Cardiac Arrest Survivors and Implantable Defibrillator Recipients:

Transcription

1 South East Wales Cardiac Network Arrhythmia Pathway Cardiac Arrest Survivors and Implantable Defibrillator Recipients: Background: Implementation of the Recommendations contained in Standard 5 of the Cardiac Disease National Service Framework for Wales This document has been produced at the request of the Cardiac Networks Coordinating Group on behalf of the South East Wales Cardiac Network (SEWCN) and the Mid and South West Wales Cardiac Network (MSWWCN). Authorship: This document is co-authored by Dr Rob Bleasdale (Consultant Cardiologist, Royal Glamorgan Hospital), Dr Phillip Campbell (Consultant Cardiologist, Royal Gwent Hospital), Dr Eiry Edmunds (Consultant Cardiologist, West Wales General Hospital), Andrea Gasson (Nurse Practitioner, Royal Glamorgan Hospital), Dr Jonathon Goodfellow, Consultant cardiologist, Princess of Wales Hospital), Mandie Welch (BHF Arrhythmia Specialist Nurse) Cardiac Arrest Survivors: Cardiac arrest remains a common cause of death, killing in the region of 250 people a day in the UK. Less than 5% of these victims survive if the event occurs out of hospital. The chain of care delivered by the Ambulance service through to the A&E department to the Heart Rhythm Specialist/ Electrophysiologist is key to the quality of treatment offered to the individual patient. All cardiac arrest survivors successfully resuscitated at the scene of their collapse should undergo a full clinical assessment and a 12 lead ECG should be recorded. Once transferred to the A&E department this information remains key to the management of the patient. All paperwork and paper copies of rhythm strips should be carefully handed over to the attending medical staff. The attending medical staff are responsible for ensuring that this information is transferred to the hospital records. This process should be backed up by an electronic download of the automated external defibrillator (AED) on the return of the ambulance/ paramedic crew to their base. This should be printed off and attached to a further copy of the patient s relevant Ambulance Trust yellow sheet. This entire document should be sent to the local Heart Rhythm Specialist/ Electrophysiologist. If the history, ECG and biochemistry confirm the diagnosis of a myocardial infarction resulting in new Q waves on the ECG then usual post myocardial infarction guidance should be followed. If however there is evidence of reversible ischaemia then in-patient revascularisation is recommended in consultation with local Heart Rhythm Specialist/ Electrophysiologist. If the cause of the cardiac arrest remains uncertain from the in hospital clinical assessment then the patient should be reviewed by local Heart Rhythm Specialist/ Electrophysiologist on that index admission. Finally even if there is strong evidence of a transient and reversible cause for the cardiac arrest, suggested by a normal ECG, a structurally normal heart demonstrated with an inpatient transthoracic echocardiogram and the absence of a family history of premature sudden cardiac death below the age of forty years, the patient should still be seen by the local Heart Rhythm Specialist/ Electrophysiologist on that index admission. South East Wales Cardiac Network Page 1 of 9 Arrhythmia Pathway Cardiac Arrest and ICDs Final Version

2 This guidance therefore culminates in all patients admitted having survived a cardiac arrest being assessed by the local Heart Rhythm Specialist/ Electrophysiologist on that index admission with exception of patients that experience a cardiac arrest during a Q wave myocardial infarction. See Appendix 1 Implantable Cardioverter Defibrillator (ICD) Recipients Presenting to the District General Hospital: The indications for ICD implantation are expanding and more and more devices are being implanted. This results in an escalating probability that these patients will present to all clinical areas of clinical care in the district general hospital (DGH). Whilst cardiologists and many physicians have had experience with patients who have these complex devices in situ many clinicians, including surgeons, may not have. ICD Patients Attending Accident and Emergency after Multiple Shock Therapies: Implantable cardiac defibrillators are sophisticated and reliable devices, however the most common complication of device therapy is inappropriate shock delivery. When patients with a discharging ICD are admitted to A&E it is often difficult for the non-specialist to determine whether or not therapy is appropriate. A correctly functioning device may be mistaken for a malfunctioning device and vice-versa. Therapy may be correctly delivered according to device programming, but be inappropriate to the presenting situation. An additional problem for such patients is that medical staff unfamiliar with ICDs frequently have unwarranted concerns about themselves receiving shocks from the ICD. Fear of coming into contact with the patient could adversely effect management. The Network has looked to provide guidance to the non-specialist about the management of ICD patients presenting with a discharging device. These guidelines are intended to supply the knowledge required to safely manage such patients when shock therapy is either appropriate or inappropriate without the need for specialist knowledge of device function or programming. A simple decision tree is provided, dividing patients in to those with, or without cardiac arrest. Action points are provided throughout the decision tree with extra information available for those points marked with an exclamation mark. The guidelines are available on the map of medicine where a mouse click will direct the user to the relevant extra information. Details of where to seek expert help is also provided. There a potential to deviate away from appendix 2 to bring list guidance in line with the map of medicine guidance on this topic which was also authored by Dr Campbell. See Appendix One Map of Medicine Implantable Cardioverter Defibrillator Guidance ICD Patients undergoing elective Surgery: See Appendix 3 ICD Patients Undergoing Emergency: This guidance has been compiled to help in Surgery Introduction: emergency decision making when a patient with an ICD requires urgent or emergency surgery. Where possible the protocol for Elective Surgery should be followed and the ICD checked and reprogrammed prior to surgery. South East Wales Cardiac Network Page 2 of 9 Arrhythmia Pathway Cardiac Arrest and ICDs Final Version

3 General Patient Considerations: ICDs are implanted to treat Ventricular Tachycardia (VT) therefore if a patient has an ICD in situ they are, by definition, at risk of serious cardiac arrhythmias and may have severe underlying structural heart disease eg severe left ventricular impairment or hypertrophic cardiomyopathy (HCM). In addition ICDs can also act as pacemakers in the event of bradycardia. Where possible a SENIOR ANAESTHETIST should be responsible for the patient and advice should be sought from the on-site CARDIOLOGIST or local implant centre. Diathermy: ICDs receive electrical information from the heart and are capable of interpreting the electrical signal. If the electrical signal received is fast the ICD may interpret this as VT or VF and deliver a therapy. This may be in the form of fast burst pacing (anti-tachy-pacing) or shock delivery. Diathermy used during surgery may give rise to electrical interference which could be detected by the ICD and misinterpreted as an electrical signal originating from the ventricle. This could give rise to inhibition of the pacemaker function, speeding up of pacing rate or triggering of the antitachycardia function. It may be necessary to inhibit the ICD (see Inhibition of ICD). If a device s battery is depleted electrical interference can cause a device to stop working completely. The use of diathermy may also induce energy in the leads causing tissue heating. For the above reasons manufacturers of ICDs and pacemakers recommend: AVOIDANCE of diathermy If diathermy is unavoidable BIPOLAR diathermy should be used Limit its use to short bursts Ensure the return electrode is positioned so that the current is far away from the ICD and leads Ensure the cables are well away from the implant site Consider external/transvenous pacing if patient is pacing dependent and pacemaker function is significantly affected by diathermy Inhibition of the ICD: If the ICD needs to be inhibited from delivering a shock a clinical magnet can be placed over the device and held in place with Micropore tape. This usually (but not always) inhibits shock delivery. If this is done The patient should have continuous cardiac monitoring during the time the ICD is inhibited Resuscitation equipment should be available at all times The ICD must be checked post-operatively to ensure correct functioning Essential Equipment:: If the patient requires pacemaker function then cardiac monitoring may misinterpret a pacing spike as evidence of cardiac activation. Rarely the pacemaker output may fail to capture the ventricle. If the defibrillator function is disabled then alternative defibrillation may be required in the event of a cardiac arrhythmia. Therefore the following must be available Continuous cardiac monitoring Alternative method of detecting a patient s pulse eg arterial line(ideally) or pulse oximeter (as minimum) South East Wales Cardiac Network Page 3 of 9 Arrhythmia Pathway Cardiac Arrest and ICDs Final Version

4 Availability of cardiopulmonary resuscitation equipment including external defibrillator and temporary external/transvenous pacing Following emergency/urgent surgery it is good practice to ensure the device is functioning normally before discharge and this should be considered as a routine in all patients with complex devices in situ. ICD Patients and the End of Life Pathways: Many patients with ICDs in situ are able to enjoy a prolonged life expectancy with a reasonable quality of life. However in patients who have progressive cardiac failure and other co-morbid conditions, the shocks from the device or even the thought of the device shocking can cause physical suffering and severe anxiety. When terminal illnesses such as end stage heart failure or cancer are diagnosed, patients may find the additional stress of anticipation an ICD shock an unnecessary burden, particularly as the outcome will have no impact on the underlying condition. The incidence of arrhythmias may increase with the development of electrolyte imbalance, hypoxia and pain, potentially leading to an increase in shock therapy. Multiple discharges are not conducive to the peaceful and dignified death. For these patients the option of deactivating the device can be a sound medical, ethical and legal decision for them. Indications for Deactivation: Patient preference in advanced disease Imminent death (activation inappropriate in the dying phase) Withdrawal of anti-arrhythmic medications While an active DNR ( Do Not Resuscitate order is in force) Discussion for ICD Deactivation: The discussion regarding deactivation should be an open discussion between patient, next of kin and supervising cardiologist, nurse specialist and/ or cardio physiologist and should take place whilst the patient is able to be involved in the decision making process. In situations where the patient is a non-cardiac specialist environment such as medical, surgical wards, hospices or at home the decision still remains the patient s and the health care professional responsible for their care should be encouraged to initiate this discussion. Many experts believe these issues should be discussed prior to implantation in order that the patient has time to consider these issues autonomously should the situation arise in the future. The patient and next of kin are to be made aware that by deactivating the ICD the device will no longer provided therapies in the event of life threatening arrhythmias. The actual turning off of the device is not a painful procedure and will only take a matter of seconds to complete. It is important to try and avoid last minute decisions, not only to avoid unnecessary distress but also to avoid these decisions being deferred to the out of hours services. In these or other urgent/emergency situations where immediate action is necessary, a magnet can be placed over the device. The magnet causes the device to become deactivated only whilst the magnet is in place. Once the magnet is removed the device becomes active again. The will not stop the device functioning as a pacemenker. South East Wales Cardiac Network Page 4 of 9 Arrhythmia Pathway Cardiac Arrest and ICDs Final Version

5 Ethical/Legal issues: To ensure that legal and ethical issued are considered, the patient must be fully informed of their options. Good clinical practice emphasises the importance of shared decision-making between health professionals and patient and, if appropriate, their families throughout the course of the patient s illness. Patients are legally and ethically able to refuse/withdraw from medical interventions which sustain life. Deactivation of ICDs needs to be addressed in the same way as withdrawing/withholding of others treatments which prolong life (BMA 2007). An ICD deactivation would not itself cause death or introduce a new pathological problem. When a patient does not have capacity to make his/her decisions, health professionals caring for them have a moral and legal duty to act in the patients best interests. An assessment of best interests includes balancing the risks and benefits associated with any given treatment. In most cases an ICD will confer greater benefit than harm. However, in some situations, the possibility that recurrent ICD activation might prevent a comfortable death could be judged to outweigh any benefit of prolonging life for a brief period of time. Any such decision process should be multidisciplinary and comply with the Mental Capacity Act Apart from ethical and legal considerations, cultural and religious differences may influence a patient s decision to deactivate. This factor must be taken into account by care providers and the patient s beliefs should be given precedence over their own. References. All Wales Care Pathway for the Last Days of Life Arrhythmia Alliance (2007). Implantable Cardioverter Defibrillators (ICDs) in dying patients. Available on line: - arrythnmiaalliance.org.uk. British Heart Foundation.( 2007) Implantable Cardioverter Defibrillators in patients who are reaching end of life. Available at: - British Medical Association. (2007).Withholding and withdrawing Life-prolonging Medical Treatment: Guidance for Decision making. London:Blackwell Publishing. British Medical Association (2005) The Mental Capacity Act 2005:- Guidance for Health Professionals. London.Available at: National Institute of Clinical Excellence.(2006). Implantable Cardioverter for Arrhythmias: Review of technology appraisal 11.` National Service Framework Tackling CHD and Arrhythmias in Wales (Draft Document 2007). Standard 5. South East Wales Cardiac Network Page 5 of 9 Arrhythmia Pathway Cardiac Arrest and ICDs Final Version

6 Appendix 1: South East Wales Cardiac Network Page 6 of 9 Arrhythmia Pathway Cardiac Arrest and ICDs Final Version

7 Appendix 2: South East Wales Cardiac Network Page 7 of 9 Arrhythmia Pathway Cardiac Arrest and ICDs Final Version

8 Appendix 3: IMPLANTABLE CARDIOVERTER DEFIBRILLATOR AND ELECTIVE SURGERY AS SOON AS A DATE FOR SURGERY IS KNOWN CONTACT YOUR LOCAL CARDIAC PHYSIOLOGY DEPARTMENT WHO WILL LIAISE WITH THE IMPLANTING CENTRE TO MAKE THE NECESSARY ARRANGEMENTS FOR DEVICE REPROGRAMMING AS REQUIRED FOR THE PROCEDURE ON THE PROCEDURE DAY, PLEASE CONTACT YOUR LOCAL CARDIAC PHYSIOLOGY DEPARTMENT WHO WILL CONFIRM WITH YOU WHO WILL BE AVAILABLE TO DE-ACTIVATE THE DEVICE This could be your local Cardiac Physiologist if facilities and expertise are available, or a Cardiac Physiologist from the Implanting Centre or in certain circumstances a Company Technical Support Representative may be called THE ICD NEEDS TO BE REPROGRAMMED TO MONITOR ONLY OR DISABLED WITH A MAGNET CARDIAC MONITORING SHOULD BE MAINTAINED THROUGHOUT PROCEDURE UNTIL ICD REACTIVATED EXTERNAL DEFIBRILLATOR SHOULD BE MADE AVAILABLE THROUGHOUT PROCEDURE DIATHERMY SHOULD BE AVIODED, WHEN UNAVOIDABLE THEN BIPOLAR SHOULD BE USED. IF MONOPOLAR IS USED THEN PLACE RETURN PAD WHERE THE CURRENT PASSES AS FAR AWAY FROM THE ICD LEADS AS POSSIBLE FOLLOWING SURGERY IT IS ESSENTIAL THAT THE DEVICE IS RE-ACTIVATED South East Wales Cardiac Network Page 8 of 9 Arrhythmia Pathway Cardiac Arrest and ICDs Final Version

9 Appendix 4: PROTOCOL FOR THE MANAGEMENT OF PATIENTS WITH IMPLANTABLE CARDIOVERTER DEFIBRILLATORS (ICD) REQUIRING URGENT/EMERGENCY SURGERY General: If there is sufficient time then the steps advised in the Elective Surgical Procedures protocol should be followed. The use of surgical diathermy/electrocautery is contraindicated in patients who have ICDs. It is however recognised that its use may at times be unavoidable. A senior anaesthetist should be responsible for the patient. Advice should be sought from the on-site cardiologist or local cardiac centre. Essential equipment: Cardio-pulmonary resuscitation equipment, external defibrillator with external pacing capabilities (and someone trained in its use). Continuous ECG monitoring. Diathermy: If diathermy use us unavoidable then bipolar is preferable to monopolar. Ensure the cables are kept away from the ICD implant site and an effective method of detecting that a true pulse is present is used ie pulse oximetry (as a minimum) and arterial line (ideally). Deactivation of ICD: In an emergency, if needed, the ICD may be deactivated by the placement of a clinical magnet over the implant site. The magnet can be secured with Micropore tape. During deactivation it is vital that the patient has continuous cardiac monitoring and any subsequent arrhythmias (VT/VF) are treated using the external defibrillator equipment. If the ICD has been deactivated then the magnet should be removed as soon as possible at the end of the procedure. ICD check following surgery: If the ICD has been deactivated using a magnet the ICD function must be checked postoperatively. Until that time the patient should be kept monitored and any arrhythmias treated appropriately. BACKGROUND: In broad terms, patients receive an implantable defibrillator because 1: they have survived a life-threatening ventricular arrhythmia and are at risk of having further life-threatening arrhythmias. 2: they have severe cardiac disease (usually with severe LV impairment) and are deemed to be at high risk of life-threatening ventricular arrhythmias. The ICD is designed to detect rapid heart rates and to respond appropriately. It does this be either trying to pace terminate a ventricular tachycardia or by delivering an electrical impulse directly to the endocardium. In addition to defibrillation ICDs may also provide a bradycardia pacing function eg there may be an accompanying complete heart block. The use of surgical diathermy/electrocautery can lead to electrical interference which may be detected and misinterpreted by the ICD. The electrical signal may be interpreted as a ventricular arrhythmia leading to inappropriate shock delivery or the signal may be interpreted as a normal cardiac impulse resulting in inappropriate inhibition of bradycardia pacing. The electrical energy may also cause tissue heating at the lead tips through high frequency current delivery. South East Wales Cardiac Network Page 9 of 9 Arrhythmia Pathway Cardiac Arrest and ICDs Final Version