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