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UTMB Department of Anesthesiology Perioperative Management of Pacemakers (PM) and Implantable Defibrillators (ICD)(Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) guidelines – included in protocols folder)8 magnets are located in the anesthesia workroom—please ask anesthesia tech for assistance.Preoperative:Inactivation of ICD detection and rendering PM asynchronous are NOT universal requirements.For emergency, obtain CXR (radiologist on call) and ECG --determine type of device (ICD, PM, CRT-ICD, CRT-PM)--determine PM-dependence; if pacemaker spikes in front of most or all P wave and/or QRS complexes, assume PM dependency).A magnet placed over an ICD generator will not change the pacer mode to asynchronous; only the ICD detection will be inactivated. A magnet placed over a PM generator will render the device asynchronous (usually).In pacemaker patients, no reprogramming is usually needed if the electrosurgery is applied below the level of the umbilicus (exception: if completely pacemaker-dependent, may need reprogramming to asynchronous mode if significant electrocautery is expected)For elective cases, should know the following: last interrogation, magnet rate, PM-dependence, type of device (PM, ICD), mode (example-DDD, VVI).Intraoperative:External defibrillation and transcutaneous pacing should be immediately available; place pads in high-risk patients only.Use short bursts of monopolar electrocautery (<5 sec, cut) if bipolar N/A.Have accurate plethysmographic and/or arterial monitoring, set ECG to “auto-pace” mode.Appropriate location of electrosurgical grounding (“Bovie pad” should allow current to be directed away from PM/ICD).Emergencies: Is patient pacemaker-dependent?Yes: pacemaker (not ICD) Limit electrosurgical bursts, place magnet for procedures above umbilicus, have magnet available for procedures below umbilicus (use only if inappropriate sensing or dropped beats), place prophylactic transcutaneous pads, evaluate pacemaker before leaving cardiac-monitored areaYes: ICD or CRT-ICD Place magnet to suspend tachyarrhythmia detection, limit electrosurgical bursts, place prophylactic transcutaneous pads, evaluate pacemaker before leaving cardiac-monitored areaNo: pacemaker (not ICD) Have magnet available, consider placement of transcutaneous pads prior to surgery, see ** belowNo: ICD or CRT-ICD Place magnet to suspend tachyarrhythmia detection, limit electrosurgical bursts, place prophylactic transcutaneous pads, evaluate pacemaker before leaving cardiac-monitored areaPostoperative: Indications for interrogation of device prior to PACU discharge or ICU transfer—Reprogrammed device prior to surgeryHemodynamically challenging surgery (cardiac, major vascular/aortic, thoracic)Intraoperative events such as CPR, temporary pacingEmergent surgery above the umbilicus, magnet use Continued hemodynamic instability**Consult EP to determine need for interrogation of device if magnet was used for urgent/emergent or elective casesNote: For large abdominal/above umbilicus cases, reprogramming may be needed in a patient with an ICD who is pacemaker-dependent. For special procedures (RF ablation, lithotripsy, cardioversion), notify EP.Important phone numbers: For emergency questions only:Medtronic-800-328-2518 Dr. Carayannopoulos (Cardiology): 409-772-1533St. Jude-800-722-3423 Shelia Saunders: 713-419-7424Boston Scientific (Guidant)-800-227-3422 Dr. A. McQuitty: 713-703-5240UTMB EP lab (730a – 5p): 772-0402 (Shelia Saunders) CRT = cardiac resynchronization therapy (ICD), biventricular pacing system ................
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