Perioperative Pacemaker Management

Posted by Clark Venable on 12/3/2004

There's an editorial in A&A titled Pacemaker Misinformation in the Perioperative Period: Programming Around the Problem by Marc Rozner. The editorial makes an important point: slapping a magnet on a pacemaker is NOT universally indicated because not ALL pacemakers will switch to continuous asynchronous mode.

In the editorial, Rozner points to the American College of Cardiology perioperative guidelines (pdf) on perioperative cardiac management. The guideline contains a section on pacemakers and AICD's. These guidelines nicely summarize why we worry about using elecrocautery in patients with implanted pacemakers or AICD's:

""The electrical current generated by electrocautery can cause a variety of responses by the implanted device, including the following: (1) temporary or permanent resetting to a backup, reset, or noise-reversion pacing mode (i.e., a dual-chamber pacemaker may be reset to VVI pacing at a fixed rate); (2) temporary or permanent inhibition of pacemaker output; (3) an increase in pacing rate due to activation of the rate-responsive sensor; (4) ICD firing due to activation by electrical noise; or (5) myocardial injury at the lead tip that may cause failure to sense and/or capture. ""

And their recommendations are as follows:

""However, under optimal circumstances, several general recommendations can be made. Patients with implanted ICDs or pacemakers should have their device evaluated before and after surgical procedures. This evaluation should include determination of the patient’s underlying rhythm and interrogation of the device to determine its programmed settings and battery status. If the pacemaker is programmed in a rate-responsive mode, this feature should be inactivated during surgery. If a patient is pacemaker dependent, pacing thresholds should be determined if the patient has not been evaluated recently in a pacemaker clinic. ICD devices should be programmed off immediately before surgery and then onagain postoperatively to prevent unwanted discharge due to spurious signals that the device might interpret as ventricular tachycardia or fibrillation. If QRS complexes cannot be seen during electrocautery, other methods of determining heart rate should be monitored to be certain device inhibition is not present.""

Kudos to the American College of Cardiology for making these guidelines available free of charge. The more I think about this the more sense it makes to require a pacemaker check within, say, six months of elective surgery and call the supporting company for specifics about any given pacemaker

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