Perioperative Management of Patients with Cardiac Rhythm Management
Devices (CRMD): Pacemakers and Implantable Cardioverter-Defibrillators
I.
Preoperative Evaluation
a. Establish presence of CRMD
i. History and Physical
ii. EKG
iii. CXR
b. Define type of CRMD
i. Manufacturer’s ID card from the patient or chart
ii. Manufacturer’s database
iii. Cardiologist consultation (recent interrogation)
c. Determine whether the patient is CRMD dependent for pacemaker
function (i.e. antibradycardia pacing function)
i. History
ii. Patient medical records
iii. EKG with paced rhythm
iv. History of AV nodal ablation resulting in CRMD implantation
v. CRMD evaluation with no spontaneous activity when placed on
VVI mode
d. Determine the CRMD function
i. Confirm pacing impulses (if present).
ii. Confirm the effect of magnet placement on CRMD function. (i.e.
asynchronous pacing, turning off AICD) (on chart or call
representative)
iii. Determine that the pacemaker captures when it paces
(interrogation).
iv. Interrogate the pacemaker/Contact manufacturer for perioperative
recommendations
e. It is the anesthesiology resident’s responsibility to ascertain the above
evaluation in preoperative clinic or when evaluating a patient prior to an
anesthetic.
i. A plan must be made to ensure optimal management
preoperatively and intraoperatively
1. Representative must be contacted to evaluate effect of
magnet and notification that interrogation/reprogramming
will be needed preop and post-operatively on DOS.
2. Representative must be contacted again night before for
reminder of need for interrogation/reprogramming.
3. If the magnet is used to turn off pacemaker/AICD, the
representative must be present postoperatively to make sure
that the original settings are restored after magnet removal.
4. Any deviation from the above plan will only be the
decision of the attending anesthesiologist doing the case on
the DOS.
ii. You must discuss this plan with an attending anesthesiologist
assigned to preop
iii. The primary service (resident, chief resident, or attending) must be
aware of the plan the night before as to placing a magnet or the
need the representative to reprogram the CRMD. Documentation
of this conversation must be made on the preoperative paperwork.
f. Company Representatives and Contact information
i. Guidant
Kevin Fosdick, RN, RCIS
Cell: 760 908-3487
1-800-CARDIAC
ii. Medtronic
Shawn Murdock
Cell: 310-600-4466
iii. St. Jude Medical
Steve Rons
Sales Rep
Cell: 619 887-0351
II.
Preoperative Management
a. Determine if electromagnetic interference (EMI) is anticipated during the
case
i. Electrocautery
ii. Radiofrequency ablation (RFA)
iii. Magnetic Resonance Imaging (MRI)
iv. Radiation Therapy
v. Extracorporeal Shock Wave Lithotripsy (ESWL)
b. Determine if reprogramming the CRMD to asynchronous pacing mode is
needed.
i. Representative should be available on the operative day as
discussed during the preoperative visit.
ii. Magnet when applicable
iii. Representative can reprogram
1. Determine optimal rate given the patient’s medical comorbidities. (i.e. HR 65-70 bpm in cardiac patient instead
of default HR of 100bpm)
c. Suspending any antitachyarrhythmia/cardioverter-defibrillation functions
present
i. Turn off the AICD portion
d. Advising the operative surgeon to consider using bipolar electrocautery or
harmonic scalpel to minimize potential adverse events
e. Assure the availability of temporary pacing and defibrillation equipment
i. Place trancutaneous pacing/defibrillator pads when
necessary/indicated.
f. Evaluate the possible effects of anesthetic techniques and of the procedure
on CRMD function and interactions.
i. Anesthetic induced physiologic changes may induce unexpected
CRMD responses or adversely affect the CRMD-patient
interactions.
III.
Intraoperative Management
a. Intraoperative EKG
b. Monitoring peripheral pulse (i.e. pulse oximetry)
i. Any unexpected interactions should postpone/discontinue case
until source of interaction is elucidated
c. Manage potential sources of EMI
i. Assure that the electrocautery receiving pad is positioned so that
the pathway does not pass through or near the CRMD system. (i.e.
superior posterior aspect of the shoulder contralateral to the
generator position for a Head and Neck case)
ii. Advise the operative surgeon:
1. avoid proximity of the cautery’s electrical field to the pulse
generator and leads
2. use short, intermittent, and irregular bursts at the lowest
feasible energy levels
3. consider use of bipolar electrocautery or harmonic
(ultrasound) scalpel in place of monopolar electrocautery
iii. Radiofrequency Ablation (RFA)
1. Should keep the RF current path as far away from the pulse
generator and lead system as possible.
2. Avoid direct contact between ablation catheter and the
CRMD and leads
iv. Lithotripsy (ESWL)
1. Avoid focusing the lithotripsy beam near the pulse
generator
2. If beam triggers on R wave of EKG, consider preoperative
disabling of atrial pacing
v. MRI
1. Generally contraindicated
2. If must be performed, consult with cardiologist, ordering
physician, radiologist, and CRMD manufacturer
vi. Radiation Therapy
1. Can be safely performed in patients with CRMDs unless in
the field of radiation
vii. Electroconvulsive Therapy (ECT)
1. May have associated transient or long-term myocardial and
nervous system effects
2. If ECT must be performed, consult with the ordering
physician and cardiologist to plan for the first and
subsequent ECTs.
3. All CRMDs should undergo a comprehensive interrogation
before the procedure.
4. ICD functions should be disabled for the shock therapy
during ECT
5. CRMD-dependent patients may require temporary
transcutatneous pacemaker to preserve rate and rhythm
during shock therapy
6. CRMD may require programming to asynchronous activity
to avoid myopotential inhibition of the device in
pacemaker-dependent patients.
d. Emergency Defibrillation
i. If emergency defibrillation is needed:
1. Reenable antitachycardia therapies by
a. Removing magnet to turn on antitachycardia
function
b. Reprogram to turn on AICD
c. Place defibrillator/cardioverter pads in an anteroposterior placement as far away from the pulse
generator
IV.
Postoperative Management
a. Continuously monitor cardiac rate and rhythm.
b. Have backup pacing and defibrillation equipment immediately available in
the postoperative period.
c. Representative should be available, as discussed in the preoperative visit
to interrogate and restore CRMD function in the immediate postoperative
period.
d. Restore all antitachyarrhythmic therapies in the ICDs.
Practice advisory for the perioperative management of patients with cardiac rhythm management devices:
pacemakers and implantable cardioverter-defibrillators: a report by the American Society of
Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Rhythm Management
Devices. American Society of Anesthesiologists Task Force on Perioperative Management of Patients
with Cardiac Rhythm Management Devices. Anesthesiology 2005;103(1):186-98.