Of AICDs, magnets, and R2 pads...

[urge]

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Do you put r2 pads on all patients you put the magnet on?

I don't. Most, if not all, of my coworkers do. Is that standard? I have them in the room but don't open them. I figure it cannot take me that long to slap them on or remove the magnet.

How much are r2 pads? I have a feeling they are $100 but I might be wrong.

Am I being too cheap?

 

[cchoukal]

It depends on why I'm placing the magnet. If I'm placing on a pacemaker to change the mode to DOO or VOO or whichever asynchronous mode is the magnet-default, I wouldn't place the defib pads. If I'm placing the magnet on an AICD to disable the defibrillator function, then, yes, the patient gets pads.

In the case of the pacemaker, I'm not sure what the pads offer.

I suppose I could envision a case where the patient were absolutely pacer dependent and the pacer interpreted interference as a rhythm and stopped pacing, in which case the pads would be important for TC pacing (but, of course, that's why you place the magnet and pace asynchronously which disables sensing). If sensing is disabled, the only concern you have is that something in the OR disables the PACING function, which is a little hard to imagine unless you were grossly negligent with regard to bovie pad placement.

If you're interested, Yao and Artusio's chapter on devices is really pretty good.

 

[bne_12mne]

In the case of the pacemaker, I'm not sure what the pads offer.

What about the ability to rapidly cardiovert an R on T mediated V-tach/fib? Paddles will work too, but presumably if you are putting a magnet on the pacer it is because the box/leads are in the "high risk zone" which means that the chest is probably prepped and draped too. That said, I do not routinely put R2 pads on just to place a magnet on a pacer, because with most devices the magnet rate (85-100) in DOO/VOO exceeds the intrinsic heart rate under anesthesia, which leaves only PVCs to worry about.

What do others think?

BNE

 

[periopdoc]

Generally, our institutional practice is to place the patches whenever we disable AICD functions (we don't use magnets, we just reprogram pacers and AICDs for whatever mode we want them to be in for surgery).

Personally, I would place them if it was going to be a struggle to get to the chest during surgery or if the patient had multiple defib episodes in the last year, or if it was a high risk surgery. If it was a knee replacement etc and the defib was placed for primary prevention, I would just be sure that I had a defib with patches on my anesthesia cart. I have only had to go under the drapes to put on the patches for defibrillation once (on a guy that did not have an AICD). It went fine except that the guy was right lateral for a thoracotomy and I placed the posterior patch right over his epidural insertion site... No sequelae.

If I was working with CRNA's or residents, I would probably place them on more patients.

Patches retail for about 30 bucks a pair. We use at least 4 pairs a day at UW so we might get them for even less. Usually they are sold in sets of ten so keep in mind that if you see them in a catalog, the price will be in the 300 dollar range for the 10 set pack. When I was purchasing them for the fire department in the mid 90's, I think that they were in the mid 40s to low 50's per pair, but this was right after fast-patch technology was introduced so the only option was to purchase brand-name patches. Still, it is probably a waste for to place them on low risk patients.

- pod

 

[jwk]

We never place pads ahead of time as a matter of routine. If they're using a monopolar cautery, we'll place the magnet. If it's a smaller procedure and they can use a bipolar, it's generally not necessary.

Yet another thing different in private practice.

 

[urge]

I'm getting into the cost/benefit side. We must put about 100 or so pads a year (due to AICDs) and I have never heard of anyone fibrillating for elective procedures. Seems like a waste to me.

I'll rephrase the question: have you ever (or your partners) had to use the R2 pads for an elective case where you deactivated the AICD?

 

[urge]

What about the ability to rapidly cardiovert an R on T mediated V-tach/fib? Paddles will work too, but presumably if you are putting a magnet on the pacer it is because the box/leads are in the "high risk zone" which means that the chest is probably prepped and draped too. That said, I do not routinely put R2 pads on just to place a magnet on a pacer, because with most devices the magnet rate (85-100) in DOO/VOO exceeds the intrinsic heart rate under anesthesia, which leaves only PVCs to worry about.

What do others think?

BNE

Pacers are not a big deal. Set it to asynchronus and call it a day.

Do you know how hard is to fibrillate some of these guys? Spend some time in the ep lab and you will realize you have about the same chances of winning the lotto than fibrillating with r over t.

 

[Licoricestick]

I'm getting into the cost/benefit side. We must put about 100 or so pads a year (due to AICDs) and I have never heard of anyone fibrillating for elective procedures. Seems like a waste to me.

I'll rephrase the question: have you ever (or your partners) had to use the R2 pads for an elective case where you deactivated the AICD?

I had a case where we wished we had placed pads - AICD deactivated (programming, not magnet), not given correct info by pacemaker tech - pt had multiple episodes of VT for which she had been overdrive paced (so of course the patient denied the defib ever going off). Intra op pulseless VT during breast lump excision and SNB. Had we had the pads on originally it would have been a lot neater and less contamination of the sterile field.

I'll admit she wasn't a low risk patient, but I can't see myself deactivating any defib in the future without putting pads on. If they're at a high enough risk to walk around the street with a defib in, then does that risk reduce under anaesthesia.....🙄

 

[periopdoc]

If they're at a high enough risk to walk around the street with a defib in, then does that risk reduce under anaesthesia.....🙄

That is an interesting question.


- pod

 

[urge]

If they're at a high enough risk to walk around the street with a defib in, then does that risk reduce under anaesthesia.....🙄

I don't know. I sure know they don't walk around with a physician monitoring them 1:1 like in the OR.

 

[bne_12mne]

Pacers are not a big deal. Set it to asynchronus and call it a day.

Do you know how hard is to fibrillate some of these guys? Spend some time in the ep lab and you will realize you have about the same chances of winning the lotto than fibrillating with r over t.

I hear you. And this is the sort of argument I make to my staff when I hear them pontificate on the R on T risk. I usually counter with the fact that most pacemaker patients are instructed to put a magnet on the device in their own home when they do over-the-phone transmissions to evaluate battery life and such! Obviously there is no monitoring or intervention capability there...

When we deactivate ICD's with a magnet, we usually do not place pads empirically, assuming that we can quickly get to the magnet to remove it in the event of arrythmia. But keep in mind the expected anti-tachycardic response after magnet removal is device specific, for example I don't think Boston Scientific devices immediatly reactivate the antitachycardic function. As much of a PITA as it is for our EP colleagues, I much prefer device reprogramming prior to surgery in patients with ICDs to make sure that there isn't inadvertent sensing, charging, and battery-drain occuring even in the absence of registered shocks that would put a patient at risk later on. With just a donut magnet placed on some AICD devices you can never be quite sure that it was deactivated properly, though with the "Smart Magnet" you have more assurance.

BNE

 

[Idiopathic]

i place them when putting a magnet on a patient with an ICD, and I think I probably always will, i cant see much reason to do so when switching to an asynchronous mode in a patient with no defibrillator