eJOURNAL CRNA TODAY TM

CONTINUING EDUCATION

March 2017

Care of Patients With Cardiovascular Implantable Electronic Devices Paige Dempsey, RN, BSN, SRNA • Paul Bennetts, CRNA, PhD • Lauryn Rametta, CRNA, DrAP

The Nation’s largest Anesthesia staffing agency! Specializing in Locum Tenesn and Permanent Placement of CRNAs and Anesthesiologiest across the country.

9 offices Nationwide CO 800.845.0992 GA 800.235.8986 GA 877.736.9439 FL 800.338.1699 MA 800.509.6427 IA 800.406.1775

Continuing Education eJournal Target Audience- Continuing Education (CE) courses are “Provider-Directed Independent Study” as defined by the AANA, “self-paced learning activity developed for individual use”. These CE’s are intended for Nurse Anesthetist’s practicing anesthesia looking to expand their knowledge. Courses are presented as a group of articles in an e-Journal which can be accessed from any web-based browser. Program- Articles are presented as individual CE material with accompanying Post Test. Course Objectives are provided at the beginning of each article with bibliography and references or links to -specific videos, websites, and/ or additional material. To get FULL CE credit for this program you’ll need to first read each article and pass each Post Test. A passing grade of at least 80% is required to get CE. You’ll have up to three testing opportunities to pass. The Post Test can be completed any time prior to expiration of the course. Attendance records are sent to the AANA at the end of each month, provided you have supplied the correct AANA ID. It is your responsibility to complete all courses in a timely fashion and before the expiration date. Educated Hand and the CRNA Today website are not responsible or liable for the untimely completion of the courses/credits. Each article is the work of the individual presenter, therefore they are experts in the topic and responsible for the content. CRNA Today reviews each article along with outside Editors and Copy Editors, doing our best to assure accurate and current knowledge Publisher

Nicholas G. Crofut CRNA

Editor-in-Chief

Thomas Schultz, PhD, CRNA

Authors

Paige Dempsey, RN, BSN, SRNA



Paul Bennetts, CRNA, PhD



Lauryn Rametta, CRNA, DrAP

Journal Designer

Sheri Harvey, Shar Graphics

Published by Educated Hand Pub, LLC 806 Greenwich Grand Ledge, MI 48837

 eJOURNAL CRNA TODAY TM

CONTINUING EDUCATION

March 2017

March 2017 Vol. 2 Issue 3

Care of Patients With Cardiovascular Implantable Electronic Devices Paige Dempsey, RN, BSN, SRNA • Paul Bennetts, CRNA, PhD • Lauryn Rametta, CRNA, DrAP

www.nwanesthesia.com “There is NO Financial Relationship between the products, devices, or services advertised with the author and CE activity. 2

DISCLAIMER The opinions expressed in this educational activity are those of the author and do not necessarily represent the views of The Educated Hand Publishing. This educational activity does not endorse one particular type of technique, nor is it intended to dictate an exclusive course of practice. It presents one of numerous recognized methods of clinical practice for consideration by CRNAs for incorporation into their practices. Variations of practice taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate. Disclosure about patient confidentiality, standards of care, or course of management does not imply endorsement or disapproval of products. For full Terms and Conditions of Use click here – www.crnatoday.com CRNA Today

Care of Patients With Cardiovascular Implantable Electronic Devices Paige Dempsey, RN, BSN, SRNA Paul Bennetts, CRNA, PhD Lauryn Rametta, CRNA, DrAP Disclosure/Conflict of Interest Statement: None

Learning Objectives Participants will be able to.. 1.Provide a basic description of the function of modern pacemakers and internal cardioverter defibrillators (ICDs). 2. Define basic pacemaker and ICD codes as developed by the North American Pacing and Electrophysiology/British Pacing and Electrophysiology Group (NASPE/BPEG). 3. Identify the common causes of electromagnetic interference (EMI) in the operating room and describe the potential effects of EMI on cardiac implantable electronic devices (CIEDs). 4. Understand the implications of electrolyte disturbances on CIED function. 5. Provide a step-wise description of appropriate anesthesia care for patients with CIEDs through the perioperative period. Introduction Cardiac arrhythmias affect 14.4 million patients in the United States and account for 40,700 deaths annually.1 Pacemakers and implantable cardioverter defibrillators (ICDs) are continuously changing to address a wider range of indications based on patient needs and the evolution of disease treatment. Each year, more than 1.5 million new devices are implanted globally.2 In addition to the increasing number of devices, the increasing complexity of cardiac implantable electronic devices (CIEDs) has made caring for these patients in the perioperative period more challenging. It is imperative that the anesthetist be aware of CIED function and potential problems that may be encountered.3 This article will provide a systematic way of assessing and approaching a patient with a CIED in order to provide the best evidence-based care for these patients throughout the perioperative period. History In the early 1930s, the first pacemaker-like device was developed by New York cardiologist Dr. Albert S. March 2017

Hyman and his brother. It was operated by a manual crank generator that sent electrical currents down a long needle located in the right atrium of the heart, which rhythmically pulsated until the heart restarted. In the mid 1950s, Dr. C. Walton Lillehei devised a system for temporary cardiac pacing with the use of epimyocardial wires. Engineer Earl E. Bakken developed the first portable transistorized batterypowered external pacemaker in 1957. This basic design is still used in pacemakers today.4 On October 8, 1958, the first fully implantable pacemaker was inserted in a patient with complete AV block in Stockholm, Sweden. The device contained a nickel cadium battery that required frequent recharging and only lasted 3 hours after implantation.4 The patient had 24 subsequent implants and lived to the age of 86.5 Although the implanted pacemaker was technically a success, clinical adoption was hindered by the limited battery life and durability of the device. In 1960, electrical engineer Wilson Greatbatch developed a device powered by mercury zinc batteries that lasted for several years. Dr. William Chardack first implanted the pacemaker in the United States on June 6, 1960 and extended the patient’s life by 18 months.4 Following the success of implantable pacemakers, the first ICD was implanted in 1980.6 Overview of Devices Pacemakers Pacemakers have continued to evolve with new batteries, leads, and programmability options that offer treatment for a wider range of cardiac conditions. Permanent pacemakers are indicated for sinus node disease, AV node disease, long Q-T syndrome, hypertrophic cardiomyopathy, and dilated cardiomyopathy.6 Pacemakers consist of a pulse generator which contains a computer and batterypowered energy source and leads that sense the electrical activity in the heart and respond by sending or inhibiting an electrical current to the heart.7 3

Understanding pacemaker codes is the first step to identifying the underlying pathology and the patient’s dependence on the device. A review of the basic pacemaker codes developed by the North American Pacing and Electrophysiology/British Pacing and Electrophysiology Group (NASPE/BPEG) can be found Table 1: NASPE / BPEG Generic Pacemaker Code (NBG) [Revised 2002] Position I

Position II

Position III

Position IV

Position V

Chambers Paced

Chambers Sensed

Response to Sensing

Programmability

Multisite Pacing

O = None O = None

O = None

O = None

O = None

A= Atrium

A = Atrium

I = Inhibited

R = Rate Modulation

A = Atrium

V = Ventricle

V = Ventricle T = Triggered

V = Ventricle

D = Dual (A+V)

D = Dual (A+V)

D = Dual (A+V)

D = Dual (T+I)

in Table 1.6 Implantable Cardioverter Defibrillators Implantable cardioverter defibrillators were first approved by the United States Food and Drug Administration (FDA) in 1985. Some common indications for ICDs include ventricular tachycardia (VT), ventricular fibrillation (VF), post myocardial infarction (MI) patients with an ejection fraction (EF) ≤ 30%, cardiomyopathy from any cause with an EF ≤ 35%, and hypertrophic cardiomyopathy. Internal cardioverter defibrillators measure each R-R interval and classify them as normal, too short or too long. When a programmed number of short R-R intervals are recognized, an antitachycardia event is activated. Depending on the type of ICD and programming, either antitachycardia pacing (ATP) will ensue or the patient will receive a shock. Antitachycardia pacing – when the CIED paces the heart faster than the arrhythmic event in order to break the re-entry cycle of the arrhythmia – can delay a shock for more than one minute. Many ICDs will start a course of ATP while charging the defibrillator; and prior to shocking, the device will reconfirm VT or VF in order to prevent inappropriate shocks. Antitachycardia pacing is better tolerated by the patient and uses less energy than a shock. ICDs will often deliver as many as 6-8 shocks per episode. Once the patient has been defibrillated, ATP is discontinued. Despite improvements in devices over the years, more than 10% of shocks are delivered 4

erroneously for rhythms other than VT or VF. The most frequent rhythm that is shocked inappropriately is supraventricular tachycardia (SVT).6 Like pacemakers, the NASPE/BPEG defibrillator (NBD) coding system is used to denote ICD function and can be found in Table 2.6 Table 2: NASPE / BPG Defibrillator (NBD) Code Position I

Position II

Position III

Position IV (or use Pacemaker Code)

Shock Chambers

Antitachycardia Tachycardia Pacing Chambers Detection

Antibradycardia Pacing Chambers

O = None

O = None

E = Electrogram

O = None

A = Atrium

A = Atrium

H = Hemodynamic A = Atrium

V = Ventricle V = Ventricle

V = Ventricle

D = Dual (A+V)

D = Dual (A+V)

D = Dual (A+V)

Preoperative Crucial data the anesthetist needs to know to care for patients with a CIED include: the indication for CIED implantation; the CIED model, programming, and battery longevity; and device functionality. Battery longevity should be ≥ 3 months to avoid increased sensitivity of the generator to electromagnetic interference (EMI).8 Along with the routine preoperative evaluation, the anesthetist should identify the make and model of the patient’s CIED. Many patients carry a wallet-size card with this information. If the patient does not know this information it can be located on the generator via a chest radiograph. The manufacturers of each device can be contacted via telephone (Table 3)1 and should be able to provide information regarding the patient’s CIED.8,9 A complete list of information the anesthetist must know can be found in Table 4.6 The anesthetist may wish to consult a device specialist such as the cardiologist caring for the patient or a representative from the CIED manufacturer in order to choose the best course of action for the patient during surgery. See Table 5 for additional information the anesthetist should share with the CIED team.6 The device prescription should include recommendations for reprogramming, inactivation of tachyarrhythmia detection (in ICDs), and potential inactivation of minute ventilation rate sensors.8 Table 3: Manufacturer Contact Information Medtronic

800-633-8766

Boston Scientific

800-227-3422

St. Jude

800-722-3774

Biotronik

800-547-0394



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Table 4: Information Provided by the CIED Service to Perioperative Team Device type, manufacturer, model Date of last interrogation; remaining battery longevity Current settings Pacing dependence Magnet behavior Individualized prescription and follow-up plans Unusual circumstances such as alert status Table 5: Information Provided to CIED Service by Perioperative Team Type of procedure Anatomic location of procedure Patient positioning for procedure Need and site for monopolar electrosurgery or other EMI Planned cardioversion or defibrillation Postprocedural plan (hospital admission, outpatient) Unusual circumstances (surgery encroaching leads or generator)

Magnet Use Clinical magnets can be used temporarily to switch pacemakers into an asynchronous mode or to inhibit anti-tachycardia therapy in ICDs. It is not required to place a magnet over all CIEDs during surgery, though a magnet must be immediately available for all patients with a CIED even if the device has been reprogrammed prior to surgery. A magnet can be easily and quickly removed, but can be difficult to use when a patient is prone or in patients with a large body habitus. By reprogramming the device, the anesthetist does not have to worry about keeping the magnet in the proper location throughout the entire procedure but changes made to programming are not readily reversible and the risk of human error may result in failure to re-enable proper therapies after the surgery is complete. It is crucial that patients be continuously monitored after reprogramming or the application of a magnet due to the increased risk for life-threatening arrhythmias.8 Device response to magnet varies widely by manufacturer and individual patient. Some manufactured devices will emit a beeping tone when the magnet is applied in the correct location; others have no audible tones at all. Each device may have different heart rate settings for magnet mode. Certain manufacturers have programmable modes that allow patients to place the magnet over their device to store an ECG tracing without interrupting the pacing function. Boston Scientific, St. Jude, and Biotronik can March 2017

program a CIED to ignore the magnet so that nothing changes with the current pacemaker settings when a magnet is applied. Battery life of the CIED generator may also affect how the device responds to a magnet.8 In pacemakers, a magnet may be used to prevent pacing inhibition from external EMI or for temporary asynchronous pacing in the presence of pacemakermediated tachycardia. While most pacemakers respond to magnets by reverting to asynchronous mode, it is important to contact a CIED representative prior to surgery to determine what each patient’s response will be, as each device may be programmed differently.3 In ICDs, a magnet will not typically affect pacing but will disable anti-tachycardia therapies. EMI during the perioperative period may be recognized as VT or VF causing the device to deliver inappropriate shocks. When EMI is anticipated, it is preferable to reprogram the device to disable shocking. If re-programming is unavailable, a magnet may be applied to inhibit anti-tachycardia therapies in most ICDs. Magnets may also be applied to ICDs in emergent situations to terminate inappropriate shocks related to a fractured lead, myopotential oversensing, or SVT.3,10 Intraoperative Monitoring should be appropriate for the patient’s underlying comorbidities and the surgical procedure. The patient’s rhythm should be monitored at all times whether general anesthesia, regional anesthesia, sedation, or monitored anesthesia care is performed. This should be done by monitoring of the ECG and the peripheral pulse by method of palpation, auscultation of heart sounds, intra-arterial tracing, or pulse oximetry. The anesthetist must be aware that EMI may occur between the heart rate monitoring system and the CIED, which is a limitation of ECG monitoring. The ECG monitor should be set to pacing mode to recognize pacing stimuli. It is important that a magnet and external defibrillator equipment be present in the operating room or immediately available for procedures requiring sedation where EMI may occur. High-risk patients, or those patients whom defibrillation pads will be difficult to place due to the surgical site, should have pads placed prophylactically prior to the start of the procedure.8 The defibrillator pads should be positioned as far away from the generator as possible, preferably anterior and posterior position on the patient’s thorax.11 5

Procedure-Specific Considerations Procedures using electrocautery, lithotripsy, radiofrequency ablation, MRI, or radiation therapy may cause damage to CIEDs or interfere with their function. Recommendations for patients undergoing surgery with the use of electrocautery include: assure the cautery tool and grounding pad are positioned so the current does not travel through or near the generator and leads; avoid close proximity of the cautery’s electrical field to the generator or leads; use short, intermittent bursts of electrocautery at the lowest feasible energy level; and use bipolar cautery when possible.9 More specifically, the grounding pad should be placed as close to the surgical site and as far away from the CIED as possible, should have good skin contact, and electrocautery should not be used within 15 centimeters of a CIED.11 Lithotripsy is another common procedure that can interfere with a CIED. During the procedure, the beam should not be focused near the generator. If the lithotripsy system triggers on the R wave, atrial pacing may need to be disabled before the procedure.7,9 It is recommended that all pacemakers and ICDs be evaluated within one month from the time of lithotripsy.8 Prior to radiofrequency ablation (RFA), ICDs should be disabled and pacemakers should be reprogrammed to asynchronous mode in dependent patients.7 The risk of interference from RFA may be reduced by preventing direct contact between the ablation catheter and the generator or leads, as well as keeping the current path as far away from the generator as possible.9 All devices should be immediately interrogated after RFA prior to patient discharge or transfer to an inpatient unit. Radiofrequency ablation in the legs is an exception.8 MRI has previously been contraindicated in any patient with a CIED due to concerns of heat generation, effects on pacing functions, and the possibility of the magnetic field producing currents down the leads. Currently, there are several companies that have released FDA-approved devices that are MRI safe. It is important to contact the device manufacturer to determine if the patient has both a MRI compatible generator and MRI compatible leads.7 Regardless of the location of the beam, ionizing radiation poses one of the greatest risks of electrical reset and reversion to a safety mode or failure of a 6

CIED due to the scattering of particles. This can lead to inappropriate shock therapy from ICDs and loss of cardiac resynchronization pacing until the device can be reprogrammed. Due to the frequent schedule of radiation therapy that patients undergo, it is recommended that those with CIEDs enroll into a remote monitoring system to enhance patient safety and detect any changes to the device during treatment. If the patient is undergoing radiation to the chest or receiving high-energy photons, their device should be interrogated within 24 hours of each treatment. Other patients would benefit from weekly device evaluations.8 In patients undergoing electroconvulsive therapy (ECT), the anesthetist should consult with the patient’s cardiologist and the ordering physician to discuss the plan and schedule for the first and successive ECTs. All CIEDs should be interrogated before the procedure. Implantable cardiac defibrillators should be disabled prior to the ECT. The anesthetist should be prepared to treat ventricular arrhythmias in these patients that occur secondary to the hemodynamic effects of ECT. Pacemakers may need to be reprogrammed into asynchronous mode in pacemaker dependent patients to avoid myopotential inhibition of the device.9 Emergent Surgery Emergent surgery for patients with a CIED presents unique issues for the anesthetist. Begin by identifying the type of device by evaluating the medical record, the patient’s registration card, contacting the manufacturer via telephone, or examining a chest radiograph for details. If a chest x-ray is all that is available, the leads on the radiograph can differentiate a pacemaker from an ICD. Cardiac defibrillator leads have coils (Fig. 1)12 and are located at least in the right ventricle (single lead); the patient may have an additional coil lead in the atrium or high superior vena cava/innominate vein location. Pacemakers do not have coils on their leads (Fig. 2)13. The next step is to obtain a 12-lead ECG. If there are pacemaker spikes in front of all or most P waves and/or QRS complexes, one should assume the patient is pacemaker dependent. For these patients, the anesthetist should recommend short bursts of electrocautery; place a magnet on the device if the procedure is above the umbilicus or includes extensive electrocautery and have a magnet immediately available for surgeries below the umbilicus; monitor CRNA Today

the patient with a pulse oximeter and/or an arterial line; and place transcutaneous pacing and defibrillator pads anterior and posterior. If the patient is pacemaker dependent with an ICD, a magnet should be placed over the device to suspend tachyarrhythmia detection in addition to the pacemaker guidelines previously mentioned. It is important to remember that a magnet placed over an ICD will not protect the patient from EMI pacing inhibition.8,14

Alkalosis, acidosis, hypoxia, and antiarrhythmic drugs such as quinidine, procainamide, lidocaine, diphenylhydrantoine, flecainide, encainide, and propafenone have also been found to increase the pacing threshold. Myocardial infarctions may result in scar tissue that is unresponsive to electrical stimulation, which may result in loss of pacemaker capture. Anesthetic drugs are not likely to change the pacing threshold.11

If no pacemaker spikes show on the preoperative ECG one can assume that the patient is not pacemaker dependent. If the patient has a pacemaker only and is not pacemaker dependent, the anesthetist should have a magnet immediately available, but not put it over the device unless necessary. All patients undergoing emergency surgery should have their device interrogated before leaving the postanesthesia care unit and prior to removal of cardiac monitoring equipment.8,14

Postoperative

Figure 1

Figure 2

Patient-Specific Considerations Other important factors the anesthetist should consider when caring for patients with CIEDs intraoperatively include electrolyte disturbances, acid-base balance, the use of anesthetic drugs, and risk of MI. Potassium and its equilibrium across the cell membrane is a determining factor in resting membrane potential (RMP). An acute increase in extracellular potassium levels will make the RMP less negative so that less current density is required at the pacemaker lead to initiate an action potential making capture easier. Examples of this situation include myocardial ischemia, rapid potassium replacement therapy, or the use of depolarizing muscle relaxants in patients with burns, trauma, or neuromuscular disease. Conversely, if the RMP becomes more negative, an increased current density would be required to reach the membrane threshold potential. A decrease in extracellular potassium results in a more negative RMP and an increased difficulty in pacemaker capture. This may be seen in patients on diuretic therapy or those undergoing hyperventilation, such a neurosurgical patients.11 March 2017

The rationale for postoperative interrogation of a device is to assure the device has not entered a back-up safety mode, the functionality was not compromised, and that preprocedural programming settings have been restored. The timing of postoperative interrogation depends on EMI exposure, type of CIED, procedure performed, magnet use, and whether or not the device was reprogrammed prior to the procedure. Patients who require immediate interrogation include: patients with ICDs who have had the antitachyarrhythmia function turned off; patients who underwent cardiac surgery, significant vascular surgery, or any other hemodynamically significant surgery; patients who experienced any intraoperative events such as cardiac arrest requiring defibrillation, cardioversion, or pacing; patients who underwent procedures with significant EMI that may have effected device function; those who underwent emergency surgery where the site of EMI exposure was above the umbilicus; and patients with logistical limitations that may prevent them from getting their device interrogated within one month. In all other circumstances, there is little to no risk of a change in device function or the device entering reset mode. In these situations it is acceptable for the patient to have their device interrogated within one month of the procedure.8 Conclusion The number of people with CIEDs continues to rise resulting in an increased number of complex patients the anesthetist will potentially care for during the perioperative period. It is vital that CRNAs approach the care of these patients in a systematic and stepwise fashion (Fig. 3)7 to ensure they have a thorough understanding of the device function, reason for implantation, and programmability. The anesthetist is encouraged to contact the device company and cardiologist to discuss the current CIED settings, the potential need for reprogramming, and specific procedural considerations. The patient should be 7

carefully monitored via ECG and pulse oximetry throughout the perioperative period and have their

device interrogated based on the type of procedure performed and specific patient need.7,11

Figure 3

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References

1. Neelankavil JP, Thompson A, Mahajan A. Managing Cardiovascular Implantable Electronic Devices (CIEDs) During Perioperative Care. Off J Anesth Patient Saf Found. 2013;28(2):29-48. http://www.apsf.org/ newsletters/html/2013/fall/01_cieds.htm. 2. Harding ME. Cardiac Implantable Electronic Device Implantation Intraoperative, Acute, and Remote Complications. AACN Adv Crit Care. 2015;26(4):312-319. doi:10.1097/NCI.0000000000000112. 3. Jacob S, Panaich SS, Maheshwari R, Haddad JW, Padanilam BJ, John SK. Clinical applications of magnets on cardiac rhythm management devices. Europace. 2011;13(9):1222-1230. doi:10.1093/europace/eur137. 4. Beck H, Boden WE, Patibandla S, et al. 50th Anniversary of the First Successful Permanent Pacemaker Implantation in the United States: Historical Review and Future Directions. Am J Cardiol. 2010;106:810818. doi:10.1016/j.amjcard.2010.04.043. 5. Ward C, Henderson S, Metcalfe NH. A short history on pacemakers. Int J Cardiol. 2013;169(4):244-248. doi:10.1016/j.ijcard.2013.08.093. 6. Rozner MA. Perioperative Pacemaker and Defibrillator Management : What You Need to Know. Anesthesiology. 2015:1-9. 7. Stone ME, Salter B, Fischer A. Perioperative management of patients with cardiac implantable electronic devices. Br J Anaesth. 2011;107 Suppl(suppl_1):i16-26. doi:10.1093/bja/aer354. 8. Crossley GH, Poole JE, Rozner MA, et al. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the Perioperative Management of Patients with Implantable Defibrillators, Pacemakers and Arrhythmia Monitors: Facilities and Patient Management. HRTHM. 2011;8:1114-1154. doi:10.1016/j.hrthm.2010.12.023. 9. Apfelbaum JL, Belott P, Connis RT, Nickinovich DG, Rozner MA, Zaidan JR. Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable Cardioverter-Defibrillators. Anesthesiology. 2011;114(2):247-261. doi:10.1097/ ALN.0b013e3181fbe7f6. 10. Rozner MA. The patient with a cardiac pacemaker or implanted defibrillator and management during anaesthesia. Curr Opin Anaesthesiol. 2007;20(3):261-268. doi:10.1097/ACO.0b013e32814f1c4a. 11.Rastogi S, Goel S, Tempe DK, Virmani S. Anaesthetic management of patients with cardiac pacemakers and defibrillators for noncardiac surgery. Ann Card Anaesth. 2005;8:21-32. https://www.learnatnorth.org/ cduren/North Seattle AT Program 2011-2012 CJ Duren-Instructor/ATEC 008 Clinical Monitoring/Week 4/Mandatory Handout Readings/Anesthetic_Management_of_Patients_with_C.pdf. 12. Defibrillator x-ray. http://www.smj.org.sg/sites/default/files/SMJ-56-538-g002.jpg. 13. Pacemaker x-ray. http://circheartfailure.ahajournals.org/content/3/3/465/F1.large.jpg. 14. Thompson A, Neelankavil JP, Mahajan A. Perioperative Management of Cardiovascular Implantable Electronic Devices (CIEDs). Curr Anesthesiol Rep. 2013;3(3):139-143. doi:10.1007/s40140-013-0026-5.

March 2017

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Questions: POST TEST 1. Which of the following are a source of EMI in the operating room? A. Electrocautery

6. Indications for permanent pacemaker placement include:

B. Radio frequency ablation (RFA)

A. Chronic atrioventricular node disease

C. Both choices are correct

B. Sinus node dysfunction C. Long Q-T syndrome

2. How many people are affected by cardiac arrhythmias in the United States each year? A. 12 million B. 14.4 million C. 6.5 million D. 20 million 3. Cardiac arrhythmias result in 40,700 deaths in the United States annually. A. True

D. Hypertrophic cardiomyopathy E. All of the above 7. The first letter in the pacemaker code as developed by the NASPE/BPEG indicates which of the following? A. The chamber being paced B. The chamber being sensed C. Pacemaker response to sensing D. Antitachycardia functions

B. False 4. A magnet can be safely applied to a CIED to convert a pacemaker to asynchronous mode 100% of the time. A. True B. False

8. What is the primary advantage in using a magnet to alter pacemaker function? A. It can be easily and quickly removed B. It is convenient for the anesthetist C. It can be used no matter what position the patient is in D. All of the above are correct

5. The first letter in the ICD code as developed by the NASPE/BPEG indicates which of the following? A. Antitachycardia pacing chamber

9. An ICD’s anti-tachyarrhythmia mode may be suspended by either the placement of a magnet or reprogramming.

B. Chamber sensed

A. True

C. Chamber shocked

B. False

D. Tachycardia detection

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10. Monopolar cautery should be used whenever possible to decrease the possibility of EMI.

16. ICDs should be disabled prior to electroconvulsive therapy (ECT).

A. True

A. True

B. False

B. False

11. A decrease in extracellular potassium results in a more negative resting membrane potential and A. Increased difficulty in pacemaker capture B. Improvement in pacemaker capture C. Increased firing of the SA node D. Increased sensitivity of the pacemaker to EMI 12. If the patient does not know what type of CIED they have, the anesthetist should first do what? A. Obtain an ECG B. Order a chest x-ray C. Ask for a copy of a recent echocardiogram D. Call the American College of Cardiology for advice 13. Electrocautery should not be used within how many centimeters of a CIED? A. 5cm B. 10cm

17. Indications for ICD placement include: A. VT B. VF C. Post MI patients with an EF ≤ 30% D. All of the choices are correct 18. What does a magnet do when placed over an ICD? A. Disables anti-tachycardia pacing B. Terminates inappropriate shock therapy C. Both choices are correct 19. What poses the greatest risk of electrical reset or failure of a CIED? A. ECTs B. Ionizing radiation C. MRI D. Electrocautery 20. Which of the following does not change the pacing threshold?

C. 15cm D. 20cm

A. Acid base disturbances

14. A grounding pad should be placed as close to the CIED and as far away from the surgical site as possible.

B. Electrolyte disturbances C. Anesthetic drugs D. Antiarrhythmic drugs

A. True B. False 15. When should patients undergoing direct radiation treatment to the chest have their CIED interrogated? A. Within 24 hours B. 1 week C. 1 month D. 3 months March 2017

Test questions must be completed online, visit CRNAToday.com

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1. American Heart Association (AHA) http://www.heart.org/HEARTORG/Conditions/Arrhythmia/ AboutArrhythmia/What-is- Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsp#.VkFLu4Tl7zI. Retrieved on Nov 9, 2015. 2. Hall, JE, and AC Guyton. “Textbook of Medical Physiology.” Saunders London (2011) 3. Silbernagl, S, and A Despopoulos. “Color Atlas of Physiology.” Thieme (2009) 4. Narouze, S, HT Benzon et al. “Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications” Reg Anesth Pain Med 40.3 (2015): 182-212.

Across



1. pacemaker of the heart (two words) 3. the surgical removal of body tissue 4. hollow part of the organ 5. the process of being interrogated 8. one that takes the lead or sets an example 11. ischemic condition 12. lodestone or attraction Down 2. insert or engraft 6. relating to the heart 7. depolarizing the heart cells 9. open roofed entrance hall 10. regular repeated pattern of sound

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