Guidelines for perioperative management of elective patients with PPM or ICD devices

The presence of a permanent pacemaker (PPM) may be associated with underlying heart disease, even more so with an implantable cardioverter defibrillator (ICD) or cardiac resynchronization (CRT) device. This confers an increased risk of surgery and anaesthesia, therefore the cardiovascular system should be carefully assessed at the pre-operative visit. In addition, the following information should be sought:

Is diathermy necessary for the procedure or can it be avoided?
What is the date of PPM/ICD/CRT implant and what was the indication for the device?
Note the follow up hospital and date of most recent check? These can be found on clinical portal.

General principles

Diathermy

The main concern regarding surgical procedures stems from the risk of electromagnetic interference from diathermy. This can be minimised by using bipolar diathermy wherever possible and using short, intermittent, irregular bursts at the lowest effective output. If unipolar diathermy must be used, the cutaneous return electrode should be as close to the operative site as possible and positioned such that the current pathway does not pass within 15 cm of the PPM/ICD system. If pacemaker inhibition occurs, inform surgeon immediately and diathermy should be used intermittently or stopped.

Magnets

In the past magnets were used in theatre to induce fixed rate pacing. In newer PPM’s magnet response is a variable and programmable function and therefore cannot be relied on to produce sustained asynchronous fixed rate pacing. In many cases this would not be desirable anyway (loss of atrial synchrony).

The pacing function of ICD’s is usually unaffected magnets. However, in the vast majority of ICD’s application of a magnet on the skin over the device will lead to suspension of all cardioversion and tachyarrhythmia therapies with return of all therapies as soon as it is removed. It may be necessary to utilise this function in emergency surgery. A magnet is available on the pacing defibrillator in bay 28 of recovery or from the Emergency department.

Perioperative monitoring

Resuscitation equipment should be available at all times. ECG monitoring should be continuous and alternative measure of pulse available e.g. pulse oximetry, intra-arterial pressure.

Contact Numbers

ECG Dept FVRH: ext 66973

Pathway

Pathway for adult patients listed for elective surgery attending the preoperative assessment clinic