Perioperative Management of Pacemakers and Implantable Cardioverter Defibrillators

Patient selection in ambulatory surgery

Patient selection is important for ambulatory surgical practices. Proper patient selection for ambulatory practices will optimize resources and lead to increased patient and provider satisfaction. As the number and complexity of procedures in ambulatory surgical centers increase, it is important to ensure that patients are best cared for in facilities that can provide appropriate levels of care. This review addresses the multiple variables and resources that should be considered when selecting patients for anesthesia in ambulatory centers and offices.

Economic Evaluation of Anesthesiology-Led Cardiac Implantable Electronic Device Service

BACKGROUND

Implementation of an anesthesiology-led cardiac implantable electronic device (CIED) service can be viewed to have economic and efficiency challenges. This study evaluates the cost savings of an anesthesiology-led CIED service.

METHODS

A total of 830 patients presented in the pre-implementation period from 1 March 2016 to 31 December 2017, and 1981 patients presented in the post-implementation period from 1 January 2018 to 31 October 2021. Interrupted time-series analysis for single-group comparisons was used to evaluate the cost savings resulting from reduction in operating room (OR) start delays for patients with CIEDs.

RESULTS

OR start-time delay was reduced by 10.6 min (95%CI: -20.5 to -0.83), comparing pre- to post-implementation. For an OR cost of USD 45/min, we estimated the direct cost to the department to be USD 1.68/min. The intervention translated into a total cost reduction during the intervention period of USD 250,000 (USD 18,000 to USD 470,000) per year for the institution and USD 9800 (USD 730 to USD 17,000) per year for the department. The yearly cost of employing a full-time team of CIED specialists would have been USD 135,456. The service triggered electrophysiology consultation on 13 device malfunctions.

CONCLUSIONS

An anesthesiology-led CIED service resulted in substantial cost savings, increased OR efficiency and patient safety.

An Unexpected Magnet Response of a Biotronik Pacemaker in Automatic Mode: A Case Report

In patients with cardiovascular implantable electronic devices, asynchronous pacing is necessary for surgeries with a risk of electromagnetic interference. Magnets are often used for asynchronous pacing. In this case report, magnet application to a Biotronik Evia DR-T pacemaker (Biotronik) programmed to a magnet response mode called automatic magnet mode (AUTO) led to a brief period of asynchronous pacing before reverting to prior settings, an unexpected response that was not revealed on the preoperative interrogation report. For Biotronik pacemakers programmed to the AUTO mode, changes in programming are needed for asynchronous pacing.

The perioperative management of small animals with previously implanted pacemakers undergoing anaesthesia

OBJECTIVE

There is little information in the veterinary literature about the perioperative management of small animal patients with previously implanted pacemakers undergoing elective or emergency non-cardiac procedures. The purpose of this article is to review the current literature with regard to human patients, with previously implanted pacemakers, undergoing general anaesthesia. Using this and the current information on pacemakers and anaesthesia in dogs and cats, we provide recommendations for small animal patients in this situation.

DATABASES USED

Google Scholar, PubMed and CAB Abstracts using and interlinking and narrowing the search terms: "dog", "cat", "small animals", "anaesthesia", "pacemaker", "perioperative", "transvenous pacing", "temporary pacing". Scientific reports and human and small animal studies from the reference lists of the retrieved papers were reviewed. In addition, related human and veterinary cardiology and anaesthesia textbooks were also included to create a narrative review of the subject.

CONCLUSIONS

The best perioperative care for these animals comes from a multidisciplinary approach involving the anaesthetist, cardiologist, surgeon and intensive care unit team. When such an approach is not feasible, the anaesthetist should be familiar with pacemaker technology and how to avoid perioperative complications such as electromagnetic interference, lead damage and reprogramming of the device. The preanaesthetic assessment should be thorough. Information regarding the indication for pacemaker placement, complications during the procedure, location, type and programming of the pacemaker should be readily available. The anaesthetic management of these veterinary patients aims to preserve cardiovascular function while avoiding hypotension, and backup pacing should be available during the perioperative period. Further prospective studies are needed to describe the best perioperative care in small animals with a previously implanted pacemaker.

Comparison of perioperative strategies in ICD patients: The perioperative ICD management study (PIM study)

BACKGROUND

The prevalence of patients with implanted cardioverter defibrillators (ICDs) and the frequency of surgery on these patients are steadily on the rise. Guidelines recommend preoperative ICD reprogramming, although this is sometimes difficult in clinical practice. Placing a magnet on the ICD is a practical alternative and even no inactivation is possible in selected cases.

METHODS

In this prospective observational study, we compared different perioperative ICD management strategies depending on the location of the surgery and the type of electrocautery used. Patients undergoing surgery above the umbilicus with monopolar electrocautery had their ICD therapy inactivated by reprogramming. When surgery below the navel or surgery above the navel with bipolar electrocautery was completed, ICD inactivation was performed using a magnet. No inactivation was performed on patients undergoing lower extremity surgery with bipolar electrocautery. Only ICD patients who were not pacemaker dependent were enrolled. After surgery, the ICDs were assessed regarding documented arrhythmias and parameters.

RESULTS

Out of 101 patients included in this study, the ICD was preoperatively reprogrammed in 42 patients (41.6%), a magnet was used on 45 patients (44.5%), and ICDs were not deactivated at all in 14 patients (13.9%). No intraoperative electromagnetic interference was detected. Postoperative ICD analysis demonstrated no changes of preset parameters.

CONCLUSIONS

All three tested ICD management strategies were proved safe in this study. Keeping the location of surgery and the type of electrocautery in mind, an intraoperative magnet or even no ICD deactivation at all could be feasible alternatives in surgery on patients with ICDs.

[Pacemaker, defibrillator and co : Perioperative handling of cardiac implantable electronic devices]

The number of patients treated with cardiac implantable electronic devices (CIED) is continously increasing. Knowledge of the medical indications and technical mode of functioning of these devices is a basic prerequisite for the safe perioperative care of this patient cohort. The CIEDs are subjected to a multitude of disturbing influences in the perioperative setting. This can result in potentially dangerous complications, such as exit block and oversensing. The safe performance of interventions is possible as long as some basic rules are followed. An interdisciplinary approach involving all participating disciplines is necessary in order to adequately deal with the high demands placed on the logistics.

Perioperative management of patients with cardiac implantable electronic devices

The use of implantable cardiac devices in people of all ages is increasing, especially in the elderly population: patients with pacemakers, cardioverter-defibrillators or cardiac resynchronization therapy devices regularly present for surgery for non-cardiac causes. This review was made in order to collect and analyze the latest evidence for the proper management of implantable cardiac devices in the perioperative period. Through a detailed exploration of PubMed, Academic Search Complete (EBSCO), ClinicalKey, Cochrane (Ovid), the search software UpToDate, textbooks and patents freely available to the public on Google, we selected 33 monographs, which matched the objectives of this publication.

Anaesthetic consideration in patients with cardiac implantable electronic devices scheduled for surgery

With advances in cardiology and cardiothoracic surgery, several newer implantable cardiac devices have become common in the surgical population. Multichamber pacemakers, implanted cardiac defibrillators and ventricular assist devices are frequent in current day practice. Many of the newer implantable cardiac electronic devices are targeted at managing heart failure. While managing such patients for non-cardiac surgeries, specific issues related to equipment characteristics and troubleshooting should be a priority for the anaesthesiologists. There is a possibility of malfunction of the devices resulting in catastrophic outcomes. Therefore, it is imperative to understand the pathophysiology, device characteristics and troubleshooting before embarking on anaesthetising patients with implantable cardiac electronic devices.

Initial Experience of an Anesthesiology-based Service for Perioperative Management of Pacemakers and Implantable Cardioverter Defibrillators

Background

Management of cardiovascular implantable electronic devices (CIEDs), including pacemakers and implantable cardioverter defibrillators, for surgical procedures is challenging due to the increasing number of patients with CIEDs and limited availability of trained providers. At the authors’ institution, a small group of anesthesiologists were trained to interrogate CIEDs, devise a management plan, and perform preoperative and postoperative programming and device testing whenever necessary.

Methods

Patients undergoing surgery between October 1, 2009 and June 30, 2013 at the University of Washington Medical Center were included in a retrospective chart review to determine the number of devices actively managed by the Electrophysiology/Cardiology Service (EPCS) versus the Anesthesiology Device Service (ADS), changes in workload over time, surgical case delays due to device management, and errors and problems encountered in device programming.

Results

The EPCS managed 254 CIEDs, the ADS managed 548, and 227 by neither service. Over time, the ADS providers managed an increasing percentage of devices with decreasing supervision from the EPCS. Only two CIEDs managed by the ADS required immediate assistance from the EPCS. Patients who were unstable postoperatively were referred to the EPCS. Although numerous issues in programming were encountered, primarily when restoring demand pacing after programming asynchronous pacing for surgery, no patient harm resulted from ADS or EPCS management of CIEDs.

Conclusions

An ADS can provide safe CIED management for surgery, but it requires specialized provider training and strong support from the EPCS. Due to the complexity of CIED management, an ADS will likely only be feasible in high-volume settings.