This is the current release of the guideline.

A summary of the Practice Advisory is presented below.

Preoperative Evaluation

• Establish whether a patient has a cardiac rhythm management device (CRMD).
  • Conduct a focused history (patient interview, medical records review, review of available chest x-rays, electrocardiogram [ECG] or any available monitor or rhythm strip information).
  • Conduct a focused physical examination (check for scars, palpate for device).
• Define the type of CRMD.
  • Obtain manufacturer's ID card from patient or other source.
  • Order chest x-ray if no other data are available.
  • Refer to supplemental resources (e.g., manufacturer's databases).
• Determine dependency on pacing function of the CRMD.
  • History of symptomatic bradyarrhythmia resulting in CRMD implantation
  • History of successful atrioventricular (A-V) nodal ablation
  • Inadequate escape rhythm at lowest programmable pacing rate
• Determine CRMD function.
  • Interrogate device (consultation with a cardiologist or pacemaker-implantable cardioverter-defibrillator (ICD) service may be necessary).
  • Determine whether the device will capture when it paces (i.e., produce a mechanical systole with a pacemaker impulse).
  • Consider contacting the manufacturer for perioperative recommendations.

Preoperative Preparation

• Determine if electromagnetic interference (EMI) is likely to occur during the planned procedure.
• Determine whether reprogramming pacing function to asynchronous mode or disabling rate responsive function is advantageous.
• Suspend anti-tachyarrhythmia functions if present.
• Advise individual performing the procedure to consider use of a bipolar electrocautery system or ultrasonic (harmonic) scalpel.
• Temporary pacing and defibrillation equipment should be immediately available.
• Evaluate the possible effects of anesthetic techniques and of the procedure on CRMD function and patient CRMD interactions.

Intraoperative Management

• Monitor operation of the CRMD.
  • Conduct ECG monitoring per American Society for Anesthesiologists (ASA) standard.
  • Monitor peripheral pulse (e.g., manual pulse palpation, pulse oximeter plethysmogram, arterial line).
• Manage potential CRMD dysfunction due to EMI.
  • Electrocautery
    • Assure that the electrosurgical receiving plate is positioned so that the current pathway does not pass through or near the CRMD system. For some cases, the receiving plate might need to be placed on a site different from the thigh (e.g., the superior posterior aspect of the shoulder contralateral to the generator position for a head and neck case).
    • Advise individual performing the procedure to avoid proximity of the cautery's electrical field to the pulse generator or leads.
    • Advise individual performing the procedure to use short, intermittent, and irregular bursts at the lowest feasible energy levels.
    • Advise individual performing the procedure to reconsider the use of a bipolar electrocautery system or ultrasonic (harmonic) scalpel in place of a monopolar electrocautery system, if possible.
  • Radio-frequency (RF) ablation
    • Advise individual performing the procedure to avoid direct contact between the ablation catheter and the pulse generator and leads.
    • Advise individual performing the procedure to keep the RF's current path as far away from the pulse generator and lead system as possible.
  • Lithotripsy
    • Advise individual performing the procedure to avoid focusing the lithotripsy beam near the pulse generator.
    • If the lithotripsy system triggers on the R-wave, consider preoperative disabling of atrial pacing.
  • Magnetic resonance imaging (MRI)
    • MRI is generally contraindicated in patients with CRMDs.
    • If MRI must be performed, consult with the ordering physician, the patient's cardiologist, the diagnostic radiologist, and the CRMD manufacturer.
  • Radiation therapy
    • Radiation therapy can be safely performed in patients who have CRMDs.
    • Surgically relocate the CRMD if the device will be in the field of radiation.
  • Electroconvulsive therapy
    • Consult with the ordering physician, the patient's cardiologist, a CRMD service, or the CRMD manufacturer.
• Emergency defibrillation or cardioversion.
  • For the patient with an ICD and magnet-disabled therapies:
    • Advise individual performing the procedure to terminate all sources of EMI while magnet is removed.
    • Remove the magnet to re-enable antitachycardia therapies.
    • Observe the patient and the monitors for appropriate CRMD therapy.
    • If the above activities fail to restore ICD function, proceed with emergency external defibrillation or cardioversion.
  • For the patient with an ICD and programming-disabled therapies:
    • Advise individual performing the procedure to terminate all sources of EMI while magnet is removed.
    • Re-enable therapies through programming if the programmer is immediately available and ready to be used.
    • Observe the patient and the monitors for appropriate CRMD therapy.
    • If the above activities fail to restore ICD function, proceed with emergency external defibrillation or cardioversion.
  • For external defibrillation:
    • Position defibrillation/cardioversion pads or paddles as far as possible from the pulse generator.
    • Position defibrillation/cardioversion pads or paddles perpendicular to the major axis of the CRMD to the extent possible by placing them in an anterior-posterior location.
    • If it is technically impossible to place the pads or paddles in locations that help to protect the CRMD, then defibrillate/cardiovert the patient in the quickest possible way and be prepared to provide pacing through other routes.
    • Use a clinically appropriate energy output.

Postoperative Management

• Continuously monitor cardiac rate and rhythm and have back-up pacing and defibrillation equipment immediately available throughout the immediate postoperative period.
• Interrogate and restore CRMD function in the immediate postoperative period.
  • Interrogate CRMD; consultation with a cardiologist or pacemaker-ICD service may be necessary.
  • Restore all anti-tachyarrhythmic therapies in ICDs.
  • Assure that all other settings of the CRMD are appropriate.

None provided

The advisory statements contained in this document represent a consensus of the current spectrum of clinical opinion and literature-based findings.

Not applicable: The guideline was not adapted from another source.

2005 Jul

American Society of Anesthesiologists - Medical Specialty Society

American Society of Anesthesiologists

Task Force on Perioperative Management of Patients with Cardiac Rhythm Management Devices

Task Force Members: James R. Zaidan, MD, MBA (Chair), Atlanta, Georgia; John L. Atlee, MD, Milwaukee, Wisconsin; Peter Belott, MD, El Cajon, California; Kurt S. Briesacher, MD, Atlanta, Georgia; Richard T. Connis, Ph.D., Woodinville, Washington; John D. Gallagher, MD, Lebanon, New Hampshire; David Hayes, MD, Rochester, Minnesota; Jane E. Hershey, MD, Highland, Maryland; Neal Kay, MD, Birmingham, Alabama; David G. Nickinovich, PhD, Bellevue, Washington; Marc A. Rozner, PhD, MD, Houston, Texas; Mark F. Trankina, MD, Birmingham, Alabama

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on July 14, 2005. The information was verified by the guideline developer on July 20, 2005.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.