pacemaker/TURBT question

[nap$ter]

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quick question for you guys -

pt on the sch for tomorrow 80yo for TURBT mult issues least of which is a DDDR pacemaker in place for sick sinus, underlying rhythm is afib at 40bpm. a paced 16%, v paced 78% of the time.

we have to have cardiology recommend to the device reps what to do with pacers intraop - frustrating because they ALWAYS say "place magnet over pacer in emergency", which is their rec for this guy, because he is "not pacer dependent". wtf is dependent if this ain't it?

i plan to tell cardiology to tell the rep to just put it to VOO preop - avoid the hassle - magnets are for emergencies, and my job is to prevent the emergencies..

thoughts?

 

[proman]

I'd recommend turning off the rate adaptive feature. I don't think you have to worry much about the pacer getting inhibited from electrocautery for a TURBT. You could call the manufacturer and give the patient ID and ask what a magnet does. I don't know what the rate adaptive feature does with a magnet.

 

[fakin' the funk]

We have to have cardiology recommend to the device reps what to do with pacers intraop - frustrating because they ALWAYS say "place magnet over pacer in emergency", which is their rec for this guy, because he is "not pacer dependent". wtf is dependent if this ain't it?

Cardiol J. 2007;14(1):83-6.

Pacemaker dependency after pacemaker implantation.
Lelakowski J, Majewski J, Bednarek J, Małecka B, Zabek A.

Abstract

Background: Pacemaker dependency (PD) can be defined as the risk of serious injury or death from sudden pacemaker failure, an event more dangerous than progressive rate decrease...

Pacemaker dependency was defined as the absence of an intrinsic rhythm of 30 beats/min during back-up pacing and after switching off the pacemaker...

Pacemaker dependency was observed in 76 (2.1%) of the 3638 patients.

 

[nap$ter]

I'd recommend turning off the rate adaptive feature. I don't think you have to worry much about the pacer getting inhibited from electrocautery for a TURBT. You could call the manufacturer and give the patient ID and ask what a magnet does. I don't know what the rate adaptive feature does with a magnet.

sorry - i do know a magnet will send it to VOO at 85; i guess my question was really whether you guys think there's much chance of EMI/bradycardia from the cautery of a TURBT....

 

[fakin' the funk]

i plan to tell cardiology to tell the rep to just put it to VOO preop - avoid the hassle - magnets are for emergencies, and my job is to prevent the emergencies..

thoughts?

I agree with your plan. VOO at some reasonable rate (e.g. 70-90), disable rate-adaptive feature, go back to DDDR in PACU.

 

[nap$ter]

Cardiol J. 2007;14(1):83-6.

Pacemaker dependency after pacemaker implantation.
Lelakowski J, Majewski J, Bednarek J, Małecka B, Zabek A.

Abstract

Background: Pacemaker dependency (PD) can be defined as the risk of serious injury or death from sudden pacemaker failure, an event more dangerous than progressive rate decrease...

Pacemaker dependency was defined as the absence of an intrinsic rhythm of 30 beats/min during back-up pacing and after switching off the pacemaker...

Pacemaker dependency was observed in 76 (2.1%) of the 3638 patients.

i dislike the dependency definition given here - it's not black or white, and whether they're dependent in the awake walkin around state only has so much bearing on the dependency under GA.

according to our cardiologists, only 2.1% of patients need to go to VOO by this definition.

 

[fakin' the funk]

i dislike the dependency definition given here - it's not black or white, and whether they're dependent in the awake walkin around state only has so much bearing on the dependency under GA.

according to our cardiologists, only 2.1% of patients need to go to VOO by this definition.

Right. It's a BS definition. Even more BS -- I've been told by a cards fellow that pacemaker dependency is "no underlying rhythm." So, clearly dependency should not be a criterion for reprogramming to async for surgery. I think WE get to make the call who needs async and who doesn't. They're just trying to do the least work possible.

 

[periopdoc]

Why not DOO?

- pod

 

[Planktonmd]

I don't think you need to even turn off the rate adaptive function or do anything for a TURBT.
I would just proceed and in the unlikely event there is a problem just place a magnet to go into VOO as you mentioned.

 

[BLADEMDA]

I don't think you need to even turn off the rate adaptive function or do anything for a TURBT.
I would just proceed and in the unlikely event there is a problem just place a magnet to go into VOO as you mentioned.

Agree. I'm telling you that after hundreds of these cases (dare I say thousands?) this isn't a real clinical issue. The new pacemakers are very safe and all you need to do is do the case with a magnet on stand-by. If you so feel inclined for your pacemaker dependent patients only have a rep or Cardiology check the device prior to discharge home.

 

[BLADEMDA]

I agree with your plan. VOO at some reasonable rate (e.g. 70-90), disable rate-adaptive feature, go back to DDDR in PACU.

How much money do you want to bet me that if you do a study on this group of patients with 100 in each subgroup (one gets reprogrammed while the other gets NOTHING) there won't be any difference in pacemaker malfunction.

 

[nap$ter]

Why not DOO?

- pod

good point.

but - i looked in pubmed - the few case reports with emi/brady or tachy events in pacemaker pts with transurethral cautery are from the distant past - given that this patient has a newer generation device and the advice i've been given (including on this forum) i am going to change my plan and just stand by with a magnet.

thanks and regards

 

[24858]

Why not DOO?

- pod

Good question. I often wondered this after CABGs when we would need to pace someone and we used VOO. I don't do CABGs anymore so I forget if there is a reason. Do you get a better atrial kick with an intrinsic atrial beat.

 

[sevoflurane]

We usually come off with DOO. Later I see how they do solo once the canulas are coming out (or before). Sometimes the intrinsic rate competes with the pacer and you get better hemodynamics with VOO or no pacer at all. Sometimes their intrinsic rate is in the low-mid 40's or they have sick sinus or something of that flavor for which we keep DOO running.

 

[epidural man]

i plan to tell cardiology to tell the rep to just put it to VOO preop - avoid the hassle - magnets are for emergencies, and my job is to prevent the emergencies..

thoughts?

It sounds like you just used the magnet for standby and left the pacer as is - good plan.

However, if you DID want to place him in VOO, why not just use the magnet during the case (place him on VOO at 85 bpm) and remove it after the case, rather than call cardiology to reprogram the device, then have them come back to reset it to the original state?

 

[sevoflurane]

What kind of pacer gets permanently reprogramed by placing a magnet on it? They are a dying breed but I think they are still out there.

 

[deleted59964]

Why not DOO?

- pod

underlying rhythm is afib

 

[nap$ter]

underlying rhythm is afib

the guy was in afib at hr of 40 - educate me - why can't you pace DOO?

 

[jetproppilot]

Agree. I'm telling you that after hundreds of these cases (dare I say thousands?) this isn't a real clinical issue. The new pacemakers are very safe and all you need to do is do the case with a magnet on stand-by. If you so feel inclined for your pacemaker dependent patients only have a rep or Cardiology check the device prior to discharge home.

Boom.

You guys are making

something out of nothing.

Fifteen years into private practice,

I've done the magnet thing.

I've done the "OMG, THE REP HAS TO BE HERE PREOP! thing.

No man.

Save your brain cells for something more important. This is a

NON ISSUE.

Blade is spot on.

I understand when residents bring up these issues.

That's good. Means they're learning.

What I don't understand is

why attending anesthesiologists, almost exclusively in

academia


make subjects like this (ohhh there's more subjects they wanna make complicated believe me) harder than they need to be.

Btw my statement has nothing to do with anyone posting on this thread.

Pointing out tho that

Academic anesthesia teaches residents a model instilled with more anxiety than needs be.

Academic anesthesiologists need to turn out

EDUCATED, INFORMED, PREPARED residents who can differentiate a

CALM from a

STORM.

Hard to do from a resident's standpoint when a lotta stuff that doesn't haffta be a storm

IS TAUGHT

to be a storm.

Save the drama.

It doesn't do

The Residents (capitalized because it needs to be capitalized )

any good.

 

[nap$ter]

Boom.

You guys are making

something out of nothing.

Fifteen years into private practice,

I've done the magnet thing.

I've done the "OMG, THE REP HAS TO BE HERE PREOP! thing.

No man.

Save your brain cells for something more important. This is a

NON ISSUE.

Blade is spot on.

I understand when residents bring up these issues.

That's good. Means they're learning.

What I don't understand is

why attending anesthesiologists, almost exclusively in

academia


make subjects like this (ohhh there's more subjects they wanna make complicated believe me) harder than they need to be.

Btw my statement has nothing to do with anyone posting on this thread.

Pointing out tho that

Academic anesthesia teaches residents a model instilled with more anxiety than needs be.

Academic anesthesiologists need to turn out

EDUCATED, INFORMED, PREPARED residents who can differentiate a

CALM from a

STORM.

Hard to do from a resident's standpoint when a lotta stuff that doesn't haffta be a storm

IS TAUGHT

to be a storm.

Save the drama.

It doesn't do

The Residents (capitalized because it needs to be capitalized )

any good.

you and blade are right. earlier in the thread it was agreed to do nothing, have a magnet on standby... but the device does need to be interrogated post-op. this in support of your anecdotes:

Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators: an updated report by the american society of anesthesiologists task force on perioperative management of patients with cardiac implantable electronic devices. 2011 google for a copy - worth a read.

being a new attending right out of residency i find the experience on this forum invaluable.

as an aside, when i walked into the room for this patient, the crna had placed the magnet over the left chest for the entire case.

the pacer was in the right chest - the pt was left-handed.

the crna "just thought he needed pacing" - had no clue that he was indeed pacing already and that her magnet placement had been done ineffectively.

we had had a discussion about management preop and the crna had claimed understanding.

you need to understand wtf you're doing.

crna = certified registered nurse assassins - watch 'em close.

disclaimer - i am quite fond of some crnas and they do a dam fine job.

also - is there really a reason you can't pace slow afib in DOO should you want to?

 

[Impromptu]

In my preanesthesia testing clinic I made it a point to call the pacemaker company to ask them what happened to that particular pacemaker and if they recommended anything specific. The residents who got those patients the next week really appreciated that.