Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Disclosures: None Today`s Talk: About pacemakers and ICDs
Document related concepts
Transcript
Pacemakers and Cardioverter Defibrillators Pacemakers and Cardioverter Defibrillators William A. Shapiro, M.D. William A. Shapiro, M.D. Professor Friend Department of Anesthesia and Perioperative Care University of California, San Francisco Department of Anesthesiology Hospital CLINIC de Barcelona Barcelona, Spain http://anesthesia.ucsf.edu/shapiro http://anesthesia.ucsf.edu/shapiro UCSF advancing health worldwide TM ! University of California San Francisco UCSF advancing health worldwide TM ! University of California San Francisco Disclosures/Acknowledgements Disclosures: None Today’s Talk: About pacemakers and ICDs commonly seen in the USA UCSF University of California San Francisco Pacemakers and Cardioverter Defibrillators Terminology and Definitions • ECG = EKG= electrocardiogram • CIED = Cardiovascular Implantable Electronic Devices • ICD = Implantable Cardiac Device • ICD = Internal/Implantable Cardioverter Defibrillator Pacemakers and Cardioverter Defibrillators 69 yo male for total right colectomy due to cancer. • PMHx: – Recurrent colon cancer, s/p chemo – HTN – History of paroxysmal Afib – OSA – GERD – Syncope 2010 ! Cardiac workup ! Pacemaker 2010 • AICD = Automatic ICD (Implantable Cardioverter Defibrillator) • AED = Automated External Defibrillator • Pacer = Pacemaker • Magnet = Not a special magnet, just a strong one • EMI- Electro-Magnetic Interference I don’t trust those newfangled battery-operated pacemakers. UCSF advancing health worldwide TM ! University of California San Francisco advancing health worldwide TM ! • PSHx: – Gastric bypass for morbid obesity 2004 – Reversal of gastric bypass with Cholecystectomy 2012 – No prior problems with GA • Cautery = Electrical Interference used by the surgeon • Bovie = Monopolar, Bipolar UCSF advancing health worldwide TM ! University of California San Francisco Pacemakers and Cardioverter Defibrillators UCSF University of California San Francisco Pacemakers and Cardioverter Defibrillators 69 yo male for total right colectomy due to cancer. • Vital signs: 139/63, 73, 20, 98% on RA, T38.3 85Kg 6’0” • Meds: – Timolol eye drops – Atenolol – Oxycontin – Aciphex • Physical Exam: - Airway: MP 2, good mouth opening, and a normal TMD - Chest: Clear - Heart: RSR no mumurs • Review of Systems: • Additional Tests: advancing health worldwide TM ! Pacemakers and Cardioverter Defibrillators What you want to know about the patient What do you want to know about the pacemaker? - Echo from 2010: Essentially normal - CXR: WNL – Airway: Normal – Cardiac: Occasional dizziness with exercise. Poor exercise tolerance. – Lungs: Clear, no wheezes – Neuro: Normal - ECG: ????? • Labs: - H/H: 8.7/26.3 - Coags: WNL UCSF University of California San Francisco advancing health worldwide TM ! UCSF University of California San Francisco advancing health worldwide TM ! UCSF University of California San Francisco advancing health worldwide TM ! Pacemakers and Cardioverter Defibrillators Pacemakers and Cardioverter Defibrillators What you want to know about the patient Pacemakers and Cardioverter Defibrillators What you want to know about the pacemaker The Pacemaker Card • Why did the patient get the pacemaker! symptoms • Is the device a pacemaker or a pacemaker + ICD? • Physician’s name • Did the symptoms resolve after the pacemaker • Is the patient pacemaker dependent? ! ECG • Device and cable serial numbers • Does the patient have his/her pacemaker card • How will the device respond to a magnet? • What other cardiac diseases does the patient have • What are the device settings before surgery? • What cardiac medications does he/she take • Are the device settings the same after surgery! before the patient leaves the hospital/PACU? UCSF University of California San Francisco advancing health worldwide TM ! UCSF University of California San Francisco Pacemakers and Cardioverter Defibrillators Pacemaker Cards advancing health worldwide TM ! • Manufacturer technical support telephone number The pacemaker card does NOT contain any information about the current programmed mode, what the magnet will do, why the pacemaker was inserted, the remaining battery life, or when the pacemaker was last checked UCSF advancing health worldwide TM ! University of California San Francisco Pacemakers and Cardioverter Defibrillators What ‘s the best way to learn about the pacemaker The EKG/ECG • Is the patient 100% paced • Atrial pacing, ventricular pacing, or both • Can you tell by the ECG if the device is also an ICD Pacemaker Codes I II III Chamber Chamber Paced Sensed Response to V--ventricle V--ventricle O--none A--atrium A--atrium I--inhibits pacing D--dual (A + V) D--dual (A + V) D--dual (A + V) O--none O--none Sensing IV V Programmable Antitachycardia Functions Function(s) P– programmable P--pacing rate and/or output S--shock M--multiprogrammable D--dual (P + S) C--communicating O—none R--rate adaptive O--none Fixed rate = Asynchronous = O Inhibited = Synchronous = I or D Bernstein, PACE, 1987! UCSF University of California San Francisco advancing health worldwide TM ! UCSF University of California San Francisco Rate Adaptive Pacing • Improves hemodynamics motion, pH, or PaCO2 sensors) • Decreases atrial fibrillation advancing health worldwide TM ! Rate Adaptive Pacing • Decreases thromboembolic events • Dual chamber sensing advancing health worldwide TM ! University of California San Francisco Advantages! chambers paced can and will vary to accommodate physiologic needs (using • Dual chamber pacing University of California San Francisco UCSF Rate Adaptive Pacing • Rate adaptive: the paced rate and the UCSF advancing health worldwide TM ! • Reduces pacemaker syndrome! UCSF University of California San Francisco advancing health worldwide TM ! UCSF University of California San Francisco advancing health worldwide TM ! Pacemakers and Cardioverter Defibrillators Pacemaker Companies • Medtronic: http://www.medtronic.com What you want to know about the pacemaker • St. Jude Medical: http://www.sjm.com • Is the device a pacemaker or a pacemaker + ICD? • Boston Scientific: http://www.bostonscientic.com! • Is the patient pacemaker dependent? ! ECG • Sorin Group: http://www.sorin.com • How will the device respond to a magnet? • Biotronik: http://www.biotronik.com • What are the device settings before surgery? • Are the device settings the same after surgery! before the patient leaves the hospital/PACU? • FDA- http://www.fda.gov/ • AHA- http://www.americanheart.org UCSF advancing health worldwide TM ! University of California San Francisco Our Patient’s ECG UCSF University of California San Francisco advancing health worldwide TM ! UCSF University of California San Francisco How does the magnet work? What will a magnet do to this pacemaker? advancing health worldwide TM ! How does the magnet work? Jacob S, et al.; Clinical applications of magnets on cardiac rhythm management devices. Europace (2011); 13, 1222. UCSF University of California San Francisco I don’t trust those newfangled battery-operated pacemakers. advancing health worldwide TM ! Most often reprograms (temporarily) the pacemaker into a fixed-rate mode UCSF University of California San Francisco How does the magnet work? advancing health worldwide TM ! Most often reprograms (temporarily) the pacemaker into a fixed-rate mode UCSF University of California San Francisco advancing health worldwide TM ! Pacemakers and Cardioverter Defibrillators Can the magnet cause R-on-T? The operating room • Electric-rich environment: monitors, cell phones No magnet mode • Surgical-cautery: unipolar versus bipolar • Where to put the electrical grounding pad • Defibrillation and cardioversion No magnet mode • Serum electrolyte abnormalities • Patient seizure, shivering, muscle fasciculations Magnet mode UCSF University of California San Francisco advancing health worldwide TM ! • Anesthesia in remote location! MRI scanner!!! For those interested in the history of R-on-T! Smirk FH. R waves interrupting T waves. Br Heart J. Jan 1949 UCSF University of California San Francisco advancing health worldwide TM ! UCSF University of California San Francisco advancing health worldwide TM ! Pacemakers and Cardioverter Defibrillators Cautery Induced Pacemaker Inhibition Cautery Induced Pacemaker Inhibition The grounding pad Cautery interference • Far away from the pacemaker or the ICD • Such that a line from the site of surgery to the grounding pad does not cross the device Magnet applied • The pad location will not guarantee no interference • Always expect interference during surgery Cautery interference UCSF University of California San Francisco advancing health worldwide TM ! Cautery Induced Pacemaker Inhibition UCSF advancing health worldwide TM ! University of California San Francisco UCSF University of California San Francisco Pacemakers and Cardioverter Defibrillators Cautery Induced Pacemaker Inhibition Our patient? Our patient? What should we do now with our patient who is NOT pacemaker dependent? Our next patient 69 yo male for left neck surgery for cancer. What should we do now with our patient who is NOT pacemaker dependent? • PMHx: – Recurrent parotid cancer, s/p chemo – HTN, OSA – GERD – Syncope 2010 ! Cardiac workup ! ICD-2010 • PSHx: – Parotid surgery- 2004 – No prior problems with GA • Nothing and have the magnet available? • Reprogram the pacemaker to fixed-rate? • Turn the pacemaker off? UCSF University of California San Francisco advancing health worldwide TM ! UCSF advancing health worldwide TM ! University of California San Francisco Anesthetic Implications • Cautery will make an ICD discharge (shock) 69 yo male for left neck surgery for cancer. • Must deactivate the ICD for surgery ! How? • Meds: – Atenolol – Oxycontin • Review of Systems: – Airway: Difficulty swallowing, difficulty with extension and flexion. – Cardiac: Occasional dizziness with exercise. Poor exercise tolerance. – Resp: Home 02 2L NC for sleep apnea. Smoked cigs for many years. – GI: Dysphagia, Feeds through a PEG tube. • AED or Defibrillator must be near by • Most ICDs now have anti-bradycardia pacing post-shock University of California San Francisco advancing health worldwide TM ! University of California San Francisco advancing health worldwide TM ! Our Patient’s ECG Our patient • A magnet will deactivate the ICD function, but it will NOT change the pacing parameters UCSF UCSF Pacemakers and Cardioverter Defibrillators Implantable Cardioverter Defibrillators (ICDs) advancing health worldwide TM ! • ECG:! ! UCSF University of California San Francisco advancing health worldwide TM ! UCSF University of California San Francisco advancing health worldwide TM ! A Different Patient’s ECG Cautery Induced Pacemaker Inhibition Cautery Induced Pacemaker Inhibition Our patient Our patient What should we do now with our patient who has an ICD and IS pacemaker dependent? What should we do now with our patient who has an ICD and IS pacemaker dependent? -- CAREFUL-- • Deactivate the ICD and have the magnet available? • Deactivate the ICD and reprogram the pacemaker to fixed-rate? • Turn off both the ICD and the pacemaker? UCSF University of California San Francisco advancing health worldwide TM ! UCSF University of California San Francisco Pacemakers and Cardioverter Defibrillators Pacemaker Emergencies • Failure to pace ! No pacing spike - battery failure - lead fracture (surgeon cut the pacemaker cable?) - pacemaker lead becomes disconnected from the generator UCSF advancing health worldwide TM ! University of California San Francisco Pacemakers and Cardioverter Defibrillators Cautery Induced Pacemaker Failure Conclusions Lead MCL5 • Do NOT be afraid of the Magnet • For pacemakers: test the magnet before surgery starts, in a monitored setting, to confirm what it will do • Failure to capture ! Pacing spikes but no QRS complex - low output ! need to increase the output (mA or volts) - electrolyte abnormality (hyperkalemia) - major organ failure! pneumothorax, hemothorax, pericardial effusion, air embolism, etc. advancing health worldwide TM ! • Deactivate the ICD for the OR. And when you do, have a defibrillator immediately available Lead MCL5 • Cautery can reprogram any pacemaker or ICD, whether or not a magnet is over the device, when cautery is used • Unexpected (new) pacemaker behavior ! call cardiologist 25mm/sec • Confirm proper pacemaker or ICD function after surgery - Eg. pacemaker tachycardia, does not inhibit when it should, etc. Shapiro WA. Anesthesiology. 1985 UCSF University of California San Francisco advancing health worldwide TM ! UCSF University of California San Francisco Pacemakers and Cardioverter Defibrillators Urban Legends • Magnets will cause R-on-T arrhythmias advancing health worldwide TM ! Pacemakers and Cardioverter Defibrillators References More Information • The Heart Rhythm Society (HRS)/ASA Expert Consensus Statement on the Perioperative Management of Patients with Implantable Defibrillators, Pacemakers and Arrhythmia Monitors. Heart Rhythm. 2011 Jul;8(7):1114-54 • Proper placement of the grounding pad will avoid device interference with surgical cautery • Applications Of Magnets On Cardiac Rhythm Management Devices: Clinical Applications Of Magnets. Jacob S. Europace. 2011 Sep;13(9):1222-30 • Everything you read on the Internet regarding anesthesia, surgery, pacemakers, and ICDs is true • Shapiro WA, Witherell CL. Contemporary Developments in the Pacemaker World. ICU Director, May 2011 advancing health worldwide TM ! University of California San Francisco Pacemakers and Cardioverter Defibrillators • Magnets are contra-indicated in the OR University of California San Francisco UCSF • 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Europace (2013) 15, 1070–1118 • Magnets increase unintended device reprogramming UCSF advancing health worldwide TM ! UCSF University of California San Francisco advancing health worldwide TM ! • [email protected] • [email protected] • http://anesthesia.ucsf.edu/shapiro UCSF University of California San Francisco advancing health worldwide TM !
