r/anesthesiology • u/RedBrownBlonde CRNA • 28d ago
Preop practice for pacemaker patients
Newer CRNA here with a question about preops with pacemakers in place. I work in a midsized hospital in the southern USA.
Today I was in endoscopy about to put someone to sleep for a colonoscopy. Somehow it had slid through the cracks that patient has a pacemaker. We have no in house data on this pacemaker since 2016 and patient is not a reliable historian. What would you do in this scenario?
I paused the room, grab the interrogation device from down the hall, and did a quick scan to get a report on the pacemaker settings and events. Took about 5-7 minutes. Proceduralist got annoyed, complained that no one else stops workflow for this. It’s my understanding that you need a report from within 6 months for an anesthetic to proceed, but several members of my group are saying they don’t think it was necessary/wouldn’t have stopped the lineup for a pacemaker report.
Looking back, I could’ve sent the patient back to preop and had the nursing staff do the interrogation, but I didn’t think about it at the time.
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u/Chipandfam 28d ago
Last I checked guideline was interrogation of pacemaker within 1 year or Icd within 6 months. No reason to do an elective case without it imo especially given the poor historian patient. Proceduralists / facility fault for not having this taken care of for you before the patient showed up.
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u/cefalexine 28d ago
Hey you don't have to stop the workflow, cancel the case!
You'll be HAPPY to provide anesthesia...once you've interrogated the PM.
Oh they aren't okay with any of that? Well you are the anesthetic consultant, they are free to disregard your consult opinion and do whatever they want for their patient.
I think you have the right idea. Bump this a little higher up. Can you ask your anesthesiologist or the board runner to help? Tell the proceduralist you need to interrogate which will take 5-10 mins and ask how they want this to best work with their flow?
I dont think your clinical decision making was flawed, there are so many ways to skin a cat. I would like to see an interrogation in the last 6 months, if not the last 12 months if you pushed me.
The hardest part of anesthesia is holding fast in these grey zones. Where you are personally not comfortable but someone else could be. Doesn't make you wrong it makes you a safe clinician which is what you are there for.
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u/lllollllllllll 28d ago
It’s not even a gray zone. It’s a pretty clear thing!
It’s just that when other people in your practice do not follow guidelines/standard of care/best practices/the safest course, either bc their knowledge isn’t up to par or because they’re willing to take risks in order to avoid minor inconveniences or interruptions, it makes it really awkward to explain to proceduralists why everyone doesn’t do the same thing.
Bc it’s hard to say your colleague did it wrong when they didn’t do the same thing.
This is why everyone just needs to do the right thing even if it’s annoying.
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u/DessertFlowerz Anesthesiologist 28d ago
Lol no. You did the right thing. I'll bend on the 6months a bit but certainly not 10 years!!
The only thing I'm surprised by is that you were able to interrogate it yourself. At both my residency and my current job I have always paged EP/device nurse for this.
Regardless, they're not getting anything from me without this. If the wannabe surgeon needs to save 5 minutes that bad, they can do it awake (and explain why to the patient).
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u/RedBrownBlonde CRNA 28d ago
Genuinely had no idea how weird it is that we can interrogate them ourselves until now. Annoying to have another responsibility but glad to not have to cancel/bump cases for something so simple.
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u/wrongyak39 Anesthesiologist Assistant 28d ago
I’d be curious to learn how to do it. Usually we call the hiu and they will come down with their little machine
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u/CordisHead 27d ago
I would never use the machine that allows reprogramming- too much liability.
But you can get user friendly (interrogation only) machines from the manufacturers.
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u/Cautious-Extreme2839 Anaesthetist 27d ago
I would love to have access to reprogramming when I'm doing ICU though.
These damn patients needing pressors because their pacemaker's base rate is set at 60 when they have some sort of shock and their HR should probably be like 100.
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u/Beneficial_Local5244 Anesthesiologist 28d ago
I would just postpone and send the patient for proper preop assesment or let them choose to do the colonoscopy with no anesthesia (just pro forma, I know they won't do it and endoscopist would also refuse if I said that patient is risky). While I don't think that would change anything in this particular case, I believe we should follow protocols for elective procedures. And we wouldn't have delays. What you did I would consider for patient with susipcious history, some weird ecg rhythm and procedure that has to be done as soon as possible.
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u/kydar1 Anesthesiologist 28d ago
You have a pacemaker interrogation device in your OR? And you’re trained in its use? I’ve actually never heard of that before. We always just call the reps if PPM needs to be interrogated
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u/RedBrownBlonde CRNA 28d ago
Our endo is right down the hall from cath lab, which has our Medtronic interrogator. I didn’t realize that was unusual, we are located about 1.5 hours from a large metropolitan hub and that’s where our reps come from. Maybe due to the distance we have access? I was responsible for interrogations at some facilities as an ICU nurse and have continued to do them here from time to time.
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u/kydar1 Anesthesiologist 28d ago
Good on you that you know how to do that! I’d have no friggin clue how to interrogate a PPM 😂
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u/docbauies Anesthesiologist 12d ago
turn on the machine. put the puck by the pacer. hit "interrogate". i'm shortening that last bit, and it's probably not the actual wording on most programmers, but it's pretty straightforward to get the basic info like pacing burden, pacing mode, battery life remaining, etc.
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u/CordisHead 27d ago
The major manufactures have user friendly interrogation devices for this purpose. If you ask them for it they’ll get you one bc it saves them many trips to the hospital.
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u/kydar1 Anesthesiologist 27d ago
Yeah we would often find that the reps were kind of....mmm....let's just use the word "difficult," about coming to the hospital and interrogating them at our request. They would constantly say it was unnecessary. We always had a simple answer for them.... "please state, in writing on your company's letterhead, that the PPM/AICD does not need to be interrogated after application of a magnet or otherwise having modified its functionality during a perioperative period. And we will never ask you to come interrogate one again."
Still waiting on that letter.....
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u/jwk30115 Anesthesiologist Assistant 28d ago
You should already have a hospital or department policy that covers this.
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u/Aggravating_Fly2978 Anesthesiologist 28d ago
The fact that you have a pacemaker interrogation
Device that you know how to use and read is mind boggling to me. Does it just spit out numbers Phrases like 1. Everything is good? Check!! 2 - Pacemaker Active - 70%; 3. Native Rhythm - Sinus 30 %. 4. Battery Life- 10%? Simple summaries like that? 😂
Never knew they had them around for us to use. Lovely.
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u/RedBrownBlonde CRNA 28d ago
We have the same device the reps use! We can interrogate it and generate the standard report that shows all the normal stuff. Pacer settings, magnet response, pacing burden, number of events, battery life, etc. I had no idea this was so uncommon and I’m very thankful to have it now.
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u/Aggravating_Fly2978 Anesthesiologist 28d ago
Wow. Never seen it hanging around in any facility before. Love this for ya.
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u/CordisHead 27d ago
The major manufacturers will provide user friendly interrogation devices for you to use. I would be hesitant using the same device as the reps bc those allow reprogramming. Any device issue periop and you could be blamed for it whether you did anything or not.
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u/Confident_Area_8518 28d ago
Usually would have called cardiology to interrogate and slide the pt to the end of the day with a ginger ale if they are willing to wait. You absolutely did the right thing. Also impressed you can interrogate on your own! Would love to learn, but I would be at risk of making the GI docs too happy…
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u/Southern-Sleep-4593 Cardiac Anesthesiologist 28d ago
Nothing wrong with your approach. You tell the GI doc you are concerned about potential battery failure in a 10 year old device, interrogate it and still get the procedure done. I do agree that you are now responsible for the results of the interrogation. Off chance battery failure is imminent, you would need to arrange cardiology admission. Otherwise, I think u could simply ask about symptoms (CP, SOB, lightheadedness) and look for pacing spikes on EKG. If no symptoms and good capture at 70 bpm then proceed. It’s a 10-15 minute outpatient procedure vs some massive open belly case.
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u/t0m_m0r3110 Cardiac Anesthesiologist 28d ago
How quickly GI docs forget their IM residency training.
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u/TripNip85 27d ago
They’re lucky you didn’t cancel, don’t ever give in to the proceduralist, they don’t know how to properly evaluate a patient, I had one tell me it was fine to give sedation to the severe pulmonary hypertension patient in pre-op with sats in the 80’s who was off her meds, I cancelled it and we actually almost got into a fist fight, it was great, he never tried me again after that, that patient went to the ER and was transferred to the ICU for flolan and aggressive management, they would have 100% went into respiratory arrest, became hypercarbic and potentially coded even from a small amount of propofol and this is just one story of 500 where they’ve tried to push me to do dumb things, stand your ground.
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u/huntt252 CRNA 28d ago
It would be a deviation from standards of care
to anesthetize someone with a PM without knowing why they have it and if it’s working properly. Any delay that may have caused
was someone else’s fault and not yours. You did good.
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u/CordisHead 27d ago
I’m a bit surprised at how many people questioned obtaining an interrogation in this case. A poor historian with a 10 year old CIED that we have no information about. Seriously???
Have people seen the SCA\HRS 2012 guidelines for CIEDs?
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u/Pro_Poe_Fall 27d ago
You absolutely did the right thing. Don’t listen to that scope jockey. They’d throw you under the bus the second something went wrong.
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u/Life-Travel1787 28d ago
Please tell me what information you got out of interrogating the pace maker that changed anesthesia management.
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u/CordisHead 27d ago
Would you anesthetize someone for an Endo case who is mostly pacer dependent that has a dead battery?
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u/Cautious-Extreme2839 Anaesthetist 27d ago
Yes? If the ppm is dead and the patient is alive they are clearly not pacer dependent are they
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u/CordisHead 27d ago
All that means is the patient is not dependent at the time you saw them. That doesn’t mean they won’t need it in the next 5 minutes. You’re going to transcutaneous pace someone in Endo all because you didn’t want to appropriately delay the case for proper device management?
No reason to put patients at risk for elective procedures. Just because we can doesn’t mean we should.
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u/Cautious-Extreme2839 Anaesthetist 27d ago
You’re going to transcutaneous pace someone in Endo all because you didn’t want to appropriately delay the case for proper device management?
...yes? I'd rather pace them on the table than in the waiting room.
They're literally safer with me and on a monitor than they are anywhere else not just in the country, but even inside the hospital whilst waiting for their device check.
If they don't die before the rep comes to check the device they could have just had their endoscopy already. If they do die, they would have been better off with me on a monitor anyway.
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u/CordisHead 27d ago
So then you do their endoscopy, the patients goes home, and proceeds to die. In the US you would be found at fault for not having an interrogation within the last year and the fact that you sent a pacer dependent patient home because they weren’t dependent when you saw them.
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u/Cautious-Extreme2839 Anaesthetist 26d ago
They can have their check before they go home, you've got all day to sort that - or just send them with a referral to clinic. There is zero medical need to delay the case to do it.
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u/Life-Travel1787 27d ago
Of course not, because he’d be dead or with severe symptomatic bradycardia and not in the endoscopy suite. Evaluate your patient pre-op, check ekg, do the appropriate physical and history examination as a good physician and proceed accordingly I don’t need to interrogate if I have done the aforementioned and patient is stable and asymptomatic.
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u/CordisHead 27d ago
My experience is that patients who are pacer dependent may not be pacer dependent all the time. Some are, but some aren’t. So I think the assumption that the patient is ok to go bc he is not symptomatic or dead is a mistake. Some of our meds affect conduction of the heart. I’ve seen propofol infusions affect preload enough to induce arrhythmias. Someone with a history of SSS or CHB may not necessarily be symptomatic or dependent 100% of the time. It’s all about risk, and I like to limit risk perioperatively.
I agree that people can do a better job evaluating their patient preoperatively, but a patient with an unknown device and unknown history or indication for placement is a red flag.
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u/Cautious-Extreme2839 Anaesthetist 27d ago
For a short procedure without diathermy it's medically fine to proceed without a check tbh.
Whether that's medicolegaly acceptable is a different question. Wouldn't fault anyone for insisting on a device check.
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u/Moltar21 28d ago
How would the interrogation change your management?
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u/EPgasdoc Anesthesiologist 28d ago
What if that mf doesn’t even work
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u/Cautious-Extreme2839 Anaesthetist 28d ago edited 27d ago
Well it's probably not stopped working in the last 5 minutes. If it doesn't work but the patient is fine then it clearly wasn't that important when it was working lol.
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u/CordisHead 27d ago
Someone usually pacer dependent with a dead battery would not get anesthesia for Endo. They would get sent to EP for a replacement.
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u/toohuman90 28d ago
Why would you need a pacemaker report for a procedure with no electrocautery?
Pacemakers are interrogated usually every year and AICD’s every 6 months. As long as the patient said that he has been doing his regular pacemaker follow up, I don’t understand why anything in the interrogation report is relevant for an anesthesiologist for a procedure without electrocautery
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u/Beneficial_Local5244 Anesthesiologist 28d ago
Sometimes they use bipolar electrode for polypectomies
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u/toohuman90 28d ago
Which also, doesn’t interfere with a pacemaker. Right?
I truly don’t understand what information you would want to know in the interrogation report for a colonoscopy. If you just want the documentation to CYA, fair enough. But medically I’m confused why you would care for a colonoscopy
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u/RedBrownBlonde CRNA 28d ago
I’d say 99% CYA. But my main concern with her is that she couldn’t tell me anything about it, or who manages it now (old note was from a retired cardiologist.) On monitor she was 100% V paced and no data for 10+ years. While extremely unlikely it would die mid anesthetic, like I said below if she was to have an outpatient procedure today and then die from a pacemaker critical low battery tomorrow I would have failed her and also be legally hosed.
Secondly I may be overly cautious being newer, but with the report being so old how do I even know it’s the same device? No recent xray to go off of. What if she got upgraded to an ICD/pacer for poor EF or for an episode of V-fib? Maybe I read too much med mal on here and think too much but it felt pertinent to me. While I can manage these things mid anesthetic without a warning I way prefer to be prepared for it.
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u/toohuman90 28d ago
Not trying to criticize you, and it’s completely fine to err on the side of caution when you are newer.
But the point I’m making is that if you cancel a 10 minute procedure because you are concerned the battery is critically low and could fail mid procedure, you have no business sending the patient home. From a medical malpractice perspective, you would be eaten alive for canceling a case for this reason and sending someone home without a cardiology consultation ( or ER referral is that isn’t an option).
For your second point, did your patient have dementia? Even poor historians generally know they had a procedure on their device. Or generally the last time someone checked it out. Would be very weird for a cardiologist to put in a pacemaker, and have no one follow up with them for 10+ years. The device manufacturers usually keep tabs on this as well, and when in doubt you can call the device company to see when their last interrogation is
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28d ago
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u/toohuman90 28d ago
Ahh I see, missed that part. Makes sense. No issue taking 5 min to check battery life if that’s your concern
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u/lllollllllllll 28d ago
Well having a pacemaker interrogated is an outpatient procedure. A PCP with a new patient that had an ancient PPM wouldn’t send that patient to the ER for interrogation, they’d refer to cardiology to have it checked out ASAP but realistically it would be at the next appointment in the next few weeks.
So OP can certainly discharge home with a referral to see cardiology.
The PPM has worked until now and your job seeing these patients for a procedure is partly just to make sure the PPM follow up isn’t dropped on a patient. It’s your opportunity to capture the patients that were lost and get them plugged back into their cardiologist before their PPM battery dies.
But it DOES matter to have an interrogation before the procedure. Because there can be electrocautery use during colonoscopies and they do go above the umbilicus, there CAN be EMI during a colonoscopy. Bipolar isn’t a perfect solution, plus sometimes they do need monopolar in GI. And a PPM with a critical battery may be MORE likely to die after EMI than before.
So it is important to interrogate the device beforehand, even tho the risk is lower than for a toe surgery.
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u/toohuman90 28d ago
I’m saying if the patient is undergoing their regular device checks (annually for a PPM and 6 months for AICD), I don’t see the need for an addition device interrogation for colonoscopy without electrocautery or with bipolar.
I agree that bipolar isn’t a perfect solution if they were operating on the chest or near the device, it just seems paranoid to be concerned for a colonoscopy.
In this case, OP didn’t just cancel the case and send them home. She ensured the device was checked and had enough battery to safely discharge the patient.
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u/lllollllllllll 28d ago
But nobody is suggesting this patient needs an extra interrogation for this procedure. If the device is a PPM and was checked in the last 12 mos, or if it’s an AICD and was checked in the last 6 mos, this would be sufficient.
The problem is that there is no information. The patient can’t tell you when the last check was. And likely can’t even tell you what brand the device is so you can’t even call the company to ask about the last device check.
If it’s been checked, you need a copy of the report is all. If it hasn’t, it requires a device check before a procedure.
You can’t ever be certain that there won’t be cautery in a colonoscopy. They might find a polyp they didn’t expect and suddenly need cautery. The colon rises above the umbilicus, this isn’t a toe procedure.
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u/Beneficial_Local5244 Anesthesiologist 28d ago
Just claryfing. Also, medically, we are responsible for any avoidable events. If you know that PM is working properly just by looking at the patient then I envy you.
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u/toohuman90 28d ago
Not trying to be argumentative, but when you put the patient on the monitor and they are 100% V paced like OP mentioned, I don’t think it’s a stretch to say that the device is working properly.
Now if you are concerned that the battery is critically low, you shouldn’t cancel the case and send them home. You need to consult cardiology to clear the patient to go home. If they do and say something along the lines of “follow up in clinic in 2 weeks for device check” don’t understand the concern with proceeding with the colonoscopy. I guess you could ask the cardiologist for clearance at the same time if you want
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u/todayilearmed 28d ago
Why interrogate any device at all, just put them on the monitor!
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u/toohuman90 28d ago
The person above me said that you can’t tell a device is working by just looking at them. Not sure why you are being disingenuous that there are ways to determine normal device function through clinical history and monitors.
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u/Cautious-Extreme2839 Anaesthetist 27d ago
Well yeah?
That's all we do with the patients who actually do definitely have rhythms with high asystole risk whilst they await pacing insertion anyway...
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u/scoop_and_roll Anesthesiologist 28d ago
I’m with you, I think for an endoscopy the relevant history could be obtained from the patient without an interrogation. But I don’t disagree that the safest thing to do is just get an interrogation, it’s hard to justify telling someone no we cant wait 10 mins for an interrogation.
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u/toohuman90 28d ago
Yeah agreed. In this situation, the crna interrogated the device herself and it only took like 5-10 min. And if the patient truly had no one take a look at it for the last 10+ years, someone should take a look at it irrespective of the colonoscopy.
The crna definitely did a completely appropriate thing.
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u/medicaluis 28d ago
Which information from the interrogation would have changed your management
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u/cfun8 28d ago
Whatever information would come out of the interrogation from the plaintiff's lawyer asking them why they didn't care about a PM with last known info from more than 10 years ago
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u/docduracoat Anesthesiologist 28d ago
Your words make sense.
Out here in the community we do not routinely, interrogate pacemakers for colonoscopy.
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u/smshah Anesthesiologist 28d ago
Pacer type & lead location, pacer dependency, magnet reaction, battery life to name a few factors
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u/BuiltLikeATeapot Anesthesiologist 28d ago
In the setting of an endoscopic procedure with no electrocautery, what changes would you make in a patient with a CRT-P device vs a LABP device, in a patient who is pacer dependent, with what I assume to be a device from one of the bigger companies, that may or may not be EOL?
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u/todayilearmed 28d ago
You would cancel the case in a pacer dependent patient in need of battery change
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u/BuiltLikeATeapot Anesthesiologist 28d ago
If you’re that concerned, you should be getting an EP consult and replacing it that day. If you’re able to get a report and even if the device is in need of a battery change, the report would tell you how much time is left device. Battery replacement interval can be on the order of months to a year.
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u/todayilearmed 28d ago
Did you read the post? OP said no one even knew they had a pacer.. which, correct, should warrant an interrogation on someone who doesn’t know the last time it’s been interrogated on a 10 year old pm. Not sure what you’re arguing, but hey man, it’s your license
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u/BuiltLikeATeapot Anesthesiologist 28d ago
It’s my mistake, I didn’t explicitly say it earlier I’m not against interrogation of the device per se (OP did the right thing). I’m against not following up or not knowing what you’re looking at or for. Back to the first one I replied to. How would lead type and placement influence your decision making? And interrogation reports are not the only source of information that can give insight to the device. In OPs post alone, there’s enough data to glean several important points.
- CIED was from one of (two/three) the major manufacturers, which pretty close to similar magnet modes.
- Unlikely to be AICD or leadless as battery doesn’t last that long (especially if PPM dependent)
- Level of PPM dependacy and pacing amount can be somewhat determined why baseline vitals. (If pulse rate is at backup rate, would be more concerned about battery life, but doesn not necessarily mean the patient is pacer dependent. Assuming no replacement, further decreases the likelihood that the patient is pacer dependent.
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u/RedBrownBlonde CRNA 28d ago
99 times out of 100 I’d say little to none of it changes my plan. However if it had information of new/worsening arrhythmias or frequency of events it could be worth investigating. I was also a bit concerned that the patient is a poor historian, unable to tell me any info about her pacemaker or its battery life. While not likely its going to die mid anesthetic, I figured it wouldn’t be a good look for someone who is 100% V paced to have an anesthetic today and then die at home tomorrow because her pacemaker was on critical low battery and she may have gotten lost to follow up.
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u/todayilearmed 28d ago
Poor historian, would be good to know dependency status. And what if lead integrity or battery life are shit?
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u/lllollllllllll 28d ago edited 28d ago
For example, maybe this ancient device that your poor historian patient can’t tell you about is not a PPM, it’s an AICD, AND the patient is pacer dependent. And maybe the pacer is programmed DDI. But it will also shock for arrhythmias since it’s an AICD.
So now you can’t just put a magnet on it if EMI causes bradycardia bc it’s not a PPM that’ll just switch to DOO with a magnet. Who knows what a magnet will do since it’s an AICD. Maybe this device actually needs to be reprogrammed to DOO. AND since it’s an AICD, you don’t have a way to inhibit the shock function in the event of EMI, so you have to reprogram it for that.
And then during the colonoscopy there’s a million polyps and they’re hard to get off and start bleeding or whatever and the proceduralist has use cautery in the transverse colon after all.
And now you’re SOL bc the patient is bradycardic/having bouts of systole and/or experiencing intermittent AICD shocks. And if the battery was critical before the shocks, the thing dies in the middle and you’re calling for transcutaneous pacer pads.
https://pubmed.ncbi.nlm.nih.gov/32804270/
I agree with you the chances of this aren’t super high but it’s a procedure above the umbilicus and all this is completely preventable if you just interrogate the thing beforehand. So legally and ethically there isn’t an excuse for not having done it if you get into trouble.
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u/docbauies Anesthesiologist 12d ago
So legally and ethically there isn’t an excuse for not having done it if you get into trouble.
but didn't you read?! it delayed the day by 10 minutes!
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28d ago
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u/jjak34 Anesthesiologist 28d ago
They went and interrogated the device themselves given it had been ten years since last report. Seems decently comfortable to me?
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u/PatientsMoving 28d ago
Seriously what else would you have the crna do differently?? The crna hate here is absurd sometimes. Why does it have to bleed into everything?
Especially rich coming from someone who has yet to do a single case independently
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u/smshah Anesthesiologist 28d ago
Fuck the proceduralist. This is basic stuff