NORTH OF ENGLAND CARDIOVASCULAR NETWORK (NECVN)

Transcription

1 NORTH OF ENGLAND CARDIOVASCULAR NETWORK (NECVN) Operational policy for optimal management of: Cardiac pacemakers, Implantable cardioverter defibrillators (ICD), Cardiac resynchronisation devices, (CRT-D, CRT-P) for patients undergoing general surgery November 2012 (For review November 2014)

2 1. Purpose To clarify the operational procedures undertaken, in the North of England Cardiovascular Network, when a patient with an implanted cardiac device requires a surgical intervention. 2. Proposed Patient flow See Attachment One 3. About Implantable Pacemakers and Cardioverter defibrillators The provision of implanted pacemakers, implantable cardioverter defibrillators and cardiac resynchronisation devices is increasing and as a consequence it is increasingly likely that patients presenting for either elective or emergency surgery will have such a device in situ. Pacemakers, implanted to treat bradycardias, have one or two standard pacemaker leads. ICDs have the same functionality as pacemakers to prevent bradycardia, but in addition can deliver a programmed range of therapy including defibrillation, in response to spontaneous tachycardia. Cardiac Resynchronisation devices, which can be either pacemakers or ICDs, have an additional lead placed in a coronary vein to help improve cardiac function in patients with heart failure. Patients may know what type of device they have, and should have a registration card showing the relevant details. Alternately evaluation of an X ray may be of use in discerning the differences between the two types of devices. ICD Device is larger Coil is clearly seen.) Pacemaker Pacemakers, ICDs and CRT devices have been designed with a high degree of tolerance to interference with filters incorporated to minimise the 2

3 effect of both electrical and magnetic interference. Problems may arise however, if the energy level of a nearby field is very high, or has a frequency component that is close to the cardiac range. The most common example of this is the use of surgical diathermy. In addition for a subset of procedures or scans which create electrical and/or magnetic interference further advice should be sought, particularly for all ICD patients. 4. During Surgery Monitoring the patients ECG throughout. Use of an alternative method of detecting a patients pulse such as an arterial line or pulse oximeter (as a minimum). In the pacemaker patient monopolar (unipolar) surgical diathermy may be sufficient to temporarily inhibit pacemaker output or may give rise to a temporary increase in pacing rate. The release of substantial energy may cause the pacemaker to enter a safety mode of operation with subsequently restricted function. Bipolar diathermy, because it causes EMI over a smaller area, is less likely to cause interference. At the time of surgery the following should be considered when surgical diathermy/electrocautery is to be used on patients with an implantable pacemaker: The indifferent plate should be positioned on the patient such that the applied diathermy does not follow the same current path as any of the implanted cardiac leads. Where the use of monopolar diathermy/electrocautery is unavoidable i. Limit its use to short bursts ii. Ensure that the return electrode is anatomically positioned so that the current pathway between the diathermy electrode and return electrode is as far away from the pacemaker/defibrillator (and leads) as possible. Where either monopolar or bipolar diathermy/electrocautery is used i. Ensure that the cables attached to diathermy/electrocautery equipment is kept well away from the site of the implant ii. Consider alternative external/transvenous pacing where pacing away from the implant is significantly affected during the use of diathermy/electrocautery. Where detectable pacemaker inhibition occurs, the surgeon should be informed immediately and diathermy discontinued or used sparingly. In the ICD patient, interference generated by any form of diathermy may be misinterpreted as VT or VF causing inappropriate initiation of therapy. Use of any type of diathermy is currently contraindicated unless the ICD has been deactivated. Once the ICD has been deactivated ensure that cardio-pulmonary resuscitation and external defibrillation equipment are immediately available. For patients where the ICD is deactivated and where access to the anterior chest wall will interfere with surgery (or the sterile field), consider connecting the patient to an external defibrillator using remote pads. 3

4 5. Use of Magnet during emergency procedures For patients with pacemakers it is not advisable to secure any magnet over the pacemaker implant The correct application of a ring magnet over an ICD (as shown below) will block all tachycardia therapy for all current ICDs. Using rectangular or square magnets will be ineffective. Ring magnets are be available from the local Coronary Care Unit (CCU) or tertiary centres but must be returned as soon as possible. However it should be noted that: Any subsequent VT/VF will need to be treated using external defibrillation equipment. Inhibition of shock delivery will only be effective whilst the magnet remains over the site, so the magnet should taped to the patient for the duration of surgery. Whenever a magnet has been applied the implanting centre must be notified. Some models of ICD should be formally checked postoperatively to determine therapy delivery status. Process of requesting advice The local District General Hospital (DGH) may have the appropriate equipment and/or staff for deactivation or reactivation. Where a full service cannot be provided, the relevant tertiary centre (James Cook University Hospital or Freeman Hospital) can usually lend the equipment on request and/or will arrange for personnel from elsewhere to attend. For deactivation/reactivation, contact the local DGH CCU to find out whether ICD follow-up services are offered. If no DGH service available, during normal working hours contact (depending on postcode) either the lead physiologist at FRH on / or the lead physiologist at JCUH on Outside of normal working hours contact the on call cardiologist via FRH switchboard or JCUH switchboard

5 6. Local referring services requiring advice Contact the tertiary centre at their earliest convenience to ask for support with equipment, local contacts or actual deactivation/reactivation Mutually convenient arrangements will be made for loan of equipment where required Once the type of device has been confirmed and the correct equipment identified, arrangements can be made for deactivation There is a requirement for each cardiac physiologist to have an annual training update. The DGH lead is responsible for coordinating this process. Freeman Hospital pacing department holds a list of all staff across the northern part of the region and has all the programmers required for all models. JCUH pacing department holds a similar list of staff across the Southern part of the region. 5