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Perioperative Care of the Patient with a Cardiac Pacemaker Or ICD

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Perioperative Care of the Patient with a Cardiac Pacemaker Or ICD medigraphic Artemisaen línea E A NO D NEST A ES Mexicana de IC IO EX L M O G O I ÍA G A E L . C C O . C Revista A N A T Í E Anestesiología S G S O O L C IO I S ED TE A ES D M AN EXICANA DE PROFESORES EXTRANJEROS Vol. 32. Supl. 1, Abril-Junio 2009 pp S190-S197 Perioperative care of the patient with a cardiac pacemaker or ICD Marc A. Rozner, PhD, MD* * Professor of Anesthesiology and Perioperative Medicine. Professor of Cardiology. The University of Texas MD Anderson Cancer Center reopertive2key2points ostopertive2key2points • Have the pacemaker or defibrillator interrogated by a • Have the device interrogated by a competent authority competent authority shortly before the anesthetic. postop. Some rate enhancements can be re-initiated, and • Obtain a copy of this interrogation. Ensure that the de- optimum heart rate and pacing parameters should be de- vice will pace the heart. termined. Any ICD patient must be monitored until the • Consider replacing any device near its elective replace- antitachycardia therapy is restored. ment period in a patient scheduled to undergo either a major surgery or surgery within 25 cm of the generator. INTRODUCTION • Determine the patient’s underlying rhythm/rate to deter- mine the need for backup pacing support. Battery operated pacemakers were developed in 1958, and • Identify the magnet rate and rhythm, if a magnet mode is implantable cardioverterdefibrillators (ICDs) followed in present and magnet use is planned. 1980. ICD advancements have three important results. First, • Program minute ventilation rate responsiveness off, if due to pacing spikes on an ECG, a pectoral (rather than ab- present. dominal) ICD might be mistaken for a (non-ICD) pacemaker. • Program all rate enhancements off. If ECGs are routinely collected from patients with «pacemak- • Consider increasing the pacing rate to optimize oxygen ers» using a magnet, then some ICDs from Boston Scientific delivery to tissues for major cases. (BOS)/Guidant/CPI might be permanently deactivated with • Disable antitachycardia therapy if a defibrillator. magnet placement(1). Second, ICD brady-pacing is NEVER converted to asynchronous mode with magnet placement. sntropertive2key2points Third, ICDs respond to, and process, electromagnetic inter- ference (EMI) differently than a pacemaker. • Monitor cardiac rhythm / peripheral pulse with pulse The complexity of cardiac generators limits generaliza- oximeter or arterial waveform. tions that can be made about the perioperative care of these • Disable the «artifact filter» on the EKG monitor. patients. Population aging, continued enhancements and • Avoid use of monopolar electrosurgery (ESU). new indications for implantation of cardiac devices will lead • Use bipolar ESU if possible; if not possible, then pure cut to increased implantations. These issues led the American (monopolar ESU) is better than «blend» or «coag». Society of Anesthesiologists (ASA) to publish a Practice • Place the ESU current return pad inwww.medigraphic.com such a way to prevent Advisory for these patients(2). Other guidelines have been electricity from crossing the generator-heart circuit, even published as well(3-6), although not all authors recommend if the pad must be placed on the distal forearm and the ICD disablement in the perioperative period(7). ICDs also wire covered with sterile drape. perform permanent cardiac pacing, so ICD issues related • If the ESU causes ventricular oversensing and pacer qui- primarily to antibrady pacing should be reviewed in the escence, limit the period(s) of asystole. Pacing section. S190 Revista Mexicana de Anestesiología Rozner MA. Perioperative care of the patient with a cardiac pacemaker or ICD Recently, some generator manufacturers have issued a they will have a ring electrode 1 to 3 cm proximal to the variety of notices regarding potential failures in both pace- lead tip. Generators with bipolar leads can be programmed makers(8-10) and ICDs(11-13). Also, for some ICDs, Guidant to the unipolar mode for pacing, sensing, or both. has found that the device improperly enters the «magnet The Pacemaking Code of the North American Society of mode», which prevents any detection (and, therefore, treat- Pacing and Electrophysiology (NASPE) and the British Pac- ment) of tachyarrhythmias. As a «work-around», Guidant ing and Electrophysiology Group (BPEG) describes basic has recommended the permanent disabling of the magnet pacing behavior (Table I)(21). Most pacemakers in the US mode through programming(14). Retrospective analysis sug- are programmed either to the DDD (dual chamber) or VVI gests that outright failure occurs in 1.4 (pacemaker) and mode (single chamber). DDI is used for patients with atrial 36.4 (ICD) per 1,000 implants in 2001-2002(15). dysrhythmias, and VDD pacing (single wire device provid- Finally, devices resembling cardiac pulse generators are ing AV synchrony) can be found in patients with AV nodal being implanted at increasing rates for pain control, thalam- disease but normal sinus node function. Atrial-only pacing ic stimulation to control Parkinson’s disease, phrenic nerve (AAI) is uncommon in the US. Biatrial pacing is being in- stimulation to stimulate the diaphragm in paralyzed patients, vestigated as a means to prevent atrial fibrillation(22), and and vagus nerve stimulation to control epilepsy and possi- biventricular (BiV) pacing (also called Cardiac Resynchro- bly obesity(16). nization Therapy [CRT]) is used to treat dilated cardiomy- Interestingly, a new report states that monopolar electro- opathy (DCM)(23-25). surgery (the «Bovie») is unlikely to interfere with either pacemaker or ICD generators(17). Other reports might not INDICATIONS agree(18,19). Permanent pacing indications (Table II) are reviewed in de- PACEMAKER OVERVIEW tail elsewhere(26). In order to be effective, BiV, HOCM, and DCM pacing must provide the stimulus for ventricular acti- More than 2,000 pacemaker models have been produced by vation, and A-V synchrony must be preserved(27). Pacemak- 27 companies, and more than 250,000 adults and children er inhibition, loss of pacing (i.e.; from native conduction, in the US undergo new pacemaker placement yearly. Nearly junctional rhythm, EMI), or AV dys-synchrony can lead to 3 million US patients have pacemakers. Outdated literature deteriorating hemodynamics in these patients. BiV pacing and limited training often lead to confusion regarding pace- can lengthen the Q-T interval in some patients, producing makers and perioperative care. torsade-depointes(28). Thus access to rapid defibrillation is These systems consist of an impulse generator and lead(s). required for the patient with BiV pacing. Leads can have one (unipolar), two (bipolar), or multiple (multipolar) electrodes with connections in multiple cham- PACEMAKER MAGNETS bers. In unipolar pacing, the generator case serves as an elec- trode, and tissue contact can be disrupted by pocket gas(20). Despite oft-repeated folklore, magnets were never intended Pacemakers with unipolar leads produce larger «spikes» on to treat pacemaker emergencies or prevent EMI effects. Rath- an analogue-recorded ECG, and they are more sensitive to er, magnet-activated switches were incorporated to produce EMI. Most pacemaking systems use bipolar pacing/sensing pacing behavior that demonstrates remaining battery life configuration, since bipolar pacing usually requires less and, sometimes, pacing threshold safety factors. Placement energy and bipolar sensing is more resistant to interference of a magnet over a generator might produce no change in from muscle artifacts or stray electromagnetic fields. Often, pacing since not all pacemakers switch to a continuous bipolar electrodes can be identified on the chest film since asynchronous mode when a magnet is placed. Also, not all Table I. NASPE/BPEG Generic Pacemaker Code (NBG) [Revised 2002]. Position I Position IIwww.medigraphic.com Position III Position IV Position V Chambers paced Chambers sensed Response to sensing Programmability Multisite pacing O = None O = None O = None O = None O = None A = Atrium A = Atrium I = Inhibited R = Rate modulation A = Atrium V = Ventricle V = Ventricle T = Triggered V = Ventricle D = Dual (A + V) D = Dual (A+V) D = Dual (T + I) D = Dual (A+V) Volumen 32, Suplemento 1, abril-junio 2009 S191 Rozner MA. Perioperative care of the patient with a cardiac pacemaker or ICD Table II. Permanent pacemaker indications. PREANESTHETIC EVALUATION AND PACEMAKER REPROGRAMMING Sinus node disease Atrioventricular (AV) node disease Preoperative management of the patient with a pacemaker Long Q-T syndrome includes evaluation and optimization of coexisting Hypertrophic obstructive cardiomyopathy (HOCM) disease(s). No special laboratory tests or x-rays are needed Dilated cardiomyopathy (DCM) for the patient with a conventional pacemaker. A patient with a BiV pacer (or ICD) might need a chest film to docu- ment the position of the coronary sinus (CS) lead, especial- ly if central line placement is planned, since spontaneous models from a given company behave the same way. Some (32,33) effect(s) of magnet placement are shown in table III(29-31). CS lead dislodgement can occur . Magnet behavior can be altered or disabled via program- Important features of the preanesthetic device evalua- ming in some devices. For all generators, calling the manu- tion are shown in Preoperative Key Points (above). Current facturer remains the most reliable method for determining NASPE and Medicare guidelines include telephonic (mag- magnet response and using this response
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