Guideline Consensus? How is the perioperative management of patients with cardiac electronic implant devices?
This guidelineProvides practical guidance for the perioperative management of patientsUndergoingSurgery who also have CIEDs.An increasing number of patients are being implanted with electronic cardiac devices, including pacemakers, implantable defibrillators, and cardiac resynchronization devices. Exposure to electromagnetic interference during surgical procedures may result in abnormal device function, including cessation of pacing function or defibrillation shock.The guidelineSummarizes some key elements of a preoperative assessment protocol to ensure that these devices are clearly identified by all and that appropriate preoperative visits are made, and it outlines some general measures that can reduceThe potential associated risksFrom electromagnetic interference inThe operating room.In addition, the guide provides detailed guidance depending on the type of device, whether the pacemaker is pacemaker dependent, and the procedure for CIEDs.
"Recommendations from the Guideline
For patients withCIEDs, electromagnetic interference in the surgical environment may result in inappropriate pacemaker function or implantable cardiac defibrillator shock.
Identifying these devices during the preoperative evaluation is particularly important in order to take appropriate precautions.
3. The preoperative evaluation team should ensure that electronic cardiac implantable devices are followed up regularly and contact the appropriate cardiology team. A properly functioning device at remote device follow-up is equivalent to a properly functioning device at on-site follow-up.
4. When anyone usingCIEDsIs at risk of exposure to electromagnetic interference (including: monitoring, positioning of fluorophores, use of short pulse fluorophores), general precautions should be followed and appropriate emergency equipment should be provided.
5. Depending on the pacemaker function (pacemaker dependent or not), different programming may be required.
6.ICDDeactivation may not be required for subumbilical procedures.
7. The guideline states that temporary deactivation of the magnetic field or deactivation of the procedure are acceptable methods of deactivating the defibrillator.
8. Instruments should be positioned accurately when using external magnets to manipulate internal positioning in the surgical setting through a magnetic anchoring system.
9. Responsibility for the patient should rest with the clinical team caring for theCIEDs, not with the cardiac physiologist and cardiology team.
10. The use of ultrasonic scalers in dental procedures does not cause problems with cardiac implant devices.
Specific perioperative recommendations are as follows.
Preoperatively, it should be clarified whether the patient has a pacemaker or ICD and specific information should be obtained regarding:Device type and manufacturer, implanting hospital, follow-up hospital, last follow-up date, whether the battery is depleted, whether the device is in a clinical study, and the location of the device. Because CIEDs are usually implanted in the left or right anterior chest region, the location of the device should also be considered when considering the surgical field; some devices may be located in the left chest wall and few will be located in the abdomen.
Continuous ECG monitoring should be performed intraoperatively; some monitors may give inaccurate rhythm beat readings, so if in doubt, check the pulse and/or use a pulse oximeter and have external defibrillation equipment, an external temporary pacemaker, and CPR equipment available. External defibrillation should be considered for patients whose ICD is inactivated and whose incision location on the anterior chest wall would interfere with the procedure (or sterile field of view). External defibrillation tablets should be placed as far away from the CIED as possible and not directly over the device (pulse generator) itself. Where diathermy/electrocoagulation is unavoidable, limit its use to short pulses at the lowest feasible energy level and, if possible, use bipolar electrocoagulation. The surgical team should ensure that the return electrode is anatomically positioned so that the current path between the fluoride electrode and the return electrode is as far away from the pacemaker/defibrillator (and lead) as possible.If detectable pacemaker suppression occurs, or if there is evidence of ongoing ICD therapy, the surgeon should be informed immediately to intermittently use or discontinue fluoride/electrocoagulation.
If the device programming is changed during the procedure, the device parameters should be restored to the preoperative settings and/or the ICD reactivation maintained as soon as possible after the procedure, which ideally should be performed in the anesthesia recovery room.
This guideline outlines best practice guidance for the perioperative management of the growing number of CIED patients:If the patient can identify these devices preoperatively, it can be determined whether additional measures are needed to ensure the safety of the procedure. Good communication with the cardiac team is essential in the perioperative management of patients with CIEDs. In addition, pacing-dependent individuals and patients with implantable defibrillators may require device reprogramming or adjustment of the operating room magnetic field during the procedure.
Original article: Thomas H, Plummer C, Wright IJ, Foley P, Turley AJ. Guidelines for the peri-operative management of people with cardiac implantable electronic Anaesthesia. 2022 Apr 16. Doi: 10.1111/anae.15728.
Translated Author Introduction
Huo Fei
Attending Physician, Department of Anesthesiology, Peking University People's Hospital
Editor: Qiu Junxin
Editor: Liu Jiafu