceeding with magnet placement only with pads placed appropriately given CIED.

Had enoxaparin 90mg yesterday at 730AM as part of her bridge(24 hours prior). She had some supratherapeutic INRs in the recent past (3.7, 4.1), stopped warfarin on Wednesday. However no one ordered a day of surgery INR. Decided on general because I didn't want to delay case for INR draw.

Surgeon bovied long and heavy, some break through sinus beats through the V pacing, nothing out of the ordinary, no shocks. Patient did fine. I think if the patient's EF had still been depressed <20 I would have delayed and called a rep. I was more comfortable with the new echo.

Thanks for all the input so far, really good discussion.

So resynchronization therapy actually works?

 

[DrOwnage]

So resynchronization therapy actually works?

Hah, the EP guys I used to work with in training said it only works like 33-50% of the time. Not sure if during that 20% phase she had a tachycardia induced cardiomyopathy from her a fib that probably might have recovered to 45% on its own. But in this case seems like it did.

 

[ethilo]

I almost always call the devices company if I can to clarify exactly what will happen if you put a magnet on them. Just tell them on the hotline that you are a doc and want to know what will happen. You give the patient's name and date of birth and they will have all the info you need about their device on their records. Very easy.

If your patient is unresponsive and can't tell you what company their device is, usually it's identifiable by CXR. I think all devices have a symbol or letters they use.

As a non cardiac guy, I try to call every time just to be totally clear and I document as much as I can about the patient's device in the record to hopefully help someone else out in the future...

 

[ethilo]

Also if you have Epic Haiku on your phone and they have a pacemaker card I snap a shot of that so it's discoverable in their record. Just a nice thing to do.

 

[DrOwnage]

Yeah the patient didn't have the card. I was stuck on hold forever with biotronik and the cardiologist got back to me before then so I scrapped it. I also put the magnet on her in preop and nothing changed so I was happy.

 

[Hork Bajir]

There's an app called "Pacemaker" which is free to download- if you take a photo of the pacemaker on a CXR (preferably zoomed in), it will tell you who the manufacturer is, and with what % certainty. Works very well IME

 

[vector2]

Magnets will switch pacemakers to asynchronous mode, but if the device is an ICD, magnets won’t change the pacing mode- they will only inhibit the tachytherapies

With certain manufacturers the devices can also be programmed to ignore a magnet, but this happens rarely enough that it’s not worth talking about

This is good information to know because I really thought CRT-D could separate out functions and respond like CRT-P by going asynchronous with its magnet pacing response (while simultaneously disabling antitach ICD functions), when it fact, like you said, it really just acts the same as an isolated ICD's pacing response to a magnet (which is to remain in whatever its non-asynchronous programmed mode was)

 

[BlueRug]

I don't understand....why don't you have the device programmer available and do it yourself?

 

[coffeebythelake]

I don't understand....why don't you have the device programmer available and do it yourself?

Do you?

 

[hiyaman]

I don't understand....why don't you have the device programmer available and do it yourself?

Is that something you do often?

I've never reprogrammed a cied and once have I needed to call the rep to come in to reprogram for a patient so idk if that's a common thing people do

 

[DrOwnage]

When I was in residency doing a long ass plastics case under microscope.... The surgeons didn't want any pressors and I was giving a crap ton of fluid and albumin but pressures were sagging like 6 hours in, also on nitrous. I had one of the cardiac anesthesiologists slip the device reprogrammer under the drapes and increase the VOO from 70 to DOO 95 BPM to increase their pressures. That's bout the closest I've come to "doing it myself."

I don't think we have all of the options here as machines go. Back in academics we had a good amount.

 

[coffeebythelake]

When I was in residency doing a long ass plastics case under microscope.... The surgeons didn't want any pressors and I was giving a crap ton of fluid and albumin but pressures were sagging like 6 hours in, also on nitrous. I had one of the cardiac anesthesiologists slip the device reprogrammer under the drapes and increase the VOO from 70 to DOO 95 BPM to increase their pressures. That's bout the closest I've come to "doing it myself."

I don't think we have all of the options here as machines go. Back in academics we had a good amount.

Honestly the correct solution in your story would have been to give the patient some phenylephrine

 

[med2010]

So charged but no shock delivered? That's interesting to say the least. And presumably a magnet over the device would have prevented this.

Correct. No magnet placed because surgery was distal to umbilicus. No shock delivered. Discovered postop on routine device interrogation when battery life was more depleted than expected.

 

[DrOwnage]

Honestly the correct solution in your story would have been to give the patient some phenylephrine

Haha was still a resident, now I wouldn't bat an eye.

 

[DrN2O]

Hah, the EP guys I used to work with in training said it only works like 33-50% of the time. Not sure if during that 20% phase she had a tachycardia induced cardiomyopathy from her a fib that probably might have recovered to 45% on its own. But in this case seems like it did.

Anything works more than 1/3 of time in cardiology is actually fantastic.

 

[Iso4ane]

What's your definition of ppm dependence? Or what do you look for? I never really got a good answer other than "they are dependent if they have excessive bradycardia without pacing". Is there a good way to see on chart review. If I'm lucky their ep has a follow up note with their history and indication for device but a lot of times there's just interrogation notes which will just say everything is good.

Basically, what would happen if you turned off the pacemaker? If they would pass out and die, that would be pacemaker dependent. If they are otherwise hemodynamically stable…not pacemaker dependent.

So you can have someone with underlying sick sinus bradycardia at 45-50bpm, who is paced 100% of the time at 60bpm, who would be fine if you completely shut off his pacemaker, this person wouldn’t be pacemaker dependent.

 

[BlueRug]

Is that something you do often?

I've never reprogrammed a cied and once have I needed to call the rep to come in to reprogram for a patient so idk if that's a common thing people do

Yes, all the time. I am cardiac trained but that should have nothing to do with it. Its very very easy.

 

[coffeebythelake]

Yes, all the time. I am cardiac trained but that should have nothing to do with it. Its very very easy.

You must have sweet talked the EP device reps or your hospital's EP service

 

[BobLoblaw78]

Call the device reps for every case and insist they interrogate pre and post surgery and they will quickly give you a device programmer if you ask! Especially if you don't live close to the reps home base. I actually just asked the rep and they had no problem giving me one.