Due to the increasing number of patients with implanted cardiac rhythm management devices (CRM) within Ayrshire and Arran and calls for advice on their management, there is a need to provide medical and nursing staff with appropriate guidance to ensure that patients with CRMs are appropriately managed.

The purpose of this guidance is to promote awareness and optimal management of a patient group who are at risk of adverse or life threatening events should interventions adversely affect the working of the CRMs e.g. diathermy, lithotripsy, electro convulsive therapy.

Prior to the procedure, it is important to ensure all relevant information regarding the implanted CRM is obtained and appropriate health professionals informed timeously.

• Confirm patient has either pacemaker, ICD or CRT-D.
• Determine type of pacemaker, ICD or CRT-D, position of device and reason for implant – appropriate history and examination, obtain manufacturers ID card.
• Determine patient dependency on device, i.e. does the patient require the device to maintain heart function all or most of the time, or is their mostly normal intrinsic cardiac rhythm.
• Determine time of last device check and identify at which hospital – obtain report.
• Perform ECG if necessary.
• Inform anaesthetist (if possible patient should attend preoperative assessment clinic prior to admission).
• Contact cardiac department ext 17010 (Ayr Hospital) and ask to speak to a CRM device physiologist for assessment of CRM device (temporary modification of settings may be required/functions may need to be suspended i.e. ICD or CRTD switched off).
• Some devices may be managed by other hospitals.
• Operating surgeon should be aware patient has a CRM device.

• Temporary transcutaneous pacing and defibrillation equipment should be available in the theatre area.
• Bipolar diathermy is preferred.
• Monopolar diathermy (during period of application) can cause loss of pacing. Monopolar diathermy may be used only after discussion with cardiac physiologist after assessing dependency on device, and after discussion with consultant anaesthetist. Ensure diathermy plate is positioned so current pathway does not pass through the device.
• If monopolar diathermy is used then do so in short irregular bursts at lowest feasible energy levels - suggested 3 seconds.
• Advice on magnets: use in emergency only or for dependent pacemaker patients to produce asynchronous pacing i.e. non demand pacing, or to temporarily suspend tachy detection, and contact cardiac physiologist immediately, use for less than 5 minutes on a monitored patient, device may require reprogramming post procedure.
• If external defibrillation is required place paddles in anterior-posterior position if possible, at least 15cm away from the device and use normal energy levels.

It is advised that following surgery or an endoscopy that the implanted CRM is checked by the cardiac physiologist prior to a discharge.

• If there are no adverse intra-operative events perform routine observations.
• If any device have been reprogrammed preoperatively these settings will need to be restored prior to discharge from recovery.
• If any adverse intra-operative events (loss of pacing, patient defibrillated, use of magnet) contact cardiac physiologist to perform device check and restore functions. Patients will require continuous ECG monitoring postoperatively.                                                                                                                                                                                                                            

In this event an emergency pack can be obtained from the Coronary Care departments at both Crosshouse and Ayr Hospital. This will contain a greater than 10 gauge magnet and contact numbers.

Contacts:

Cardiologist on call - available through switchboard.

Cardiac Device Services - Ayr Hospital - Telephone 17010 or page 1080.

Employees are reminded that they may have patients/carers who require communication in an alternative format e.g. other languages or signing. Additionally, some patients/carers may have difficulties with written material. At all times, communication and material should be in the patient’s/carer’s preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on clinical guidelines e.g. choice of gender of health care professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability or impairment that makes it difficult for them to be treated/examined as set out for a particular procedure requiring adaptations to be made.

Patients’ sexual orientation may or may not be relevant to the implementation of this guideline, however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexual orientation may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality Impact Assessment Tool Kit. No additional equality & diversity issues were identified.

American Society of Anaesthesiologists (Oct 2004) Practice advisory for the preoperative management of patients with pacemakers and cardiac rhythm management of patients with pacemakers and cardiac rhythm management devices: pacemakers and implantable cardioverter-defibrillators:
http://webarchive.nationalarchives.gov.uk/20150121092345/http://www.mhra.gov.uk/Safetyinformation/Generalsafetyinformationandadvice/Product-specificinformationandadvice/Product-specificinformationandadvice-A-F/Cardiacpacemakersanddefibrillators(implantable)/index.htm

Or available on the Medicines & Healthcare products Regulatory Agency (MHRA) home page and follow the following steps:
>click on the Safety Information tab and then
> General safety information and advice >Product specific information and advice
> Cardiac Pacemakers and defibrillators (implantable)
> Guidelines for ICD – Pacemakers Perioperative Management.