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Pacemakers/AICDs

Discussion in 'Anesthesiology' started by DrRobert, Jan 6, 2009.

  1. DrRobert

    DrRobert Day or Night
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    Just wondering how people on this board are dealing with patients that have Pacemakers and/or AICDs and present for non-cardiac surgery... do you have the device reps come to the pre-op holding area to deal with them, use a magnet, etc.
     
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  3. huktonfonix

    huktonfonix board certified!
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    Every single one of us. Pacer/AICDs are so common it would be unusual if you dont have to deal with it. In an ideal academic setting, you have someone come in to interrogate the pacer (rep/pacer clinic) if there is no recent interrogation. You can check the model with an xray if the patient doesnt know or have the card to see what the default mode is. I personally see no need to routinely use a magnet, but I do have it available.
     
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  4. turnupthevapor

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    You better use a magnet for AICDS if monopolar cautery is used as it may trigger a shock (I have seen this)

    I believe it is recommended to have the AICD disabled prior to the OR.

    Our EP dudes disagree with this. They feel if there if VF/VT its easier to just remove the magnet and let the patient get shocked rather than firing up the transcutaneous pads.

    I agree with this because it also saves you from coordinating with the EP rep as well. Our EP dudes also assure me it is very unlikely the magnet will affect the current programming of the device.

    For pacemakers with no AICD I just have the magnet at the bedside and use it if the surgeon is unable to use bipolar or short bursts of unipolar and they are PM depandant
     
  5. Arch Guillotti

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    For some reason I thought I read somewhere that placing a magnet could potentially disable the AICD:confused:
     
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  6. turnupthevapor

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    while the magnet is on it is disabled, do you mean after it is removed it may remain disabled?
     
  7. Arch Guillotti

    Arch Guillotti Senior Member
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    yes, so I thought
     
  8. Arch Guillotti

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  9. SleepIsGood

    SleepIsGood Support the ASA !
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    At our place we hve the magnet by the Anesthesia Machine. Then...we dont really worry too much about it, but cards typically comes by in the PACUto check up on the pt.
     
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  10. Arch Guillotti

    Arch Guillotti Senior Member
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    same here
     
  11. BLADEMDA

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    For what it is worth here is how I see it done:

    For AICD devices where Monopolar cautery is used a Magnet is placed over the AICD. In the PACU or prior to discharge a rep must check the device to GUARANTEE it is functioning properly.

    This saves a time consuming step of having a rep deactivate the device before surgey. But, the official recommendation is to have a rep deactive and reactivate an AICD. This seems like overkill and it is hard enough to get them to "check" the device in PACU.

    Now, some reps will tell you the device is fine after you remove the magent. The rep doesn't even want to show up later in PACU. Those guys will tell you it is a waste of their time. But, go ahead and ask for WRITTEN proof that an AICD device doesn't need to be checked after a magnet has been placed over it: you won't get it.

    I won't assume the liability that the AICD is functioning properly after monopolar usage. You must insist the device be checked at some point prior to discharge.
     
  12. proman

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    Not all ICDs respond the same way to magnets. Not all ICDs made by the same company respond the same way, that's why it's safest to deactivate the defib part. Our EP guys had a fit a while ago and now the reps do it. For the money they make on the devices, it's a small sacrifice.
     
  13. BLADEMDA

    BLADEMDA ASA Member
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    Please list ONE AICD where a magnet placed over the device and left there doesn't deactivate it. Every Rep claims that a magnet will deactivate their brand. I know there are some "defective" AICD's out there but they are few and far between plus the patients kmow if their AICD was recalled by the manufacturer.

    Anyway, I can't get the reps to show up preop unless it is an extenuating circumstance. I can get them to come post-op.
     
  14. starsop93

    starsop93 Junior Member
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    It can be tricky.

    Medtronics pretty reliably respond as pacers do. i.e. magnet shuts off tachy therapy and removal returns it to the previous programming.

    St. Judes CAN be programmed to ignore a magnet.

    Guidant is a mess. They can be programmed to ignore a magnet and can be programmed to permanently shut off all tachy therapy if the magnet is left on for >30 sec. Also, one of the ways to "fix" all those Guidant ICDs that malfunctioned was to turn OFF the magnet responsiveness. So some Guidants out there will NOT shut off with a magnet, and some will shut off and STAY shut off if the magnet is on there for more than 30 sec.

    The most important thing is to have someone (either cardiology or rep) tell you what a magnet will do to that device. That can be done as a preop workup. Then you and the surgeon need to determine from that whether it needs to be shut off for the procedure, be turned back on at the end of it, or just be prepared with a magnet in the room.

    Yeah it can be a pain, but if your patient's ICD discharges during retinal surgery or you send a patient out into the world having inadvertently shut off their ICD, you could be a world of hurt.

    (Much info gleaned from publications by Marc Rozner, MD, PhD)
     
  15. BLADEMDA

    BLADEMDA ASA Member
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    My St. Jude rep. claims all AICD's in my area ARE magnet sensitive.
    Guidant agrees some "older" AICD's can be a problem but those patients are told about potential problems with surgery. The rep. told me to call her with model number/i.d. if I have any doubts.

    All reps agree to check AICD's prior to discharge. Thus, no patient goes home without having his/her AICD verified as functioning properly.

    Over 200 cases and counting so far with this strategy and no problems.
    We will continue to utilize it as it seems to work fine.

    Of Course, the BOARD exam remains to have every AICD turned off prior to surgery which involves monopolar and turned back on prior to discharge.
     
  16. fakin' the funk

    fakin' the funk ASA Member
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    I think it's completely f%& ked that a topic this complicated (and critical) is not taught AT ALL in medical school and we, the responsible party, are meant to learn it "on the job."
     
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  17. BLADEMDA

    BLADEMDA ASA Member
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    Welcome to the real world. You never stop learning in this business; or, I should say as long as you Practice new things/technology etc. are always being released. Get used to it.
     
  18. starsop93

    starsop93 Junior Member
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    Understood. I know how hard it is to get someone in the AM to shut it off. On the other hand, so much of the info about an individuals device can be gleaned at a relatively convenient time in preop workup so it shouldn't be much of a problem except for urgent and emergent cases.
     
  19. starsop93

    starsop93 Junior Member
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    I'm sure ICDs are taught in med school. As far as the nuts and bolts of how to manage such devices, that's what residency is for. I think the FDA really dropped the ball in not forcing the companies to have a consistent response in the way that pacers do, but that's relegated to history now.

    It really is up to us as anesthesiologists to come up with a practical, rational, and safe plan that all can agree and stick to at whatever institution you practice at. Not that different from other things really. If you are uncomfortable with the workup of an ICD or it needs to be turned off and nobody can do it, you have to cancel the case.
     
  20. cfdavid

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    Bro, I hear ya. I was on a case the other day, and the PD Attending comes in and puts a magnet over the pacemaker/defibrilator (not even sure which it was and the CA-1 was being pushed hard, so he wasn't even sure.


    *******O.k., as I understand it, there are essentially 3 methods of using an implant.

    1) bradycardic patients that rely on the pacemaker to maintain normal sinus rythm

    2) tachcardic patients that rely on the pacemaker to maintain normal sinus rythm (not sure how this is actually done, frankly)

    3) patients with various heart blocks that need monitoring for asystole, in which case the defibrilator/cardioverter kicks in.

    *****My other understanding is than monocaudery devices completely mess with the ECG on the monitor (even if placing the ground lead in the proper place), and thus can cause the pacer/defibrilator to either send a pacing signal, OR defibrilate a patient whose heart is doing just fine, in reality.

    SO, the magnet disables the pacemaker and the anesthesiologist is then able (to the best of his/her ability) monitor the ECG for pt problems (again, as best as the bove will allow)??

    Is this correct logic? Can someone with more experience elaborate on how a pacer corrects tachy??

    Sorry for the "dumb" framing of this question/topic, but like my med student colleague suggests, we just don't get this stuff formally, and baby Miller 4th edition is not much help.

    Thanks,

    cf
     
  21. Planktonmd

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    David,
    For a magnet to work on a pacer or an AICD the magnet function has to be enabled which allows the magnet to control a switch on the device.
    Most devices have that function enabled but in some cases it is disabled like in patients who are exposed frequently to magnetic fields due to their work or life style.
    Placing a magnet on a pace maker does not disable it, it just disables the sensing function which puts it in an asynchronous mode (pacing continuously).
    Placing a magnet on an AICD disables the arrhythmia detection function so the device will not deliver a shock as a response to electrical interference or actual arrhythmia.
    I hope this helps.
     
  22. dr doze

    dr doze To be able to forget means to sanity
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    .
     
    #22 dr doze, Jan 20, 2009
    Last edited: Mar 10, 2009
  23. cfdavid

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    Actually Plank, that really does help.

    I did some additional reading after posting this a.m. and it's making a lot more sense. I also read the ASA guideline pdf that one of the other guys linked. Plus, I just picked up Blueprints Medicine (haven't had medicine yet which is my last rotation of 3rd year) and the first few chapters talk about some of these cardiac issues that I mostly forgot since last year.....

    Thanks,

    cf
     
  24. Exsurg

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  25. schip

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    Have the rep or EP come and turn the off the device as you will drain the battery by using a magnet. If they don't want to "be bothered" get a programmer and be trained how to do it yourself. It s not diffcult.
     
  26. anesthesiadoc

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    It might help to further define "deactivate." Magnets will stop the defibrillator function on the AICD. But perhaps a bigger concern is the pacer function. It's critical to define whether a patient is pacer dependent, and also to determine the company who manufactured the AICD.

    Medtronic pacer/defibrillators will typically disable the defibrillator and reset the pacer to asynchronous pacing, turning the detect function off for both. Unlike Medtronic pacers, the Guidant AICD's, when a magnet is placed upon them, will not only disable any defibrillation function but will also turn the pacer function completely off (so it's important to clarify if the patient is pacer dependent preoperatively.)

    The bigger risk to this patient demographic is not the concern of premature/inappropriate defibrillator discharge. instead it's the possibility of asystole in the event that the pacer is interpreting electrocautery as intrinsic electrical activity in the heart, and "thinks" it doesn't need to pace anymore.

    In addition to a magnet, it's often a good idea to place external defibrillator/pacing pads on these patients prior to induction as an added precaution in the event of malfunction.

    At least, that's how we think about it in our little hospital.
     
  27. tucker27705

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    Our group is about to promulgate a protocol. My current protocol is as follows:
    Regardless of AICD or PM or combo, I call the rep and ask how that model no. will respond to a magnet-or is supposed to.
    Depending on the case, I either will or will not apply the magnet. Generally not, unless it is an AICD.
    I always write a PACU order for the rep to interrogate prior to discharge to confirm the intended programming is in effect.

    On one occasion we went to the OR for a thoracic case. Upon application of the magnet it did not have the expected response. I called the rep to room prior to induction (she was down the street at Starbucks and I made everyone wait). Bonus, she was cute, this cheered up the peeved surgeon. She interrogated and found the battery was 5 years old and intended to be replaced at 4 years. She got a new battery from her car and the first procedure performed after induction was replacement of the battery by the thoracic surgeon. (with pads on).

    This and a few other recent cases have prompted us to come up with a standard protocol.

    T
     
  28. BLADEMDA

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    From MEDTRONIC- OFFICIAL WRITTEN DOCUMENT
    Option 1: Medtronic's general recommendation for suspending therapies in Medtronic ICDs is to apply a Magnet or Smart Magnet ("Magnet") supplied by Medtronic. (See Magnet Use for Suspending Medtronic ICD Detection Standard Letter issued by CRDM Technical Services

    Medtronic
    U.S.) The Magnet, when placed over the device, suspends detection of rapid (tachycardia) electrical signals without affecting pacing therapy, eliminating the need for programming the device off. As soon as the Magnet is removed from the device, detection and therapies will return to previously programmed (non-Magnet mode operation) settings. No further programming with the removal of the Magnet is necessary. The presence of a Medtronic representative is not required for Magnet use. Medtronic is available to provide scheduled training and instructions prior to the first use of the Magnet.
    a.The MCP is responsible for ensuring that the patient is constantly monitored for potential life-
    threatening arrhythmias before, during and after the procedure.
    b.The MCP is responsible for ensuring external defibrillation and pacing options are available to
    deliver therapy should patient monitoring indicate a need for these therapies. If an arrhythmia is
    detected, remove the magnet to return the ICD to normal detection and therapy delivery. The
    Magnet response will result in temporary suspension of tachyarrhythrnia detection in all
    Medtronic defibrillators
     
  29. Chloroform4Life

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    Bumping an old thread....

    How are you guys managing pacers/aicds these days. Has the technology changed much over the past 6 years?

    One of the old school anesthesiologists in my group says he never places a magnet on a pacemaker or aicds because then he would have to call in a rep to interrogate it after the case. So he doesn't do anything differently for these patients. That seems odd to me and completely different from everything I've been taught.

    For Metronic devices, I have called rep before and has been told on phone to just put magnet on it and everything should return to normal after magnet is taken off and they don't need to come in to check it. Is this adequate? How common is reprogramming with magnets/electrocautery?
     
  30. kidthor

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    One of our EP guys suggested that magnets are usually fine, but a select few patients may actually have the magnet function intentionally turned off - and for that reason alone he thought it prudent to have the rep or EP interrogate the pacemaker pre-op.
     
  31. Planktonmd

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    The newer devices seem to be more immune to interference, but the ASA still recommends to interrogate the device before discharge, which I think is reasonable.
     
  32. Ignatius J

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    I had a Halo device placement in the left upper extremity with a pacemaker recently in a dependant patient. I did not reprogram the pacemaker or use a magnet. Left it alone. I had a magnet to switch to VOO if needed.

    Never was there one interference with the cautery that was used. And I kept a close eye on it. At times they were just a couple inches away.

    Point being, has anyone seen actual interference with the pacing/ICD function and what procedure was it?
     
  33. Ignatius J

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    I think this is reasonable. However, it is not logistical in my practice. Not in the least. We don't have cardiologists willing to do it regularly during their scheduled days and reps can sometimes be in other cities or counties and not be able to stop by for hours. One could argue that it could be prearranged but then we would have so many arrangements with our elderly vascular folks that it would move up the hospital chain to higher more pre-op folks and nothing would ever get done. We would just be fighting and fighting it.
     
  34. Chloroform4Life

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    Does this mean you never use a magnet or call a rep unless something is actually going wrong with the pacemaker? Do you not treat patients with pacers any differently except having a magnet available?

    I'm not criticizing your practice. I'm just curious and if this is how you practice, have you never been burned by a problem?

    Sometimes I do think we overestimate the risk of a problem due to case reports. But I don't have enough experience yet to stray from the consensus guidelines.
     
  35. BLADEMDA

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    Which guidelines? The BS ones issued by the ASA or the real ones issued by the EP specialists?
     
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  36. FFP

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    You know what will happen if one of these folks dies because of device malfunction after discharge?
     
  37. BLADEMDA

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    I've seen issues with these devices. Medtronic makes the best device in terms of quality and reliability IMHO.

    An AICD is different than a pacemaker in terms of management. Please see my links for detailed explanation.
     
  38. Ignatius J

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    I understand that. However, it hasn't happened to my knowledge. Not saying I agree with it or that it's the best way to do it. But the proposal to have every device interrogated prior to discharge just isn't logistical in my practice. We see a ton of elderly patients. The PACU would be overflowing. Just won't happen.

    As an aside, that's why I asked the question as to who all has seen a device fire or quit pacing during cautery. The reason I let it ride with my patient the other day was because I knew I could quickly convert to magnet mode asynchronous if necessary, but I also wanted to see how susceptible these things were to interference. The cautery was inches away from the pacer and I saw no interference. I may be more apt to let these devices ride without touching them with a magnet.
     
  39. Ignatius J

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    No, I call reps not infrequently. As to how I treat the patients, that depends of course on the surgery, the type of device, pacer dependance, etc. I talked to a Medtronic rep one time in a pacer-dependent AICD patient (just turned off the AICD without effect on pacer) that he only recommended reprogramming for procedures in the thoracic cavity. I was very skeptical as I was not taught that way but I have since confirmed that with other reps. Nevertheless, you can't just take one person at their word so I remain vigilant in my observations.

    As of now, no I have never been burned by a problem. I am more and more into not touching these devices when patients come in with them. That does not mean I won't. And again, that's why I am interested in your experiences to see if anyone has actually seen the cautery interfere with a pacer or fire off an AICD. Because I had cautery quite close to one and there was zero interference. It won't make or break what I do now, but using accumulated data points to help guide our practice is what we do as physicians.
     
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  40. Ezekiel2517

    Ezekiel2517 Anesthesiologist
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    In our practice, have seen/heard of AICD's fire due to cautery a few times already in my career. Most recently, it was during a L humerus ORIF. For urgent/emergent cases where the ICD was not reprogrammed preop, just place a magnet
     
  41. FFP

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    Placing a magnet leads to unpredictable behavior in AICDs.
     
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  42. Ezekiel2517

    Ezekiel2517 Anesthesiologist
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    Would you rather have it shock the pt multiple times during a case? I put the magnet on for ICD's that haven't been reprogrammed b/c it predictably covers my ass
     
  43. Ezekiel2517

    Ezekiel2517 Anesthesiologist
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    And magnets aren't actually unpredictable in ICD's
     
  44. FFP

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    They are predictable only in pacemakers (most of them will convert to asynchronous pacing mode). One cannot predict what an AICD will do.
     
  45. Ignatius J

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    Interesting. Curiously, what happened after? For an AICD, I would probably go magnet if it is the proximal humerus. For belly cases, I just let it ride now (the one I called the Medtronic rep on was an open nephrectomy) and haven't had any issues. I see partners that still throw the magnet on for belly cases. I don't think it is necessary.
     
  46. FFP

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    At the rep's advice, I have done one without a magnet in a right breast lumpectomy. The AICD was then interrogated by the rep in the PACU - no issues.
     
  47. Ezekiel2517

    Ezekiel2517 Anesthesiologist
    Physician 10+ Year Member

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    Cardiologist checked the device, was found to have fired multiple times during case, pt was paralyzed during case
     
  48. urge

    10+ Year Member

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    Has any of you ever done an icd implantation where the EP crooks cannot make the patient fibrillate to test the device no matter how hard they try?

    I will put it to you that only a very small fraction of all icds are really needed.

    It doesn't matter if you put a magnet, or not, check them post op, or not, as these devices are implanted in people who don't need them.
     
  49. BLADEMDA

    BLADEMDA ASA Member
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    1. I've seen monopolar cautery cause an AICD to discharge several times. That patient's battery life was depleted by 1/3 after the case. No magnet was applied during the case (VAT).

    2. I've seen Monopolar cautery cause an AICD to go haywire during a total should replacement. The bovie was about 4 inches from the device and the pacemaker portion of the device malfunctioned. A magnet was applied during the case.

    3. I've seen a Monopolar cautery cause a pacemaker to "reprogram itself" with a new rate of 120. That pacemaker required a "reset" to the correct rate of 75.

    Case number 2 was cancelled and resecheduled for another date. The pacemaker was set to an asynchronous mode (which it should have been set to in the first place).
     

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