Avoiding Electromagnetic Interference with Implanted Cardiac Rythm Devices

(CRMD) Marjorie Voltero, CGRN

mm

Expand knowledge of Cardiac Rhythm Management Devices (CRMD)

Explore recent trends in chronic disease management leading to increased use of CRMD in the GI patient population

Review current literature recommendations in management of electrocautery use in patients with an implanted electronic device.

Identify conditions that may result in a higher risk of electromagnetic interference (EMI)

Initiate individual plan of care for GI patient

Pacemaker history 1950 -John Hopps;

Canadian Electrical Engineer; researching effects of radio frequency in hypothermia

Late 1950’s- Wilson Greatbatch; another engineer working on oscillator to record heart sounds.

1980’s pacemaker use more widely used

Implanted Cardioverter-Defibrillator (ICD) history

1980: Dr. Levi Watkins Jr. First ICD implantation

at John’s Hopkins Hospital

1990’s pacemaker and ICD

Innovation continues….

The Short Form of the NASPE/BPEG Defibrillator

(NBD)Code:ICD-S = ICD with shock capability only

ICD-B = ICD with bradycardia pacing as well as shock

ICD-T = ICD with tachycardia (and bradycardia) pacing as

well as shock

INDICATION EXAMPLES

Symptomatic bradycardia AV Block Maximize medical

therapy for CAD Severe heart failure,

cardiomyopathy (EF less than 35%) -reduces sudden cardiac death

History of a lethal arrythmia (VT, VF)

Non-lethal arrythmia override

(PAF, SVT)

PROGRAMMING EXAMPLES

Programming is set to the individual patient needs and the device capabilities

May sense or pace ventricle, atria or both

May be programmed to override a non lethal tachyarrythmia

Sense or not sense AV pacing sensing and firing in

both chambers CRT Cardiac Resynchronization

Therapy (DCM patients) ability to pace both ventricles

M agnet response individual

In addition to ICD and pacemakers:

Neurostimulators *brain *gastric (under study)

*spinal cord *urinary bladder

stimulators

Drug infusion pumps (pain,

chemo)Auditory

(cochlear)

Patient admitted to Endo Unit for EGD

Patient admitted to pacemaker only

Exam positive for gastric antral vascular ectasia (GAVE )

Treated with APC Patient’s ICD

delivered a shock to the patient

Patient’s cardiologist called. (also denied ICD)

Electrophysiology Fellow consulted and interrogated device

No damage done, no patient adverse effects

Multidisciplinary team-Endoscopist-RN-Cardiac Anesthesia

-Electrophysiology MD

Multiple revisions/clarifications

Unit policy developed and implemented

“moving target” New information Individual MD

practices vary

2005 American Society of Anesthesiologists (ASA)

* Report on Perioperative Management of Patients with CRMDs

2005 Society of Gastroenterology Nurses and Associates (SGNA)

* Current Issues 2007 American Society for Gastrointestinal

Endoscopy (ASGE)* Technology Status Evaluation

2009 New York State Board for Nursing * Practice Alerts & Guidelines

AICD/Pacemaker Interruptions with a Magnet during Colonscopy Procedures

WHAT IS NOT IN THE LITERATURE

No absolute rules No absolute recommended

standards of care. Suggestions based on current knowledge and experience

“universal recommendations applying to all patients in all settings cannot be made at this time.” (ASGE, 2007)

WHAT IS AVAILABLE Evolving technologies require

constant reevaluation and assessment of risk

The more information providers have the better we can plan for patient safety!

BALANCE KNOWLEDGE OF DEVICE WITH KNOWLEDGE OF

INTERVENTIONS REQUIRED

Sense EMI as intrinsic cardiac electrical activity:**inhibiting pacemaker from firing (pacer dependant at risk)** ICD may discharge a shock when not

required Sense EMI as “noise” and revert to “noise

suppression mode” (pacemaker-asynchronous) *repetitive short bursts of even low level cautery

High levels of current may damage device, battery or surrounding tissue

Electrical impulses conducted to ICD and cause firing

General consensus in literature: **use of cautery in remote sites is unlikely to cause EMI definition of remote sites varies: bellow the waist, further than 4 or six inches from the device generator and leads ** maintain electrical current flow away from device, generator and leads of device **bipolar cautery is preferable to monopolar

return electrode is in the device and no grounding is necessary ** lower wattage and shorter duration of cautery reduces the risk for EMI (most GI procedures)

•Cautery applications within 6 inches of the device generator and /or leads.

*depends on patient’s anatomy: possibly stomach, esophagus, splenic flexure or transverse colon

•Monopolar modalities that require sustained cautery application

*(APC (GAVE), complicated polypectomies, EMR, RFA-Halo)

Boards of Registration: * No specific language in

Massachusetts BORN re: magnet application…

“RN needs the “knowledge, skills and abilities” to safely perform whatever the activity.” (framework for decision-making nursing practice activities)

NY Board requires: * Physician order * RN education, knowledge

and skills * Institution written policy and

procedure * monitoring and emergency

equipment w/defibrillator

SGNA:-”Current Issues” 2005

SGNA Website: General Discussions*various settings

*different practices

Consistent with evidence currently available

Sample of different approaches:

Contact company Contact cardiologist Contact pacer lab RN Automatically apply magnet

during cautery use

PACEMAKER

Internal switch closes to magnet application

Pacemaker will pace at a preset continuous rate

Rate varies dependant on individual programming

Does not shut off the pacemaker

Performs the same as if being interrogated

ICD

Internal switch closes to magnet application

ICD is inhibited from sensing

Does not sense; does not shock

Does not shut off the ICD in majority of models (exception Guidant and Biotronik)

Medical decision for Endoscopist to make if magnet is required or not. May need to consult expert to determine what

precautions to take Is the patient pacemaker dependant? (consider

consult) What type of cautery is planned? (ie: APC vs

Symmetry) How proximal is the site to device generator and

leads? (ie:rectal vs esophageal) How is the device programmed to respond to magnet

placement? Correct pad placement; grounding to prevent

current from moving to device generator or leads. The more information you have the better you

can plan for patient safety!

Clear communication between MD and RN

Magnet use as brief as possible

Maintain continuous EKG monitoring (good quality)

Manual defibrillator readily available with qualified users

Algorithm for magnet use during endoscopic cautery for a patient with a pacemaker or an ICDBegin here:

Is the device an ICD? No, the device is a pacemaker onlyYes

Is the ICD model a Boston ScientificOr a Biotronik? No

Yes

•MD orders magnet use based on:-Proximity of cautery use

to the device -the type of cautery required.

Is the patient’s devicecare managed by MGHCardiology?

Yes

No

Consult EP Fellow Pager # 6-9292

•Apply magnet directly over the device before cautery and remove after cautery use

Request device check after the procedure from EP fellow if:

•The ICD device delivered a shock because of cautery use .

•Manual defibrillation or cardioversion was required .

•Device was programmed before the procedure by EP or Cardiology

•If any malfunction was noted

When a magnet is required:

•Continuous EKG monitoring of the patient’s rhythm

•Remove the magnet if a lethal arrhythmia occurs. The magnet needs to be removed to at least a 3 foot distance away. The device should deliver a shock within 15 to 20 seconds once the magnet is removed.

•In the unlikely event that manual defibrillation is

required have a manual defibrillator and competent staff readily available.

•See also: Endoscopy Unit Guidelines

Endoscopy Nursing Policy

Nov, 2009

Endoscopy in Patients with Implanted Devices, Technology Status Evaluation Report, 2007 American Society for Gastrointestinal Endoscopy. Vol. 65, No. 4.Practice Alerts and Guidelines; AICD/Pacemaker Interruptions with a Magnet during Colonoscopy Procedures. http://www.op.nysed.gov/nursepacemaker.htmCurrent Issues, 2005 Gastroenterology Nursing, vol.28 issue 3. Practice Advisory for the Perioperative Management of Patients with Cardiac Rhythm Management Devices: Pacemakers and Implantable Cardioverter-Defibrillators, Anesthiology, vol.103, (1) July 2005.