Pace maker and ICD Flashcards
What is the first step in managing a preop pt with implanted cardiac rhythm devices
If available, review ECG/rhythm strip, CXR, CPAP ICD/pacemaker information form, interrogation report, and/or cardiology note. Use these to determine underlying heart rhythm, device type, magnet behavior, and other applicable information.
If the device has no defibrillator and no electromagnetic interference (EMI) anticipated with procedure, can procedure be proceeded?
Yes
- no defibrillator
2. EMI will NOT be of significant duration & EMI pathway NOT be near device or leads (<15cm)
Proceed with magnet available but usually better if not used. Consider verifying magnet response
- no defibrillator
- EMI will be of significant duration & EMI pathway be near device or leads (<15cm)
- but pt is NOT pacemaker dependant
Proceed with magnet available but usually better if not used. Consider verifying magnet response
- no defibrillator
- EMI will be of significant duration & EMI pathway be near device or leads (<15cm)
- pt is pacemaker dependant
- magnet use is feasible
Verify pacing response to magnet and consider impact of asynchronous pacing. Apply magnet prophylactically or if any evidence of problematic bradycardia.
- no defibrillator
- EMI will be of significant duration & EMI pathway be near device or leads (<15cm)
- pt is pacemaker dependant
- magnet use is NOT feasible
Contact EP RN to reprogram pacemaker
- The device has defibrillator
2. NOT anticipate EMI with procedure
Proceed with procedure. Consider having magnet and cutaneous defibrillation pads available. Remember, magnet will not affect pacing behavior
- The device has defibrillator
- Anticipate EMI with procedure
- EMI will unlikely be of significant duration & EMI pathway NOT be near device or leads (<15cm)
- magnet use is feasible
Apply magnet to disable defibrillator. Consider verifying magnet response (and if Guidant/Boston Scientific see page 4). 1 Monitor rhythm for pacemaker inhibition. Ensure external defibrillation equipment available and consider applying cutaneous defibrillation pads. If VT/VF occurs, remove magnet to enable ICD and prepare for backup external defibrillation.
- The device has defibrillator
- Anticipate EMI with procedure
- EMI will unlikely be of significant duration & EMI pathway NOT be near device or leads (
Contact EP RN to reprogram device to disable defibrillation therapy. Ensure external defibrillation equipment available. Apply cutaneous defibrillation pads, if possible.
- The device has defibrillator
- Anticipate EMI with procedure
- EMI will likely be of significant duration & EMI pathway NOT be near device or leads (
Consider magnet application if feasible2 and verify magnet response (and if Guidant/Boston Scientific see page 4). 1 Otherwise contact EP RN to reprogram and disable defibrillation therapy. Ensure external defibrillation equipment available.
Apply cutaneous defibrillation pads if possible, especially if defibrillation turned off.
- The device has defibrillator
- Anticipate EMI with procedure
- EMI will likely be of significant duration & EMI pathway NOT be near device or leads (
Contact EP RN to reprogram device to adjust pacemaker and disable defibrillator. Ensure external defibrillation equipment available and apply cutaneous defibrillation pads if possible.
General
Monitor for undesired rate responsive pacing functions or disable if indicated. After procedure, call for post-procedure device interrogation if indicated
How to verify magnet response?
- CPAP ICD/PPM form
- d/w company representative
- interrogation report
- magnet on–>EKG (12 lead), hemodynamic changes, symptoms, etc.
Does magnet affect pacing behavior if the device has a defibrillator?
NO, it only affect defibrillator function
Magnet use feasible means?
A magnet can be maintained securely in position over the device during the procedure and manipulated if needed.
How to determine pacemaker dependence?
- A &/or V pacing on ECG–>stop or lowering pacing rate–>intrinsic rhythm & conduction
- know reason for needing PM
- estimate perioperative stress
Asynchronous pacing modes
- by programming or by magnet
- VOO or DOO: unaffected by underlying cardiac activity
- AOO rarely used
- deterioration: asynchrony/A-V competition or R on T phenomenon
VOO
- detrimental to CO except in Af
2. may be tolerated by healthier pt for short case
rate-responsive features
- sensor–>automatically adjust rates
- generally time-limited
- not disabled by magnet
- consider disabling it prior surgery if acceleration of HR is detrimental
WHEN TO INTERROGATE POST-OPERATIVELY?
- programming change preoperatively
- external defibrillation used
- possible device damage or dysfunction
- clinically indicated
- if likely not resuming pre-magnet setting if magnet used
Electrocautery considerations?
- grouding pad –>EMI pathway far away from device
- short, non-sustained burst of monopolar electrocautery
- bipolar electrocautery
How to determine device manufacturer?
- CPAP form, implant report, Pt
- CXR: code letters
- manufacturer’s hotline: name, DOB
- Asynchronous pacing rate
Contact phone numbers
EP nurse (Mon-Fri): (314) 424-0487 EP Fellow (after hours): (314) 424-4680 Guidant/Boston Scientific (800) 227-3422 Medtronic (800) 878-5616 St. Jude (800) 722-3423
CRT-Ds
Cardiac Resynchronization Therapy Defibrillators (CRT-Ds).
Boston Scientific ICDs & CRT-Ds
- If programmed to respond to magnet–>can use magnet to inhibit tachy therapy
- small subset need to contact technical services
