Post on 26-Jul-2020
transcript
Cautery (ELECTRO MAGNETIC INTERFERENCE) & cardiac devices in endoscopy
background
• Increasing aging population
• Advancements in technology
• Implantable cardioverter/defibrillators primary therapeutic modality forpatients at risk for sudden cardiac death
• Endoscopy nurses now have patients with multiple comorbiditiesundergoing procedures
Identification of patients
• Cardiac implantable electronic devices (CIED) include pacemakersand cardioverter/defibrillator devices (ICD)
• Any patient with CIED is identified prior to undergoing endoscopyprocedures
• Special precautions need to be taken
• Multiple co-morbidities?
Important considerations
• Medical reason for the device
• Type of device
• Date when last interrogated
• ICDs: has the device fired before?
• Anti-coagulants?
Types of Electrocautery
• Monopolar cautery (the ground is the patient)
• Bipolar cautery (the ground is within the instrument)
• Argon plasma coagulator (APC) (gas/laser)
Electrocautery
• Electrocautery used during endoscopic procedures can cause CIEDsto inappropriately sense because of electromagnetic interference(EMI)
• Devices can:
• Inappropriately fire
• Inappropriately be inhibited
• Inappropriately trigger cardioversion or defibrillation
Pacemakers
• Several different types:
• 100% paced all of the time OR
• Demand- only needed in certain circumstances (i.e. drop in heart rate)
• Type of pacemaker patient receives depends on indication forpacemaker
• Patients with pacemakers should have wallet card identifying type ofpacemaker they have
100% paced
Demand pacemaker-atrial fibrillation
Implanted Cardiac Defibrillators
• Three functions:
• Pacemaker
• Overdrive pacing
• Defibrillation
• Treated differently than pacemakers
Overdrive pacing
Defibrillatorfunction
• Little research available to guide practice, most evidence anecdotal
• Few guidelines and most associated with the OR
• Guertin D, Osman F, et al (2007) Electromagnetic interference andImplanted and Implanted Cardiac Devices
• Looked at 41 patients with ICDs
• 40 patients were (L) pectoral placements, 1 (L) abdominal
• Devices programmed to detection but tachyarrhythmia therapies off
• 41 patients – 52 endoscopies, 5 upper, 28 lower, 8 both, 2 repeat
• 18 required therapeutic intervention, of these 10 underwent unipolarelectrocautery
• Post procedure ICD interrogation did not document tachyarrhythmiadetection or pacemaker inhibition
• Limits to the study – no oesophageal intervention and small cohort
Our practice
• Policy was developed with the head of our Electrophysiology Lab
• Ideally patients are pre-identified
• Pre-admission assessment also includes a section for this
• Anti-coagulants?
Electrocautery & Pacemakers
• Do not need cardiac monitoring - monitor heart rate with SaO2 probe
• Should have magnet in room but does not have to be on patient
• If cautery is used, the pacemaker may sense the cautery as aheartbeat and not pace when it should
• Could result in bradycardia
• If heart rate slows, place magnet over pacemaker- this puts thepacemaker briefly in asynchronous mode
• When magnet is removed pacemaker resumes normal function
Electrocautery & ICDs
• More complicated
• Patient must be on cardiac monitor for the duration of procedure
• May require two nurses in procedure room
• Magnet is placed over the device site during cautery only
• Must be coordinated with physician
• Magnet should not be held over the device for longer than 30 seconds
• Assign an RN with prior cardiac nursing experience
• Bipolar cautery is best but if monopolar is used, place groundingpad opposite to ICD site, preferably the thigh
• Magnet is held over the device for the length of the cautery time-remind the physician less than 30 seconds
• When magnet is not needed, it should be at least 2 ft. away from thedevice
• Newer devices will beep if magnet is held too long- the patient willhave to go to cardiac lab to have device interrogated
Where do we go from here?
• More research needed as there are more types of therapy out there
• Spinal or neuro transmitters
• Cochlear devices
• Phrenic nerve stimulators
References• American Society for Gastrointestinal Endoscopy (2007). Endoscopy in patients with
implanted electronic devices. Gastrointestinal Endoscopy, 65(4), 561-570.
• Capital District Health Authority (2014). Cardiac Implantable Electronic Device(CIED)- Endoscopic Procedures Policy. Retrieved fromhttp://policy.nshealth.ca/Site_Published/DHA9/document_render.aspx?documentRender.IdType=6&documentRender.GenericField=&documentRender.Id=49926
• Guertin, D., Faheen, O., Ling, T., et al (2007). Electromagnetic interference (EMI)and arrhythmic events in ICD patients undergoing gastrointestinal procedure. Pacing
and Clinical Electrophysiology, 30(6), 734-739.
• Jacob, S., Panaich, S., Maheshwari, R., et al (2011). Clinical applications ofmagnets on cardiac rhythm management devices. Europace, 13(9), 1222-1230.
• Tsai, A. (2017). Perioperative management of permanent pacemakers (PPMs) andautomatic implantable cardioverter-defibrillators (AICDs). Retrieved fromemedicine.Medscape.com/article/2500090
Questions