IED
Last modified: 08 September 2022, 6:50:48 AM AEST
Gems1 / 11
- avoid diathermy across pacemaker system
- minimise EMI
- bipolar / harmonic scalpel > monopolar
- duration = short 5 seconds
- cut > coag / blend
- irregular > regular bursts
- lowest energy
- 3 key questions
- 1: EMI associated with procedure?
- 2: patient pacemaker-dependent?
- 3: distance from EMI to IED < 15 cm?
- Pragmatically
- If surgery > 15 cm, have magnet ready, and proceed
- If EMI causing problems, then pause surgery, and place magnet
Magnet2 / 11
- call company to advise effect of magnet
- PPM = magnets make them work harder = more pacing
- ICD = magnets make them work less hard = no defibrillation
Details3 / 11
- Indication
- Date of insertion
- Type, eg. single chamber
- Mode of pacing
- Company
- Serial Number
- Last checked
- Effect of magnet
- CXR + ECG
Reprogramming4 / 11
- change pacing mode for the case
- eg. critical AS, severe diastolic failure
- Turn off rate modulation
- This can be triggered by MV sensing = mechanical ventilation may trigger
- helpful in patient with CRT
Risks = Intraoperative5 / 11
- General = damage to device
- PPM = inadequate pacing = asystole
- AICD = inappropriate defib
Risks = Insertion6 / 11
- B = respiratory
- Pneumothorax
- C = cardiovascular
- arterial puncture
- arrhythmia
- VAE
- cardiac perforation / tamponade
CXR7 / 11
- AICD
- thicker distal region on RV lead (coils)
- has coils
EMI = Electromagnetic inference8 / 11
- inhibition of pacing (for PPM)
- EMI sensed as cardiac electrical activity and no pacemaker delivered
- result = reduced cardiac output / asystole for pacemaker-dependent patients
- inappropriate shocking
- due to sensing EMI as tachyarrhythmia
- direct damage to device
- accidental damage to lead / device
- management
- diathermy as far away as possible
- bipolar diathermy > monopolar
- short bursts > long
- at least 12 cm away from defib pads / lithotripsy
- grounding pad as distal as possible from device
Intraoperative failure9 / 11
- Device
- generator failure = battery, malfunction
- lead failure = dislodgement, fracture
- sensor failure = failure to capture
- Patient
- acid-base abnormality
- EUC abnormality
- ischaemia / infarction
- anti-arrhythmics = overdose / withdrawal
Scenarios10 / 11
- Radiofrequency ablation procedures
- AICD = disable
- PPM = asynchronous
- MRI
- generation of heat
- magnetic fields may induce current in leads
- now some MRI safe
- Extracorporeal shock wave lithotripsy
- AICD = disable
- shock wave can displace semiconductor components and lead connections
- ECT
- AICD = disable
- interrogate postop to ensure function
- PPM = interrogate post procedure
IED insertion anaesthesia options
- LA +/- sedation
- RA = Pec block
- GA
References11 / 11
https://www.anesthesiaconsiderations.com/pacemakers-and-icds