ASA guidelines for peri operative pacemakers and ICD management

1. Preoperative management centers upon:

 Establishing whether or not a patient has a cardiac rhythm management device (CRMD), by focused history, review of chest radiography (CXR), electrocardiogram (ECG), and physical examination

 Defining the type of device by reviewing the manufacturer's card, interrogating it with a CRMD programming device, CXR, or querying the manufacturer's databases

 Determining whether a patient is device dependent for antibradycardia pacing by patient history and device interrogation

 Determining the device's function through consultation with a cardiologist or CRMD service

Next the preoperative preparation should include the following steps:

 Determine whether electromagnetic interference would be present during the planned procedure.

 Determine whether reprogramming the device to asynchronous pacing mode or disabling the rate responsiveness function is needed.

 Suspend the device's antitachyarrhythmia functions, if present.

 Advise the use of bipolar electrocautery system if the patient is pacemaker dependent. If monopolar electrocautery must be used, recommend the use of short, irregular bursts.

 Assure the availability of temporary pacing and external defibrillation equipment.

The task force recommends changing to an asynchronous pacing mode for all patients who are pacer-dependent. This can be accomplished either by programming or magnet application.

CAUTION: There is no reliable way to assess proper magnet placement.

 Magnet application to a combined ICD/pacemaker may disable the tachyarrhythmia therapy function depending on the manufacturer of the device but not alter the pacing mode to an asynchronous mode. Therefore, in these devices only a consultant can change the pacing mode by using a device programmer.

 Not all ICDs respond to magnet placement.

 Some ICDs are permanently disabled by magnet placement.

2. Intraoperative management includes:

 Managing potential sources of electromagnetic interference:

 Electrocautery: Position the return pad in such a way that the current pathway does not pass through or in the vicinity of the device; suggest the use of short, intermittent bursts of cautery; suggest the use a bipolar cautery which reduces the current flow through the body.

 RF ablation: Keep the RF current path as far away from the device as possible.

 Lithotripsy: Avoid focusing of the lithotripsy beam near the generator, disable atrial pacing if the lithotripsy triggers on the R wave.

 MRI is contraindicated for all devices.

The external defibrillation pads should be placed as far away from the generator as possible in order to minimize damaging the device in case of emergency defibrillation. Before attempting emergency defibrillation or cardioversion in patients with disabled ICDs, the magnet should be removed to re-enable the tachyarrhythmia therapy function of the device. If the device does not deliver the appropriate shock then external defibrillation or cardioversion should be immediately performed.

3. Postoperative management

The postoperative management should include interrogation of the device and restoration of the tachyarrhythmia therapy function of the device in the postanesthesia care unit or intensive care unit.³⁴Until the defibrillating function of the device is restored the function should be monitored with continuous ECG.

No patient should be discharged from a monitored area until the device has been interrogated postoperatively.