围手术期间心脏植入装置的管理专家共识（论文资料）课件

围手术期间心脏植入装置的管理 专家共识解读 南昌大学第二附属医院 鲍慧慧 The Heart Rhythm Society Expert Consensus （2011 AHA/ACC/ASA/STS） Committee Staff 8AHA/ACC/4ASA/1STS Nashville, TN； Seattle, WA；Houston； TX, Rochester, MN Baltimore； Cleveland, OH Greenville, NC；Hanover, NH Charleston, SC；West Des Moines, IA Cleveland, OH；Jacksonville, FL Charlottesville, VA；Nashville, TN Engineers from： 概 要 介 绍 医疗操作期间可能出现的问题 Problems that can occur during medical procedures Preoperative evaluation of a patient with a 心脏植入性电子装置（ CIED）患者术前评估 心脏植入性电子装置（ CIED）患者手术中管理 与思考 Intraoperative management and considerations 心脏植入性电子装置术中的评估Intraoperative evaluation of CIEDs Abbreviations CIED：Cardiovascular implantable electronic devices EMI ： Electromagnetic interference ECT ： Electroconvulsive therapy CIED team： Physician, nurse, and technicians Perioperative team：Anesthesiologist , surgeon，physician, nurse More than 3,000,000 devices were implanted in the globe 全球约有三百万以上患者心脏植入装置 700,000 devices was implanted in 2009 2009年有700,000患者心脏植入装置 Increasing at the rate of 15% every year 每年以15% 速度递增 Introduction uEnsure patients with devices safe in perioperative period uNeed for a consistent statement 1、Rapid changes in CIED technology 2、Expanding use of EMI 3、 Confusing recommendations Introduction Problems that can occur during medical procedures EMI Electrosurgical energy EMI and CIEDs Electrosurgical energy Identification of problems specific to patients with CIED during medical procedures Oversensing Rate responsive algorithms Reset Pulse generator damage Lead-tissue interface damage EMI and CIEDs Transient effection such as ： Pacing inhibition Inappropriate tracking of electrical noise Damage at the lead-tissue interface Pulse generator damage Electrical reset mode Rate responsive algorithms Extent of abnormal behavior depends on ： Strength Duration Particular type of interference Clinical impact depends on ： Patients intrinsic rate and rhythm Pacing mode Functioning of protective circuitry engineered to filter out extraneous electrical currents EMI and CIEDs Electrosurgical energy Bipolar electrosurgery ：(e.g. electrical forceps） Used far less commonly only for coagulation and not dissection Monopolar electrosurgery Utilized for most surgical procedures Electrode：“ Pen or stylus” to the operative site Return electrode ：patients body Interactions with CIEDs including ： Inhibition Triggering unneeded tachyarrhythmia therapy Electrical reset Oversensing Electrosurgical energy Directly to the pulse generator or system electrode Permanent damage of the CIED pulse generator Damage to the lead-myocardial interface causing an increase of pacing thresholds No damage if the distance is 6 inches Electrosurgical energy Determine consequences of oversensing： Duration of exposure Path of the current Patients underlying rhythm Oversensing in ICDs results in ： inhibition of pacing ATP therapy ICD shocks Oversensing ICD require a certain duration of continuous high-rate sensing to fulfill arrhythmia detection criteria An approach that limits electrosurgery usage to short bursts may be a safer approach to patient- CIED management than either reprogramming the CIED or placement of a magnet over the pulse generator Oversensing CIED uses a minute-ventilation sensor for rate response Rate responsive algorithms occurs because the impedance measurement is miscalculated due to the current from the electrosurgery. Also in some CIEDs, the magnetic switch can be activated by electrosurgery, causing rapid pacing Rate responsive algorithms Device reset is more caused by therapeutic ionizing radiation than EMI corruption of the memory in the circuitry (2) a surge of energy coursing through the pulse generator that simulates the initial connection of the power source We recommend contacting the technical support service of the manufacturer Reset Pacing and antitachycardia therapy parameters are unique to each manufacturer Some newer Boston Scientific ICDs have Safety Core Safety Core is a back-up mode intended for major hardware failures that provides high-voltage therapy with a simple unipolar VVI pacing Reset Electrical energy can enter the pulse generator： uBreach of lead insulation uCorruption of the sealing rings with conductive fluid bridge to the lead connector Pulse generator damage Surgeries close to the CIED should be done with bipolar rather than monopolar electrosurgery （e.g. breast, shoulder, head and neck, pulse generator replacement,or carotid procedures） Surgery on the ipsilateral hand, the return electrode should be on the ipsilateral arm 1 Pulse generator damage Lead tissue interface damage Electrosurgical collateral damage to the lead-myocardial interface Resulting in： Increase in pacing threshold Loss of capture Induction of arrhythmias How to mitigate the risk（1） Keeping the current path away from CIED diminishes the potential for adverse interaction with the CIED For example：below the umbilicus is less likely to cause interference than above the umbilicus Using bipolar electrosurgery whenever possible Minimizing the length of monopolar electrosurgery bursts to 5 seconds or less Cardioversion Catheter ablation for cardiac arrhythmias Diagnostic radiation Therapeutic radiation Electroconvulsive Therapy Transurethral needle ablation (TUNA) Transurethral resection of the prostate (TURP) Gastroenterology procedures Tissue expanders Stimulators Radiofrequency identification devices (RFID) Other wireless technology Lithotripsy Iontophoresis Photodynamic therapy Dental procedures Special situations Cardioversion External cardioversion was associated with transient dysfunction of older CIEDs, particularly used unipolar leads using an anterior-lateral electrode position：transient loss of capture and electrical reset In a recent clinical study，44 patients with CIEDs Using an anterior-posterior electrode， positioned with 8 cm between the anterior electrode and the CIED No CIED malfunction In a case-series of three patients, high pacing thresholds after the cardioversion Experience of several committee members： pulse generator reset Cardioversion Radiofrequency energy delivery near CIEDs may result in： Electrical reset Reprogramming Oversensing Inappropriate inhibition Undersensing Inappropriate arrhythmia detection（ ICD） pulse generator malfunction Catheter ablation for cardiac arrhythmias u Household microwave energy has no significant impact on pacemakers and ICDs u No specific studies are available in terms of microwave ablation, whether the energy is delivered to the epicardium or endocardium Catheter ablation for cardiac arrhythmias Diagnostic radiation Diagnostic radiation generally does not have any significant adverse effect on CIEDs With the newest generation of multislice computed tomography machines that use higher radiation doses, transient effects on CIEDs due to oversensing Therapeutic radiation can damage CIED function Modern CIEDs utilize metal oxide semiconductors in the integrated circuitry When the semiconductors are exposed to ionizing radiation, damage occurs to the silicon and the silicon oxide insulators within the semiconductor Sudden output failure or runaway pacing has been reported Therapeutic radiation Direct radiation of pacemakers and ICDs should be strictly avoided and accumulated doses 5 Gy Scatter neutron may occur electrical reset Importantly, the use of conventional x-ray shielding during radiotherapy does not protect the pulse generator from the effects of the scattered neutrons If the photon beam energy exceeds 10 MV, evaluation of CIED function immediately Therapeutic radiation In ECT, an electric current is delivered to the brain, triggering a brief seizure Damage to CIED function： Noise reversion mode Myopotential oversensing Bradycardia Inappropriate ICD shocks Electroconvulsive therapy（ECT） The physician needs to know the ICD tachycardia detection rate and should have a magnet handy in case the sinus rate gets near that rate Pretreatment with short-acting beta- blockers might also be considered in such patients Electroconvulsive therapy Transurethral resection of the prostate (TURP) Placing the patient return electrode on a leg Limiting applications of TURP-related electrosurgery to 1 to 2 seconds every 10 seconds Reduce the risk of inhibition in individuals who are pacemaker dependent Avoid ICD inappropriate detections Colonoscopy、gastrocopy and Capsule endoscopy ： No reporting cause interference Tissue expanders： Devices called tissue expanders are used by plastic surgeons to prepare for reconstructive breast surgery Receive tissue expanders without magnetic aiming guides Radiofrequency identification devices (RFID)： avoid placing identification tags close to the pulse generator Other wireless technology： Several studies have evaluated interaction of GSM with CIEDs and found interference when the wireless device is closer than 10 cm to the CIED pocket Transurethral needle ablation (TUNA) Electromyelograms (EMGs) and nerve conduction testing Iontophoresis Photodynamic therapy Dental procedures There are no reports of this technology in altering CIED functionality Preoperative evaluation of a patient with a CIED Timely, thorough preoperative evaluation is essential for the safe perioperative management of patients with CIEDs and should include a multidisciplinary and systematic approach CIED team AND perioperative team The most effective prescription for the perioperative care of a patient with a CIED Preoperative recommendations The Procedure team must advise the CIED team about the nature of the planned procedure General principles guiding include: Inactivation of ICD detection is not a universal requirement for all procedures. Rendering PMs asynchronous in pacemaker-dependent patients is not a universal Pacemakers that need to be protected from inhibition may be made asynchronous by programming or by placement of a magnet applied over the pulse generator, provided the pulse generator is accessible. ICD arrhythmia detection can be suspended by placement of a magnet over the pulse generator A magnet placed over an ICD generator will not render pacemaker function in an ICD asynchronous. Preoperative recommendations Rendering a PM asynchronous in a PM-dependent patient is preferable for most procedures above the umbilicus. In pacemaker patients, no reprogramming is usually needed if below the level of the umbilicus. Patients with pacemakers undergoing elective surgery should have had a device check as part of routine care within the past 12 months patients with ICDs undergoing elective surgery should have had a device check as part of routine care within the past 6 months Preoperative recommendations Preoperative evaluation of a patient with a CIED Essential elements of the information given to the CIED physician Essential elements of the preoperative CIED evaluation Essential elements of the information given to the CIED physician Essential elements of the preoperative CIED evaluation to be provided to the operative team Essential elements of the preoperative CIED evaluation to be provided to the operative team Approach to emergent procedures 1、Identify the type of device Evaluate the medical record Examine the patient registration card Telephone the company to clarify device type Examine the chest radiograph 2、Determine if the patient is pacing Obtain a 12-lead ECG or rhythm strip documentation If there are pacemaker spikes in front of all or most P wave and/or QRS complexes, assume pacemaker dependency Approach to emergent procedures 3、 Pacemaker dependent? Yes: pacemaker (not ICD) ，Use short electrosurgical bursts, place magnet over device for procedures above umbilicus or extensive electrosurgery, have magnet immediately available for procedures below umbilicus l Monitor patient with plethysmography l Transcut