Guideline Title: Peri-operative management of patients fitted with Permanent Pacemakers (PPMs) and Implantable Cardioverter Defibrillators (ICDs). Author(s): Jessica Osman (Chief Pacing Physiologist), Dr Mark Dayer (Consultant Cardiologist), Mohammad Lone (Associate Specialist Anaesthetics), Matthew Ward (Consultant Anaesthetist). Document Lead: Dr Mark Dayer, Dr Matthew Ward. Accepted by: Planned Care Divisional Active date: 11/01/2011 Governance Meeting Ratification date: 11/01/2011 Review date: 11/01/2014 Applies to: All those working with Exclusions: surgical patients with PPMs or ICDs. Purpose: To clarify the peri-operative management of elective surgical patients with PPMs/ICDs. Key Points (see Appendix) Diathermy and other electronic devices may cause PPMs or ICDs to malfunction intra-operatively. This may lead to cessation of pacing or inappropriate defibrillation that could ultimately lead to death. If a patient has a PPM or ICD this must be highlighted at pre-assessment and on admission to hospital. This must be reiterated at the safety briefing and WHO checklist immediately prior to surgery. The Cardiac Physiologists MUST be advised about all patients (except in the case of urgent out-of-hours surgery) so that the programmed settings can be reviewed and altered if necessary. PPMs should have been checked within 12 months of surgery. ICDs should have been checked within 6 months of surgery. If diathermy is necessary, bipolar diathermy should be used. Monopolar diathermy must only be used if absolutely necessary; the exit plate must be as far from the device as possible. Use short bursts of less than one second on the lowest current possible. ICDs should be switched to monitor only immediately prior to surgery and then back to their normal mode immediately post surgery. This can either be performed by the Cardiac Physiologists reprogramming the device OR by taping a magnet over the device and then removing it after surgery. An alternative means of pacing must be immediately available If a PPM is used for complete heart block, an alternative means of pacing must be available, for example external pacing. A magnet should be available so that in the event of diathermy-induced PPM inhibition, the magnet can be placed (and remain) over the PPM to initiate continuous pacing. However it is important to monitor the patient closely as magnet operation can vary between PPMs. 90% of ICD patients and all cardiac resynchronisation therapy (CRT) PPM patients, by definition have poor ventricular function and will need careful monitoring. There is no pacing service out of hours. Please see text for procedure. Page 1 of 9
Peri-operative Management of PPMs/ICDs Pre-operative POAC (Preoperative Assessment Clinic) When a patient with a PPM/ICD is identified: Identify the indication for the device clearly in the documentation. Document this using the checklist in Appendix 5 Contact the Cardiac Physiologists (x2953) to: - Advise on the date of surgery. - Identify the last time the device was checked. If the device has not been checked recently (within past 12 months for a PPM and 6 months for an ICD) this will need to be arranged prior to surgery. - Check the programmed parameters and confirm if any changes are required for the duration of surgery. - Check what effect placing a magnet will have on the function of the device. This should be recorded in the notes. - Determine whether the leads are programmed to operate in unipolar or bipolar mode; a unipolar lead is more prone to detect interference. Inform the surgeon and anaesthetist that the patient has an implanted cardiac device. Admitting ward / SAL (Surgical Admission Lounge) Identify the patient with a PPM/ICD and confirm that the appropriate POAC checks have been adhered to. Reconfirm the device check date (within past 12 months PPM and 6 months for ICD) in case surgery has been delayed. Inform the anaesthetist/surgeon if the device has not been checked. For patients with an ICD, inform the Cardiac Physiologist (x2953) of the likely time to theatre and duration of the procedure. Patients with an ICD should not be the last on the list as the Pacing Department closes at 17:00 hrs. Intra-operative Theatres Patients with PPMs/ICDs should be highlighted at the safety briefing. Patients with PPMs/ICDs should not be last on the list. Identify the device location (left infra-clavicular/right infra-clavicular/abdominal wall). Avoid diathermy wherever possible. If diathermy is essential Use bipolar diathermy if at all possible. Site the exit plate as far as possible from the PPM/ICD. Use the diathermy probe at least 15 cm away from the PPM/ICD. Page 2 of 9
Use short bursts (one second or less) using smallest current necessary. Have a magnet available to be applied to PPMs in the event of inhibition (pauses) caused by diathermy (see appendix 3). A magnet will usually cause the PPM to switch to a continuous pacing mode. However it is important to monitor the patient closely as magnet operation can vary between PPMs (please note a magnet will have NO effect on the bradycardia functions of an ICD, if inhibition (pauses) is seen on an ICD patient, diathermy should be stopped). Programme the ICD to monitor only mode to avoid unwanted shock therapy OR apply a magnet. For patients dependent upon the PPM e.g. for complete heart block, then an alternative method for immediate pacing is mandatory. For patients with an ICD which has been programmed off then an alternative method for immediate defibrillation is mandatory. It is advisable to have an alternative method of pacing and defibrillation for all patients. Postoperative Recovery (PACU) Identify the patient with PPM/ICD back from Theatre. Routine monitoring with pulse oximetry and NIBP with ECG immediately available if required. Arrange PPM/ICD check-up ASAP by calling 2953 if diathermy has been used, the settings have been changed or a magnet used Ward Identify the patient with PPM/ICD back from Theatre. Pulse oximetry and NIBP with ECG immediately available if required. If not performed in recovery, arrange PPM/ICD check-up ASAP by calling 2953 if diathermy has been used, the settings have been changed or a magnet used Out of hours There is currently no out-of-hours pacing service. Advice may be sought from the consultant cardiologist on-call. The advice outlined above will still apply here. Facilities for external pacing and defibrillation must be available and external pacing/defibrillation pads should be attached prior to the procedure. For a simple PPM, a magnet should be available in the event of diathermy induced PPM inhibition. If the device is an ICD then a magnet should be taped over the device at the start of the procedure to prevent inappropriate therapies being delivered. At the start of the next working day the pacemaker clinic should be contacted so that a pacing check can be arranged. If a magnet has been used and there is any indication the device may not be functioning adequately ie inappropriate defibrillation, lack of defibrillation or failure of capture, the patients ECG should be monitored post-op until the device can be checked. The patient may need to remain in recovery or go to the coronary Page 3 of 9
care or high dependency unit. This should be discussed with the cardiologist and intensivist on call Page 4 of 9
Appendix 1: Flowchart for ICD patients undergoing Surgery or procedures involving diathermy/ magnetic fields Identify patient with an ICD at POAC. Notify Cardiac Physiologist that patient is due to have surgery and advise them of the date. As soon as it is known, notify Cardiac Physiologist of time of surgery, to ensure appropriate staff available. Cardiac Physiologist will come to theatre prior to anaesthetic being given to switch tachy therapies off. Cardiac Physiologist will look through patient s file at settings, battery, last followup and the amount patient uses therapies/pacing Depending on the time of surgery, i.e. will surgery be finished before 17:00hrs, decide whether to use magnet or Cardiac Physiologist to come and switch device off. If a magnet is to be used see magnet flow chart External defibrillator paddles should be attached (AP position). The patient ECG can be monitored through these paddles and the patient should be externally cardioverted according to the trust protocol in the event of pulseless VT or VF. Cardiac Physiologist will perform checks and switch device back on (restore initial settings) whilst the patient is in recovery room. The patient s ECG MUST be monitored until the device is reprogrammed. Contact the Cardiac Physiologists post surgery to arrange a post operative check and for ICD to be switched back on. This MUST be before 17:00hrs. Page 5 of 9
Appendix 2 Flowchart for PPM patients undergoing Surgery or procedures involving diathermy/magnetic fields Identify patient with a PPM at POAC. Notify Cardiac Physiologist that patient is due to have surgery and advise them of the date. Cardiac Physiologist will review patient s file and determine date of last follow-up and review programmed settings. Cardiac Physiologist will let notifying team know whether a check is necessary before procedure. Where possible, the PPM will be programmed to bipolar sense to minimise the effect of the magnetic field/chances of inhibition If pacing check needed Pacing Physiologist will try to schedule for same day as the patients procedure, if possible. If not we will send the patient an outpatient appt. to see us before the procedure date. During procedure ensure the patient s ECG is closely monitored. Emergency pacing equipment such as pace aid through the external defibrillator should be available, especially for patients who are pacing frequently. It is important to note that depending on the PPM model and settings magnet operation will vary between devices, in most cases, a magnet should induce continuous asynchronous pacing, but the length of time that this mode will be effective will vary and the patient should be closely monitored. If inhibition reoccurs whilst the magnet is in place, remove the magnet briefly and then replace, and continue with short bursts of diathermy removing and replacing the magnet between bursts. If the magnet does not force the PPM to pace and inhibition/pauses are seen on the ECG, the procedure must be stopped or external pacing must be started. A magnet should be available to place over the PPM if inhibition of the PPM it witnessed during the procedure. Contact the Pacing Physiologists post surgery to arrange a post operative check. This MUST be before 17:00hrs; otherwise the check will be done following working day. Page 6 of 9
Appendix 3: How to use a magnet Any magnet will affect the functioning of an ICD or PPM. The Pacemaker clinic will provide 3 magnets so a magnet should always be available in theatre. PPM ICD Monitor patient s ECG. Monitor patient s ECG. In the event of PPM inhibition, and ventricular pauses, place magnet directly over PPM. Immediately prior to surgery, securely tape magnet directly over ICD to disable tachy therapies. Continue to monitor ECG to ensure paced rhythm observed. Ensure magnet is removed post procedure. Continue to monitor ECG, if patient has episode of VT or VF remove magnet immediately for therapies to be enabled. Ensure magnet is removed post procedure. All devices should be checked by cardiology post-operatively. For patients with ICD, they should remain in an area of high dependency until the device is checked Page 7 of 9
Appendix 4: Further information and explanation of Key points and Management advice Surgical Diathermy and Cardiac PPMs or ICDs Devices can be adversely affected by surgical equipment in 2 ways: 1. Diathermy in particular directly interferes with PPM/ICD function if the electrical pulses of the diathermy current are detected by the device, when they will be recognised as heart beats. 2. The generator for the equipment (or any electrical equipment) may generate a sufficient magnetic field to interfere with the PPM programming. False detection of electrical signals as cardiac signals will suppress PPM function and effectively turn the device off. This does not matter if the patient has a normal underlying rhythm (common in ICD patients), and may not matter much in patients who only have occasional pacing requirements, but some paced patients will be totally dependent upon their device for any cardiac function and others will only have a very slow ventricular escape rhythm with which they may have an extremely poor cardiac output. False detection of diathermy signals by an ICD can be recognised as a ventricular arrhythmia and trigger ICD activity to attempt to correct it. This activity may be Anti-Tachycardia Pacing or shocks. When ATP occurs inappropriately this may trigger VF and also lead to shocks. Inappropriate shocks can be fatal. Pulsatile magnetic fields may re-program the PPM. The precise effects are unpredictable. A continuous magnetic field applied to the device will affect PPMs and ICDs differently. PPMs will generally be switched into a fixed rate continuous pacing mode, which is a safe mode of function. ICDs do not have their pacing function altered but the magnetic field will suspend all anti-tachycardia therapy. Occasionally powerful external fields can damage the pacing circuitry and alternating fields such as those found in an MRI scanner can heat the leads to dangerous temperatures. Be aware that 90% of ICD patients and all cardiac resynchronisation therapy (CRT) PPM patients, by definition have poor ventricular function and will need careful monitoring. Patients with simple PPM will generally not have very poor LV function as they would have been upgraded to an ICD or CRT. For further information see Salukhe et al. British Journal of Anaesthesia 93 (1): 95-104 (2004), DOI: 10.1093/bja/aeh170. Page 8 of 9
Patient label Appendix 5 Peri-operative management of pacemakers and implantable cardiac defibrillators Checklist for patients with pacemakers (PPM) or Implantable Cardiac Defibrillators (ICD) POAC Date of pre-assessment Date of Surgery Planned operation Type of device PPM ICD Indication for device Underlying rhythm Date of last device check (Within 6 months for ICD, 12 months for PPM) Cardiac physiology informed ADMISSION Cardiac physiology informed Theatres/ anaesthetist informed THEATRES PPM/ ICD discussed at safety brief Magnet available No Effect of magnet Bipolar diathermy No Plate as far from device as possible Current as low as possible Alternative means of No pacing/ defibrillation available POST-OPERATIVE Any adverse intra-operative events No Device checked by cardiac physiology No If not have arrangements been made for this to happen Device must be checked prior to discharge from recovery or as soon as possible Page 9 of 9