Electrosurgery-induced ventricular fibrillation during pacemaker replacement--a unique mechanism

Causes of Perioperative Cardiac Arrest: Mnemonic, Classification, Monitoring, and Actions

Perioperative cardiac arrest (POCA) is a catastrophic complication that requires immediate recognition and correction of the underlying cause to improve patient outcomes. While the hypoxia, hypovolemia, hydrogen ions (acidosis), hypo-/hyperkalemia, and hypothermia (Hs) and toxins, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary), and thrombosis (coronary) (Ts) mnemonic is a valuable tool for rapid differential diagnosis, it does not cover all possible causes leading to POCA. To address this limitation, we propose using the preload-contractility-afterload-rate and rhythm (PCARR) construct to categorize POCA, which is comprehensive, systemic, and physiologically logical. We provide evidence for each component in the PCARR construct and emphasize that it complements the Hs and Ts mnemonic rather than replacing it. Furthermore, we discuss the significance of utilizing monitored variables such as electrocardiography, pulse oxygen saturation, end-tidal carbon dioxide, and blood pressure to identify clues to the underlying cause of POCA. To aid in investigating POCA causes, we suggest the Anesthetic care, Surgery, Echocardiography, Relevant Check and History (A-SERCH) list of actions. We recommend combining the Hs and Ts mnemonic, the PCARR construct, monitoring, and the A-SERCH list of actions in a rational manner to investigate POCA causes. These proposals require real-world testing to assess their feasibility.

Pacemakers and Implantable Cardiac Defibrillators in Dermatologic Surgery

BACKGROUND

Electrosurgery used during dermatologic surgical procedures can cause malfunction of pacemakers and implantable cardiac defibrillators (ICDs), producing problems with rhythm detection, proper function, or alteration of the device. Well-documented safety data on electrosurgery in patients with cardiac devices are limited. At Mayo Clinic in Rochester, Minnesota, the Pacemaker Clinic manages all patients with pacemakers and ICDs undergoing dermatologic surgery. The preoperative and postoperative evaluations provide a unique opportunity to evaluate the safety of dermatologic surgery with electrosurgery in such patients.

OBJECTIVES

The objective was to review the evaluation and management, by an experienced cardiology team, of patients with cardiac devices undergoing dermatologic surgery and to characterize perioperative complications.

METHODS

A retrospective chart review of all patients identified with pacemakers or ICDs undergoing Mohs micrographic or dermatologic excisional surgery with electrosurgery at Mayo Clinic 2001 through 2004 were identified. Data were abstracted to identify any possible complications.

RESULTS

The 173 patients with pacemakers and 13 with ICDs undergoing dermatologic surgery had no documented complications from electrosurgery.

CONCLUSION

The lack of complications associated with pacemakers and ICDs with electrosurgery is reassuring. The authors support published recommendations about techniques and precautions to optimize safety during electrosurgery in patients with cardiac devices. The care of patients with ICDs in particular requires special consideration.

The postmodern heart: war veterans' experiences of invasive cardiac technology

BACKGROUND

The consequences of war and medical discourse have historical connections to pacemaker technology. Understanding these consequences is important because war veterans, medicine and cardiac technology have a shared history that continues into the present. The incidence of Australian war veterans needing cardiac pacemakers has increased many-fold in recent years, due to advancing age. This need was recognized by the Australian Department of Veteran Affairs and a cardiac programme was established in the veteran hospital that was the setting for this study.

AIM

This paper reports on a study aimed at capturing the interest and sensitizing the practice of nurses involved in the care of war veterans and other health care consumers who have been diagnosed as requiring a cardiac pacemaker. The study sought to answer the question, 'How does the war veteran experience his body in relation to invasive cardiac technology?'.

METHOD

The research was guided by the principles of interpretive interactionism, and used unstructured interviews with eight male war veterans. The data were collected in 2000.

FINDINGS

Thematic and content analysis revealed five themes: emotional knowing; the medical encounter; belief in the myth of miracle; technological constraint; and the altered heart. The findings indicated that the human dimension was characterized by experiences of ambivalence, inner conflict, powerlessness and suffering.

CONCLUSION

Nursing is at the interface of science and patient care, and this study contributes to nursing knowledge by focusing on a previously unresearched topic, namely embodied interactions between war veterans and invasive cardiac pacemakers. Within a highly technical area such as cardiology, nurses can still work around the technology and keep patients as their primary focus, thus promoting quality care. A humanistic rather than a technological focus locates nurses between patients and cardiac technology. In this in-between location, nurses are not an extension of cardiac technology but a valuable source of information, education, and counselling.

Electrosurgery in Otolaryngology???Head and Neck Surgery: Principles, Advances, and Complications

OBJECTIVES/HYPOTHESIS

Electrosurgical instruments are routinely used in many applications by otolaryngologist-head and neck surgeons; and a complete description of their historical development, physics of operation, histological effects, and technological advancements is necessary for our specialty to take full advantage of this instrumentation. Because of the electrical current, heat production, and common use associated with these instruments, compounded by the complex environments in which they are used, potential complications must be considered and are likely underreported in the literature. This thesis describes the important aspects of electrosurgery along with a study of complications so otolaryngologists can use these instruments to their fullest potential while limiting complications.

STUDY DESIGN

National survey of electrosurgical complications.

METHODS

A survey addressing potential complications of electrosurgery was developed based on a review of the electrosurgical and complications literature. The electrosurgical complications were organized in the following categories: 1) unanticipated direct burns as a result of the active electrode contacting some tissue unintentionally; 2) unintentional burns as a result of capacitive coupling where radiofrequency (RF) current passes through a metallic instrument (such as forceps) and burns tissue in contact with that metallic instrument; 3) fires occurring as a result of electrosurgical instruments; 4) electromagnetic interference with a pacemaker, defibrillator, or cardiac monitoring device; and 5) other complications not included in the previous categories. The survey was mailed to the 620 members of the Society of University of Otolaryngologists.

RESULTS

Of the 620 surveys mailed, 35 were returned by the post office for lack of a forwarding address and 296 were returned completed for a response rate of 49.7%. The respondents performed a total of 99,664 cases in the previous year. During that year, 324 complications related to electrosurgical instruments were reported. These included 219 unanticipated direct burns, 48 burns as a result current flow through a metallic retractor or instrument (capacitative coupling), 13 grounding pad burns, 11 fires, 32 cases of electromagnetic interference, and 1 hair loss at an incision site as a result of a cutting electrosurgical instrument. Information regarding the circumstances surrounding these complications and outcome are presented.

CONCLUSIONS

Electrosurgery has proliferated since its original application by William T. Bovie and Harvey Cushing in the 1920s. Because surgeons use this technology frequently, a thorough understanding of these instruments and their potential complications is critical to their safe and successful use. Electrosurgical units operate on basic fundamental principles of physics and involve the passage of electrical current through tissue to create the desired tissue effect. With knowledge of the history, physics, techniques, histological effects, and safety issues of electrosurgery, the field will continue to proliferate and electrosurgery will continue to assist surgeons in alleviating human suffering.