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Guidelines for preoperative, intraoperative and postoperative care of the patient with a Permanent Pacemaker or Implanted Cardioverter Defibrillator

Preoperative

· For outpatients with devices who are being scheduled for surgery, contact the Michigan Heart Pacemaker/ICD Clinic (712-5200) 8am-5pm, with the patient name, date of birth, surgery date and time. We appreciate at least 24 hour notice. For inpatients, device evaluation may be requested through the PCIS system. A Pacemaker nurse will be scheduled to evaluate & program the device in the preoperative area. To contact the Pacemaker nurse the same day as surgery please page her at 670-1825. Pacemaker Nurse coverage is available Monday through Friday, 7:30am ­5:00pm. If the patient is followed by Michigan Heart we will have a record of the device implant information. If an elective surgery is scheduled to be done after 5 pm, please notify the pacemaker clinic and arrangements will be made to have a company representative here. If the patient is not followed by Michigan Heart, please ask the patient to bring their Pacemaker/ICD identification card with them, the day of surgery (or if in the hospital, be sure that the ID card is available at the time of the Pacemaker nurse's evaluation). ICD patients will have the tachycardia therapy (ATP and shocks) deactivated before surgery that may require cautery. This prevents the ICD from detecting the cautery electrical signal and thereby delivering an inappropriate shock. Pacemaker patients that are pacemaker dependent (underlying heart rate < 40 bpm), will be programmed to VOO or DOO at 80 bpm. This mode provides asynchronous pacing (no sensing), preventing pacing inhibition during cautery. The pacemaker nurse will document the settings of the pacemaker or ICD in the progress notes, along with the beeper number to page, when the patient is in recovery.

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Intraoperative

For emergent surgery, with no time to program the implanted device: Implanted Cardioverter Defibrillator

· · · · · · · Place a doughnut magnet directly over the device. All ICD devices have ATP (anti-tachy pacing) & Shock therapy SUSPENDED, with magnet application. Some ICD patients are also pacemaker dependent. Magnet application does not render the pacemaker function of the ICD asynchronous. Be aware that cautery can still inhibit pacing. Some ICD devices will emit an QRS-synchronous beeping tone with magnet application (Guidant). When the magnet is removed, the ICD is active and will provide therapy if a tachycardia is detected. Some Guidant ICD devices may be deactivated with magnet application, depending on how the device is programmed. Contact the Pacemaker Nurse (712-5200), or the EP physician on call (712-8000) to interrogate the ICD post-operatively, to be certain that the device is programmed appropriately.

Pacemaker

· · · · If there is a concern about possible pacemaker inhibition during cautery, place a doughnut magnet directly over the device. Doughnut magnet application on a pacemaker provides VOO or DOO asynchronous pacing, at the magnet pacing rate for that particular manufacturer. Removal of the magnet restores the original settings and pacemaker function. Some sample magnet rates are: 100 bpm (Guidant/CPI) 98 bpm (St. Jude) 90 bpm (Biotronik) 85 bpm (Medtronic) low rate limit (usually 50,60 or 70 bpm) (Pacesetter, Intermedics, Biotronik)

Postoperative

· · · Page the Pacemaker nurse when the patient is in recovery, to reprogram the ICD or pacemaker back to the preoperative settings. If no changes were made to the pacemaker settings pre-operatively (patient was noted to NOT be pacemaker dependent), there is no need to page the pacemaker nurse for postoperative reprogramming. If the patient will be entering the recovery unit after 5pm, contact the Pacemaker/ICD company representative for reprogramming. The telephone or pager number of the company representative, will be written in the progress note, by the pacemaker nurse that evaluated the patient pre-operatively.

Addendum

· · · · · · · · When using cautery near an implanted ICD or pacemaker, it is best to use bipolar cautery. If using unipolar cautery, position the grounding plate away from the device, preferably on a lower extremity. If pacing inhibition is noted, despite device programming or magnet application, provide short cautery bursts, to limit the length of time in asystole. If external defibrillation of the heart is required, place the shocking paddles away from the site of the implanted ICD or pacemaker. Direct shock on the device may permanently damage the circuitry. Device programming is not required for eye laser treatments, or cataract surgery. Device programming is not required for routine dental procedures, unless the dental surgery requires cautery. ICD deactivation is suggested for endoscopy procedures requiring cautery use. Device programming is not required for radiation oncology treatments. However weekly device evaluation is recommended to assess for possible cumulative radiation effect on device circuitry. Pacemaker patients may call in their magnet rate weekly to our tranmsitter service. ICD patients will be scheduled for weekly device interrogation. Device interrogation after every ECT (electroconvulsive therapy) is required to ascertain if the pacemaker has reset to a backup pacing mode.

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PM/ICD guidelines Michigan Heart, PC Revised 5/05/cc

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