Embargoed for release until approved by ASA House of Delegates. No part of this document may be released, distributed or reprinted until approved. Any unauthorized copying, reproduction, appropriation or communication of the contents of this document without the express written consent of the American Society of Anesthesiologists is subject to civil and criminal prosecution to the fullest extent possible, including punitive damages Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable Cardioverter-Defibrillators 2020 An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Implantable Electronic Devices* 1 PRACTICE advisories are systematically developed reports that are intended to assist decision- 2 making in areas of patient care. Advisories provide a synthesis of scientific literature and analysis of 3 expert opinion, clinical feasibility data, open forum commentary, and consensus surveys. Practice 4 advisories developed by the American Society of Anesthesiologists (ASA) are not intended as standards, 5 guidelines, or absolute requirements, and their use cannot guarantee any specific outcome. They may be 6 adopted, modified, or rejected according to clinical needs and constraints, and they are not intended to 7 replace local institutional policies. 8 Practice advisories summarize the state of the literature and report opinions obtained from expert 9 consultants and ASA members. They are not supported by scientific literature to the same degree as 10 standards or guidelines because of the lack of sufficient numbers of adequately controlled studies. 11 Practice advisories are subject to periodic revision as warranted by the evolution of medical knowledge, 12 technology, and practice. 13 This document updates the “Practice Advisory for the Perioperative Management of Patients with 14 Cardiac Implantable Electronic Devices: Pacemakers and Implantable Cardioverter-Defibrillators. An 15 Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Management 16 of Patients with Cardiac Implantable Electronic Devices, adopted by the ASA in 2010 and published in 17 2011.1 18 Methodology 19 Definition of Cardiac Implantable Electronic Devices 20 For this Advisory, a cardiac implantable electronic device (CIED) refers to any permanently implanted * Updated by the Committee on Standards and Practice Parameters: Jeffrey L. Apfelbaum, M.D. (Committee Chair), Chicago, Illinois; Peter M. Schulman, M.D. (Task Force Co-Chair), Portland, Oregon, Aman Mahajan M.D. Ph.D. (Task Force Co-Chair), Pittsburg, Pennsylvania; Richard T. Connis, Ph.D. (Chief Methodologist), Woodinville, Washington; and Madhulika Agarkar, M.P.H. (Methodologist), Schaumburg, Illinois. Received from the American Society of Anesthesiologists, Schaumburg, Illinois. Submitted for publication October __, 2019. Accepted for publication October __, 2019. Supported by the American Society of Anesthesiologists and developed under the direction of the Committee on Standards and Practice Parameters, Jeffrey L. Apfelbaum, M.D. (Chair). Approved by the ASA House of Delegates on October __, 2019. A complete bibliography used to develop this updated Advisory, arranged alphabetically by author, is available as Supplemental Digital Content 1, http://links.lww.com/ALN/XXXXXXXX. Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. This Practice Advisory, as well as all published ASA Practice Parameters, may be obtained at no cost through the Journal Web site, www.anesthesiology.org. PRACTICE ADVISORY 21 cardiac pacemaker or any implantable cardioverter-defibrillator (ICD). The term CIED also refers to any 22 cardiac resynchronization therapy (CRT) device.† 23 Purposes of the Advisory 24 The purposes of this Advisory update are to: (1) facilitate safe and effective perioperative 25 management of the patient with a CIED, and (2) reduce the incidence of adverse outcomes. 26 Perioperative management refers to the preoperative, intraoperative, postoperative or recovery period 27 in any setting where an anesthesia provider will be delivering anesthesia care. Adverse outcomes 28 associated with CIED function, but are not limited to, damage to the device, inability of the device to 29 deliver pacing or shocks, lead-tissue interface damage, changes in pacing behavior, electrical reset to 30 the backup pacing mode, and inappropriate ICD therapies.‡ 31 Adverse clinical outcomes include, but are not limited to, hypotension, tachyarrhythmia and 32 bradyarrhythmia, myocardial tissue damage, and myocardial ischemia and infarction. Other related 33 adverse outcomes may include extended hospital stay, delay and cancellation of surgery, readmission 34 to manage device malfunction, and additional hospital resource utilization and cost. 35 Focus of the Advisory 36 This updated Advisory focuses on the perioperative management of the patient who has a 37 preexisting, permanently implanted CIED for treatment of bradyarrhythmia, tachyarrhythmia or heart 38 failure. This Advisory applies to all CIED patients receiving general or regional anesthesia, sedation or 39 monitored anesthesia care. Both inpatient and outpatient procedures are addressed by this update. 40 This update does not address the perioperative management of the patient without a permanently 41 implanted CIED, including those: (1) with a temporary CIED, (2) with a noncardiac implantable device 42 (e.g., neurological or spinal cord stimulator), (3) with an implantable mechanical cardiac assist device 43 (e.g., ventricular assist device), or (4) undergoing CIED implantation or revision. This update does not 44 address procedures where there are no known perioperative CIED concerns (e.g., plain radiography, 45 fluoroscopy, mammograms, or ultrasound). In addition, this update does not address patient comfort or 46 management of pain during a procedure. 47 Application of the Advisory 48 This updated Advisory is intended for use by anesthesiologists and all other individuals who 49 deliver or who are responsible for anesthesia care. The update may also serve as a resource for other 50 physicians and health care professionals who manage patients with CIEDs. 51 † Generic pacemaker and defibrillator codes are provided in Tables 1 and 2. Note that every ICD includes both pacing and shock therapies for the management of bradyarrhythmias and tachyarrhythmias. ‡ Inappropriate ICD therapy refers to the delivery of antitachycardia therapy (paced or shock) in the absence of a clinically indicated tachyarrhythmia. Inappropriate ICD therapy can harm a patient by inducing ischemia, worsening the arrhythmia, or causing the patient to move during a delicate procedure. 2 PRACTICE ADVISORY 52 Task Force Members and Consultants 53 The original Advisory was developed by an ASA appointed task force of 12 members, consisting of 54 anesthesiologists and cardiologists in private and academic practices from various geographic areas of 55 the United States, and two methodologists from the ASA Committee on Standards and Practice 56 Parameters. In 2017, the ASA Committee on Standards and Practice Parameters requested that the 57 Advisory be updated. This update is a revision developed by an ASA-appointed task force of 5 members, 58 including 3 anesthesiologists and two methodologists. Conflict of interest documentation regarding 59 current or potential financial and other interests pertinent to the practice guideline were disclosed by all 60 task force members and managed. 61 62 Process and Evaluation of Evidence 63 This updated Advisory was developed by means of a five-step process. First, consensus was 64 reached on the criteria for evidence. Second, original published articles from peer-reviewed journals 65 relevant to the perioperative management of CIEDs were evaluated and added to literature reported in 66 the previous update. Third, consultants who had expertise or interest in central venous catheterization, 67 and who practiced or worked in various settings (e.g., private and academic practice) were asked to 68 participate in opinion surveys addressing the appropriateness, completeness, and feasibility of 69 implementation of the draft recommendations, and to review and comment on a draft of the Guidelines. 70 Fourth, additional opinions were solicited from random samples of active ASA members. Fifth, all 71 available information was used to build consensus to finalize the Advisory. A summary of 72 recommendations can be found in appendix 1. 73 Preparation of this updated Advisory followed a rigorous methodological process. Evidence was 74 obtained from two principal sources: scientific evidence and opinion-based evidence. Detailed 75 descriptions of the ASA process and methodology used in these Guidelines may be found in other related 76 publications.2-5 Appendix 5 contains information on the evidence model, the literature search process, 77 literature findings, and survey results. 78 Within the text of the Advisory, literature classifications are reported for each intervention using the 79 following classifications: Category A, level 1: Meta-analysis of randomized controlled trials (RCTs); 80 Category A level 2, multiple RCTs, and Category A, level 3: a single RCT. Category B, level 1: 81 nonrandomized studies with group comparisons, Category B, level 2: nonrandomized studies with 82 associative findings; Category B, level 3: