Skip to main content

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.

Comments

Post a Comment

Popular posts from this blog

power injectable peripherally inserted central catheters

Clinical experience with power injectable peripherally inserted central catheters in intensive care patients     Introduction In intensive care units (ICU), peripherally inserted central catheters (PICC) may be an alternative option to standard central venous catheters, particularly in patients with coagulation disorders or at high risk for infection. Some limits of PICCs (such as low flow rates) may be overcome by the use of power-injectable catheters . Method We have retrospectively reviewed all the power injectable PICCs inserted in adult and pediatric patients in the ICU during a 12-month period, focusing on the rate of complications at insertion and during maintenance. Results We have collected 89 power injectable PICCs (in adults and in children), both multiple and single lumen. All insertions were successful. There were no major complications at insertion and no episodes of catheter-related blood stream infection. Non-infective complications ...
1 comment
Read more

Things to Avoid in Anesthesia for Pregnant with Pulmonary hypertension

Anesthesia for Pregnant woman with Pulmonary Hypertension is a real challenge for anesthesiologist. It is very crucial to remember the pathophysiology of pulmonary hypertension in pregnant women and to avoid some practices that will worsen the cardiac status. 1-Avoid single shot spinal anesthesia. Some authorities consider pulmonary hypertension as absolute contraindication for single shot spinal anesthesia specially in patients with NYHA III ,IV. Spinal anesthesia causes major hemodynamic instability(decrease SVR, decrease VR, decrease in CO) The preferred neuroaxial techniques are (epidural anesthesia and CSE with minimal spinal dose) 2-Avoid PAC. Pulmonary Artery catheters insertion may lead to pulmonary artery rupture or thrombosis. TEE is better cardiac monitor/Arteial line is mandatory. 3-Avoid Nitrous oxide in gas mixture.N2O increase the PVR 4-If MV to be started, avoid High TV and PEEP 5-Avoid Oxytocin Boluses, or rapid administration of Pitocin. Oxytocin causes ...
Post a Comment
Read more

The 12 decision making steps for post dural puncture headache treatment

Treatment decision-making algorithm for postdural puncture headache. 1. When diagnosis is made, all patients should receive supportive measures (reassurance, bed rest, analgesics, hydration, quiet environment). 2. Severity of symptoms should be classified using VAS scale (mild 1–3, moderate 4–6, severe 7–10). 3. Virtually all patients will improve in time even without additional therapy. (dashed lines) 4. Symptoms worsen or fail to resolve within 5 days. 5. Patient preference dictates the choice between pharmacologic (less effective) and epidural blood patch (EBP). 6. In patients with severe symptoms, EBP is strongly suggested. 7. The most common pharmacologic measure is  caffeine  prescription. 8. The failure, worsening, or recurrence of symptoms after pharmacologic measures favors the use of EBP. 9. In addition to EBP, other epidural treatment options can be considered in select patients (eg,  dextran , saline). 10. A period of 24 h should lapse before repeating EBP. 11...
1 comment
Read more