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Practice Parameter  |   February 2011
Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable Cardioverter-Defibrillators: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Implantable Electronic Devices
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Practice Parameter / Cardiovascular Anesthesia / Technology / Equipment / Monitoring
Practice Parameter   |   February 2011
Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable Cardioverter-Defibrillators: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Implantable Electronic Devices
Anesthesiology 2 2011, Vol.114, 247-261. doi:10.1097/ALN.0b013e3181fbe7f6
Anesthesiology 2 2011, Vol.114, 247-261. doi:10.1097/ALN.0b013e3181fbe7f6
PRACTICE advisories  are systematically developed reports that are intended to assist decision-making in areas of patient care. Advisories are based on a synthesis of scientific literature and analysis of expert opinion, clinical feasibility data, open forum commentary, and consensus surveys. Advisories developed by the American Society of Anesthesiologists (ASA) are not intended as standards, guidelines, or absolute requirements, and their use cannot guarantee any specific outcome. They may be adopted, modified, or rejected according to clinical needs and constraints.
The use of practice advisories cannot guarantee any specific outcome. Practice advisories summarize the state of the literature and report opinions obtained from expert consultants and ASA members. Practice advisories are not supported by scientific literature to the same degree as standards or guidelines because of the lack of sufficient numbers of adequately controlled studies. Practice advisories are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.
This document updates the “Practice Advisory for the Perioperative Management of Patients with Cardiac Rhythm Management Devices: Pacemakers and Implantable Cardioverter-Defibrillators, adopted by the ASA in 2004 and published in 2005.1
Methodology
A. Definition of Cardiac Implantable Electronic Devices
For this Advisory, a cardiac implantable electronic device (CIED) refers to any permanently implanted cardiac pacemaker or any implantable cardioverter-defibrillator (ICD). The term CIED also refers to any cardiac resynchronization device.2
B. Purposes of the Advisory
The purposes of this Advisory update are to (1) facilitate safe and effective perioperative management of the patient with a CIED and (2) reduce the incidence of adverse outcomes. Perioperative management refers to the preoperative, intraoperative, postoperative, or recovery period in any setting where an anesthesia provider will be delivering anesthesia care. Adverse outcomes associated with a CIED include, but are not limited to, damage to the device, inability of the device to deliver pacing or shocks, lead-tissue interface damage, changes in pacing behavior, electrical reset to the backup pacing mode, or inappropriate ICD therapies.3Adverse clinical outcomes include, but are not limited to, hypotension, tachyarrhythmia or bradyarrhythmia, myocardial tissue damage, and myocardial ischemia or infarction. Other related outcomes may include extended hospital stay, delay or cancellation of surgery, readmission to manage device malfunction, or additional hospital resource utilization and cost.
C. Focus
This updated Advisory focuses on the perioperative management of the patient who has a preexisting, permanently implanted CIED for treatment of bradyarrhythmia, tachyarrhythmia, or heart failure. Both inpatient and outpatient procedures are addressed by this update. This update does not address the perioperative management of any patient undergoing CIED implantation or revision. It is not applicable to any patient (1) without a permanently implanted pacemaker or ICD, (2) with a temporary CIED, (3) with a noncardiac implantable device (e.g.  , neurologic or spinal cord stimulator), or (4) with an implantable mechanical cardiac assist device (e.g.  , ventricular assist device). This updated Advisory does not address procedures where there are no known perioperative CIED concerns, such as plain radiography, fluoroscopy, mammograms, or ultrasound.
D. Application
This updated Advisory is intended for use by anesthesiologists and all other individuals who deliver or are responsible for anesthesia care. The update may also serve as a resource for other physicians and health care professionals who manage patients with CIEDs.
E. Task Force Members and Consultants
The original Advisory was developed by an ASA-appointed task force of 12 members, consisting of anesthesiologists and cardiologists in private and academic practices from various geographic areas of the United States and two methodologists from the ASA Committee on Standards and Practice Parameters.
The Task Force developed the original Advisory by means of a six-step process. First, they reached consensus on the criteria for evidence. Second, original published articles from peer-reviewed journals relevant to the perioperative management of cardiac rhythm management devices were evaluated. Third, consultants who had expertise or interest in CIEDs and who practiced or worked in various settings (e.g.  , private and academic practice) were asked to (1) participate in opinion surveys on the effectiveness of various perioperative management strategies and (2) review and comment on a draft of the Advisory developed by the Task Force. Fourth, additional opinions were solicited from random samples of active members of both the ASA and the Heart Rhythm Society (HRS).4Fifth, the Task Force held an open forum at a national anesthesia meeting and at a major cardiology meeting to solicit input on the key concepts of this Advisory.5Sixth, all available information was used to build consensus within the Task Force to finalize the Advisory.
In 2009, the ASA Committee on Standards and Practice Parameters requested that scientific evidence for this Advisory be updated. The update consists of an evaluation of literature that includes new studies obtained after publication of the original Advisory.
F. Availability and Strength of Evidence
Preparation of this update used the same methodological process as used in the original Advisory to obtain new scientific evidence. Opinion-based evidence obtained from the original Advisory is reported in this update. The protocol for reporting each source of evidence is described below.
G. Scientific Evidence
Study findings from published scientific literature were aggregated and are reported in summary form by evidence category, as described below. All literature (e.g.  , randomized controlled trials, observational studies, and case reports) relevant to each topic was considered when evaluating the findings. However, for reporting purposes in this document, only the highest level of evidence (i.e.  , levels 1, 2, or 3 identified below) within each category (i.e.  , A, B, or C) is included in the summary.
Category A: Supportive Literature.
Randomized controlled trials report statistically significant (P  < 0.01) differences between clinical interventions for a specified clinical outcome.
Level 1.
The literature contains multiple, randomized controlled trials, and the aggregated findings are supported by meta-analysis.6
Level 2.
The literature contains multiple, randomized controlled trials, but there is an insufficient number of studies to conduct a viable meta-analysis for the purpose of this Advisory.
Level 3.
The literature contains a single, randomized controlled trial.
Category B: Suggestive Literature.
Information from observational studies permits inference of beneficial or harmful relationships among clinical interventions and clinical outcomes.
Level 1.
The literature contains observational comparisons (e.g.  , cohort, case-control research designs) of clinical interventions or conditions and indicates statistically significant differences between clinical interventions for a specified clinical outcome.
Level 2.
The literature contains noncomparative observational studies with associative (e.g.  , relative risk and correlation) or descriptive statistics.
Level 3.
The literature contains case reports.
Category C: Equivocal Literature.
The literature cannot determine whether there are beneficial or harmful relationships among clinical interventions and clinical outcomes.
Level 1.
Meta-analysis did not find significant differences among groups or conditions.
Level 2.
There is an insufficient number of studies to conduct meta-analysis, and (1) randomized controlled trials have not found significant differences among groups or conditions or (2) randomized controlled trials report inconsistent findings.
Level 3.
Observational studies report inconsistent findings or do not permit inference of beneficial or harmful relationships.
Category D: Insufficient Evidence from Literature.
The lack of scientific evidence in the literature is described by the following terms:
Silent.
No identified studies address the specified relationships among interventions and outcomes.
Inadequate.
The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes. The literature either does not meet the criteria for content as defined in the Focus of the Advisory or does not permit a clear interpretation of findings because of methodological concerns (e.g.  , confounding in study design or implementation).
H. Opinion-based Evidence
The original Advisory contained formal survey information collected from expert consultants, a random sample of members of the ASA, and a random sample of members of the HRS. Additional information was obtained from open-forum presentations and other invited and public sources. All opinion-based evidence relevant to each topic (e.g.  , survey data, open-forum testimony, Internet-based comments, letters, and editorials) was considered in the development of the original Advisory.
Survey responses from Task Force–appointed expert consultants are reported in summary form in the text, with a listing of consultant survey responses reported in 3. In addition, survey responses from active ASA and HRS members are reported in summary form in the text, with a listing of survey responses reported in 3.
Advisories
I. Preoperative Evaluation
A focused preoperative evaluation of CIED patients consists of the following: (1) establishing whether a patient has a CIED, (2) defining the type of device, (3) determining whether a patient is CIED-dependent for antibradycardia pacing function, and (4) determining device function.
Although no controlled trials of the clinical impact of performing a focused preoperative evaluation for CIED patients were found, case reports suggest that incomplete preoperative examination of patients with CIEDs may lead to adverse outcomes (e.g.  , inhibited CIED function and asystole) (Category B3 evidence  ).1,2 
The majority of consultants, ASA members, and HRS members agree that the above four preoperative evaluation activities should be conducted.7
Advisory for Preoperative Evaluation.
A focused preoperative evaluation should include establishing whether a patient has a CIED, defining the type of device, determining whether a patient is CIED-dependent for pacemaking function, and determining CIED function.
Determining whether a patient has a CIED should be based on the following: (1) a focused history including, but not limited to, the patient interview, medical records review, and review of available chest x-rays, electrocardiograms, or any available monitor or rhythm strip information; and (2) a focused physical examination (i.e.  , checking for scars and palpating for device).
Defining the type of device is accomplished by (1) obtaining the manufacturer's identification card from the patient or other source, (2) ordering chest x-rays if no other data are available,8or (3) referring to supplemental resources (e.g.  , manufacturer's databases, pacemaker clinic records, and consultation with a cardiologist).
CIED dependence for pacemaking function may be determined by one or more of the following: (1) a verbal history or an indication in the medical record that the patient has experienced a bradyarrhythmia that has caused syncope or other symptoms requiring CIED implantation, (2) a history of successful atrioventricular nodal ablation that resulted in CIED placement, or (3) a CIED evaluation that shows no evidence of spontaneous ventricular activity when the pacemaking function of the CIED is programmed to VVI pacing mode at the lowest programmable rate.
CIED function is ideally assessed by a comprehensive evaluation of the device.3 If a comprehensive evaluation is not possible, then, at a minimum, confirm whether pacing impulses are present and create a paced beat. Consultation with a cardiologist or CIED service may be necessary. Contacting the manufacturer for perioperative recommendations may be a consideration.
II. Preoperative Preparation
Preparation for patient safety and proper maintenance of the device during a procedure includes (1) determining whether electromagnetic interference (EMI) is likely to occur during the planned procedure; (2) determining whether preoperative reprogramming the CIED pacemaking function to an asynchronous pacing mode or disabling any special algorithms, including rate adaptive functions, is needed; (3) suspending antitachyarrhythmia functions if present; (4) advising the individual performing the procedure to consider use of a bipolar electrocautery system or ultrasonic (harmonic) scalpel to minimize potential adverse effects of EMI on the pulse generator or leads; (5) assuring the availability of temporary pacing and defibrillation equipment; and (6) evaluating the possible effects of anesthetic techniques on CIED function and patient-CIED interactions.
Numerous descriptive studies and case reports suggest that the following procedures are likely to be associated with EMI: (1) electrocautery,4–10 (2) radiofrequency ablation,11–16 and (3) magnetic resonance imaging (MRI),17–30 (Category B2–B3 evidence  ). Studies with observational findings report the occurrence of EMI during radiation therapy,31–33 whereas other observational studies and case reports indicate no apparent EMI effects (Category B2–B3 evidence  ).34,35 Studies with observational findings report the occurrence of EMI during lithotripsy,36,37 whereas other observational studies and case reports indicate no apparent EMI effects (Category B2–B3 evidence  ).38–41 No studies were found that reported EMI during electroconvulsive therapy (ECT) (Category D evidence  ). Case reports indicate that inappropriately high pacing rates may occur as a result of EMI effects between cardiac monitoring equipment and CIEDs with active minute entilation sensors.42–44 
No controlled trials of the clinical impact of programming the pacemaking function to an asynchronous mode for a procedure were found (Category D evidence  ). Although a case report suggests that such reprogramming may be beneficial during electrocautery,45 other reports indicate that EMI may continue to affect reprogrammed pacemakers (Category B3 evidence  ).46,47 The literature lacks sufficient guidance regarding the potential perioperative impact of anesthetic techniques on CIED function (Category D evidence  ).
The majority of consultants, ASA members, and HRS members agree that it should be determined whether EMI is likely to occur before a planned procedure. The majority of consultants agree that a CIED's rate-adaptive therapy should be turned off before a procedure, whereas the ASA and HRS members are equivocal. The majority of consultants and HRS members disagree that all patients' CIEDs should be programmed to an asynchronous mode before surgery, whereas the ASA members are equivocal. In addition, the majority of consultants and HRS members agree that pacemaker-dependent patients' CIEDs should be programmed to an asynchronous mode before surgery, whereas the ASA members are again equivocal. The majority of consultants, ASA members, and HRS members agree that (1) suspending antitachyarrhythmia functions if present, (2) advising the individual performing the procedure to consider use of a bipolar electrocautery system to minimize potential adverse effects of EMI on the pulse generator or leads, (3) assuring the availability of temporary pacing and defibrillation equipment, and (4) evaluating the possible effects of anesthetic techniques on CIED function and patient-CIED interactions are important steps in promoting patient safety and successfully managing patients with CIEDs. The consultants and ASA members agree, and HRS members are equivocal regarding the consideration of using an ultrasonic scalpel.
Advisory for Preoperative Preparation.
Planned procedures should include a determination of whether EMI is likely to occur for either conventional pacemakers or ICDs. If EMI is likely to occur, the conventional pacing function of a CIED should be altered by changing to an asynchronous pacing mode9in pacemaker-dependent patients and suspending special algorithms, including rate-adaptive functions.10These alterations may be accomplished by programming or applying a magnet when applicable.11However, the Task Force cautions against the routine use of the magnet over an ICD.12In addition, an ICD's antitachyarrhythmia functions should be suspended if present. For the ICD patient who depends on pacing function for control of bradyarrhythmia, these functions should be altered by programming as noted above. Consultation with a cardiologist or pacemaker ICD service may be necessary.
For all CIEDs, consider advising the individual performing the procedure to use a bipolar electrocautery system or an ultrasonic scalpel when applicable. Temporary pacing and defibrillation equipment should be immediately available before, during, and after a procedure.
Finally, the Task Force believes that anesthetic techniques do not influence CIED function. However, anesthetic-induced physiologic changes (i.e.  , cardiac rate, rhythm, or ischemia) in the patient may induce unexpected CIED responses or adversely affect the CIED-patient interaction.
III. Intraoperative Management
The primary activities associated with intraoperative management of a CIED include the following: (1) monitoring the operation of the device; (2) preventing potential CIED dysfunction; and (3) performing emergency defibrillation, cardioversion, or heart rate support.
Intraoperative Monitoring.
Intraoperative monitoring includes continuous electrocardiography as well as monitoring of the peripheral pulse (e.g.  , palpation of the pulse, auscultation of heart sounds, monitoring of a tracing of intra-arterial pressure, ultrasound peripheral pulse monitoring, or pulse plethysmography or oximetry).48 Although no controlled trials were found that examine the clinical impact of electrocardiography or peripheral pulse monitoring for CIED patients, case reports note the importance of intraoperative electrocardiography monitoring in the detection of pacemaker or cardiac dysfunction for these patients (Category B3 evidence  ).2,49–53 
The majority of consultants, ASA members, and HRS members agree that (1) continuous electrocardiographic monitoring should be done for all CIED patients and (2) continuous peripheral pulse monitoring should be conducted.
Advisory for Intraoperative Monitoring.
ECG and peripheral pulse monitoring are important components of perioperative management of the patient with a CIED. A patient's electrocardiogram should be continuously displayed, as required by ASA standards, from the beginning of anesthesia until the patient is transferred out of the anesthetizing location, with additional electrocardiographic monitoring in the postoperative period as indicated by the patient's medical condition.48,54 These standards should apply to all CIED patients receiving general or regional anesthesia, sedation, or monitored anesthesia care. Continuous peripheral pulse monitoring should be performed for all CIED patients receiving general or regional anesthesia, sedation, or monitored anesthesia care. If unanticipated device interactions are found, consider discontinuation of the procedure until the source of interference can be eliminated or managed.
Managing Potential Sources of EMI.
Procedures using electrocautery, radiofrequency ablation, lithotripsy, MRI, or radiation therapy may damage CIEDs or interfere with CIED function, potentially resulting in severe adverse outcomes. Sources of EMI are often unique to specific procedures, and the management of each of these potential EMI sources is reported separately below.
Electrocautery.
Management of potential sources of EMI associated with electrocautery includes (1) assuring that the cautery tool and current return pad13are positioned so the current pathway does not pass through or near the CIED pulse generator and leads; (2) avoiding proximity of the cautery's electrical field to the pulse generator or leads; (3) using short, intermittent, and irregular bursts at the lowest feasible energy levels; and (4) using a bipolar electrocautery system or an ultrasonic (harmonic) scalpel if possible.
There is insufficient literature to evaluate whether positioning the current pathway away from the CIED pulse generator and leads reduces the occurrence of EMI.
Two case reports52,55 and one observational study56 suggest that EMI may occur in spite of positioning the current return pad as far as possible away from the generator and leads (Category B2–B3 evidence  ). One case report suggested that application of unipolar electrocautery on the sternum resulted in complete pacemaker inhibition (Category B3 evidence  ).1 
Although no recent studies were found examining the benefit of using short, intermittent bursts at the lowest feasible energy levels, previous literature14suggests that short, intermittent bursts may be useful in completing procedures without notable EMI interference (Category B2–B3 evidence  ).57–60 One case report describes pacemaker failure when short bursts of electrocautery current were used (Category B3 evidence  ).60 
Finally, case reports suggest that surgery for pacemaker patients may proceed uneventfully when bipolar electrocautery systems45,46,49 or harmonic scalpels61,62 are used (Category B3 evidence  ). However, a case report describes pacemaker failure occurring when bipolar electrocautery was used (Category B3 evidence  .63 
The majority of consultants, ASA members, and HRS members agree that the current return pad should be positioned so the electrosurgical current pathway does not pass through or near the CIED pulse generator or leads. The majority of consultants, ASA members, and HRS members agree that direct contact between the electrocautery system and the CIED pulse generator or its leads should be avoided. The majority of consultants, ASA members, and HRS members agree that short, intermittent bursts should be performed. The majority of consultants and ASA members agree that harmonic scalpels should be used when possible, and HRS members are equivocal. The majority of consultants, ASA members, and HRS members agree that bipolar electrocautery systems should be used when possible.
Advisory for Managing EMI from Electrocautery.
The Task Force believes that EMI could be minimized during certain procedures using a variety of intraoperative management techniques. The risk of intraoperative interference from electrocautery systems may be minimized by (1) positioning the cautery tool and current return pad, so the current pathway does not pass through or near the CIED system15; (2) avoiding proximity of the cautery's electrical field to the pulse generator and leads, including avoidance of waving the activated electrode over the generator16; (3) using short, intermittent, and irregular bursts at the lowest feasible energy levels; and (4) using bipolar electrocautery systems or ultrasonic (harmonic) scalpels if possible. Advising or reminding the individual performing the procedure to implement these management techniques should be considered.
Radiofrequency (RF) Ablation.
Management of potential sources of EMI associated with RF ablation primarily involves keeping the RF current path (electrode tip to current return pad) as far away from the pulse generator and lead system as possible. One observational study reports 3 of 12 cases that resulted in a significant drop in resistance on the pacemaker leads when RF ablation was used in proximity to the leads (Category B2 evidence  ).64 One case report suggests that positioning of the RF ablation cluster electrode no closer than 5 cm from the pacer leads allowed the procedure to continue uneventfully (Category B3 evidence  ).65 
The majority of consultants, ASA members, and HRS members agree that the individual performing the procedure should avoid direct contact between the ablation catheter and the CIED and leads and should keep the RF ablation current path as far away from the pulse generator and lead system as possible.
Advisory for Managing EMI from RF Ablation.
The risk of interference from RF ablation may be reduced by avoiding direct contact between the ablation catheter and the pulse generator and leads and keeping the RF's current path (electrode tip to current return pad) as far away from the pulse generator and leads as possible. During all RF ablative procedures, consider discussing with the individual performing the procedure any concerns regarding the proximity of the ablation catheter to the CIED leads.
Lithotripsy.
Management of potential sources of EMI associated with lithotripsy includes (1) avoiding focus of the lithotripsy beam near the pulse generator and (2) disabling atrial pacing if the lithotripsy system triggers on the R-wave. The literature is silent regarding the benefits of focusing the lithotripsy beam away from the pulse generator as well as the benefits of disabling atrial pacing during lithotripsy (Category D evidence  ).
The majority of consultants, ASA members, and HRS members agree that focusing the lithotripsy beam near the pulse generator should be avoided, and all three groups are equivocal regarding whether atrial pacing should be disabled before a procedure if the lithotripsy system triggers on the R-wave.
Advisory for Managing EMI from Lithotripsy.
During lithotripsy, the lithotripsy beam should not be focused near the pulse generator. If the lithotripsy system triggers on the R-wave, atrial pacing might need to be disabled before the procedure.
Magnetic Resonance Imaging.
There is insufficient rigorous literature to examine the effects of specific management activities related to CIED patients receiving MRI (Category D evidence  ). Observational studies and case reports suggest that the MRI may be completed without notable EMI under specific circumstances and with appropriate patient qualification and monitoring (Category B2–B3 evidence  ).17,66–69 However, other literature generally suggests that MRI is contraindicated (Category B2–B3 evidence  ).21–25,28,30 
The majority of consultants, ASA members, and HRS members generally agree that an MRI is contraindicated for all CIED patients.
Advisory for Managing EMI from Magnetic Resonance Imaging.
An MRI is generally contraindicated for CIED patients. If an MRI must be performed, consult with the ordering physician, the patient's pacemaker specialist or cardiologist, the diagnostic radiologist, and the CIED manufacturer.
Radiation Therapy.
The literature does not provide sufficient guidance regarding specific management activities related to CIED patients undergoing radiation therapy (Category D evidence  ).
None of the consultants or HRS members and only 10% of the ASA members agree that radiation therapy is contraindicated for all CIED patients. Fifty-seven percent of the consultants, 59% of the HRS members, and 37% of the ASA members agree that radiation therapy is contraindicated for some but not all CIED patients, whereas 43% of the consultants, 41% of the HRS members, and 53% of the ASA members agree that radiation therapy is not contraindicated for any CIED patient.
Advisory for Managing EMI from Radiation Therapy.
The Task Force believes that radiation therapy can be safely performed for CIED patients.17The device must be outside the field of radiation. Therefore, some pulse generators will require surgical relocation before commencing radiation. Most manufacturers recommend verification of pulse generator function during and at the completion of radiation. Problems may include pacemaker failure and runaway pacemaker.18
Electroconvulsive Therapy.
No clinical studies were found that report EMI effects or permanent CIED malfunctions associated with electroconvulsive therapy (ECT) (Category D evidence  ). One study reports two cases where patients' ICDs were turned off before ECT but does not report the effect of the therapy on ICD function (Category B3 evidence  ).70 However, the author indicates that treatment with ECT might be associated with significant cardiac risks. Transient electrocardiographic changes (e.g.  , increased P-wave amplitude, altered QRS shape, and T-wave and ST-T abnormalities) may result from ECT, and additional cardiac complications (e.g.  , arrhythmia or ischemia) may occur in patients with preexisting cardiac disease. Finally, physiologic stresses after ECT, such as a period of bradycardia and reduced blood pressure followed by tachycardia and a rise in blood pressure, may account for cardiac failure in the extended postoperative period (i.e.  , several hours or days after ECT) among patients with marginal cardiac function.
Advisory for Managing EMI from Electroconvulsive Therapy.
Although transient or long-term myocardial and nervous system effects may be associated with ECT, the Task Force believes that such therapies may be administered to CIED patients without significant damage to a disabled CIED. If ECT must be performed, consult with the ordering physician and the patient's cardiologist to plan for the first and subsequent ECT's. All CIEDs should undergo a comprehensive interrogation before the procedure(s). ICD functions should be disabled for shock therapy during ECT; however, be prepared to treat ventricula arrhythmias that occur secondary to the hemodynamic effects of ECT. CIED-dependent patients may require a temporary pacing system to preserve cardiac rate and rhythm during shock therapy. Also, the CIED may require programming to asynchronous activity to avoid myopotential inhibition of the device in pacemaker-dependent patients.
Emergency Defibrillation or Cardioversion.
During the perioperative period, emergency defibrillation or cardioversion may become necessary for the CIED patient. In this case, the primary concern is to minimize the current flowing through the pulse generator and lead system. Case reports suggest that optimal positioning of the defibrillation or cardioversion pads or paddles may be an important factor in the prevention of adverse CIED-related outcomes.71–75 
The majority of consultants, ASA members, and HRS members agree that positioning the defibrillation or cardioversion pads as far as possible from the pulse generator should be done. The majority of consultants, ASA members, and HRS members also agree that the anterior-posterior position should be used and that a clinically appropriate energy output should be used regardless of the type of CIED.
Advisory for Emergency Defibrillation or Cardioversion.
Before attempting emergency defibrillation or cardioversion of the patient with an ICD and magnet-disabled therapies, all sources of EMI should be terminated and the magnet removed to reenable antitachycardia therapies. The patient should then be observed for appropriate CIED therapy. For the patient with an ICD and antiarrhythmic therapies that have been disabled by programming, consider reenabling therapies through programming. If the above activities fail to restore ICD function, proceed with emergency external defibrillation or cardioversion.
Overriding the above discussion is the need to follow existing ACLS and emergency guidelines76 to provide rapid cardioversion or defibrillation, and attention should be turned to providing this therapy as quickly as possible.
If a life-threatening arrhythmia occurs, follow ACLS guidelines for energy level and for paddle placement. If possible, attempt to minimize the current flowing through the pulse generator and lead system by (1) positioning the defibrillation or cardioversion pads or paddles as far as possible from the pulse generator and (2) positioning defibrillation or cardioversion pads or paddles perpendicular to the major axis of the CIED pulse generator and leads to the extent possible by placing them in an anterior-posterior location. A clinically-appropriate energy output should always be used regardless of the presence of a CIED, and the paddles should be positioned as best as can be done in an emergency.
IV. Postoperative Management
Postoperative management of CIED patients primarily consists of interrogating and restoring CIED function. One observational study and a case report indicate that postoperative pacemaker checks revealed the need to alter pacing mode or other parameters, which included increasing ventricular pacing output because of pacing threshold increase (Category B2-B3 evidence  ).77,78 The case report also indicates that a postoperative check of a pacemaker identified a safety mode reset, which they attributed to EMI from monopolar electrosurgery. A second observational study indicates that a postoperative ICD check identified the appearance of the elective replacement indicator, probably from EMI during surgery (Category B2 evidence  ).79 In addition, this report identifies EMI detections on the atrial lead in both pacemakers and defibrillators and on the ventricular lead in patients with pacemakers, without significant consequence to the patients.
The majority of consultants, ASA members, and HRS members agree that postoperative patient management should include interrogating and restoring CIED function in the postanesthesia care unit or the intensive care unit.
Advisory for Postoperative Management.
Cardiac rate and rhythm should be monitored continuously throughout the immediate postoperative period. Back-up pacing capability and cardioversion-defibrillation equipment should be immediately available at all times.
Postoperative interrogation and restoration of CIED function are basic elements of postoperative management. The CIED first should be interrogated to assess postoperative device functions.19If interrogation determines that CIED settings are inappropriate, then the device should be reprogrammed to appropriate settings. For an ICD, all antitachyarrhythmic therapies should be restored. Consultation with a cardiologist or pacemaker-ICD service may be necessary.
Appendix 1: Generic Pacemaker and Defibrillator Codes
The generic pacemaker and defibrillator codes were developed as joint projects by the North American Society of Pacing and Electrophysiology (NASPE)20and the British Pacing and Electrophysiology Group (BPEG).80,81 The five positions refer to the order of the programmed settings on the CIED (tables 1 and 2).
Table 1.  Generic Pacemaker Code (NBG): NASPE/BPEG Revised (2002)
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Table 1.  Generic Pacemaker Code (NBG): NASPE/BPEG Revised (2002)
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Table 2.  Generic Defibrillator Code (NBD): NASPE/BPEG
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Table 2.  Generic Defibrillator Code (NBD): NASPE/BPEG
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Appendix 2: Summary of Advisory Statements‡‡‡‡
Appendix 3: Methods and Analyses
State of the Literature
For this updated Advisory, a review of the studies used in the development of the original Advisory and published after 1990 were combined with studies published subsequent to approval of the original Advisory. The updated literature review was based on evidence linkages, consisting of directional statements about relationships between specific perioperative management activities and CIED function or clinical outcomes.
For the literature review, potentially relevant studies were identified via  electronic and manual searches of the literature. The updated electronic search covered a 7-yr period from 2004 to 2010. The manual search covered a 21-yr period of time from 1990 to 2010. Because CIEDs represent a rapidly changing technology, previous literature (i.e.  , literature published before 1990) was rarely included in the evaluation of evidence for this Practice Advisory. More than 300 citations that addressed topics related to the evidence linkages were initially identified. These articles were reviewed and combined with pre-2004 articles used in the original Advisory, resulting in a total of 134 articles that contained direct linkage-related evidence. There was no sufficient literature with well-defined experimental designs and statistical information to conduct an analysis of aggregated studies (i.e.  , meta-analysis) contained in the evidence linkage. A complete bibliography used to develop this updated Advisory, organized by section, is available as Supplemental Digital Content 1, .
For the original Advisory, an interobserver agreement among Task Force members and two methodologists was established by interrater reliability testing. Agreement levels using a kappa (κ) statistic for two-rater agreement pairs were as follows: (1) type of study design, κ= 0.72 to 0.90; (2) type of analysis, κ= 0.80 to 0.90; (3) evidence linkage assignment, κ= 0.84 to 1.00; and (4) literature inclusion for database, κ= 0.70 to 1.00. Three-rater chance-corrected agreement values were as follows: (1) study design, Sav = 0.81, Var (Sav) = 0.010; (2) type of analysis, Sav = 0.86, Var (Sav) = 0.009; (3) linkage assignment, Sav = 0.82 Var (Sav) = 0.005; and (4) literature database inclusion, Sav = 0.78 Var (Sav) = 0.031. These values represent moderate-to-high levels of agreement.
Consensus-based Evidence
For the original Advisory, consensus was obtained from multiple sources, including (1) survey opinions from consultants who were selected based on their knowledge or expertise in perioperative management of CIEDs, (2) survey opinions from randomly selected samples of active members of the American Society of Anesthesiologists and active members of the Heart Rhythm Society, (3) testimony from attendees of two publicly-held open forums at a national anesthesia meeting and at a major cardiology meeting, (4) Internet commentary, and (5) Task Force opinion and interpretation. The survey rate of return was 56% (n = 23/41) for Consultants, 15% (n = 89/600) for the ASA membership, and 15% (n = 44/300) for the HRS membership (tables 3 and 4).
Table 3.  Example of a Stepwise Approach to the Perioperative Management of the Patient with a Cardiac Implantable Electronic Device
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Table 3.  Example of a Stepwise Approach to the Perioperative Management of the Patient with a Cardiac Implantable Electronic Device
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Table 3.  Continued
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Table 3.  Continued
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Table 4.  Consultant and Membership Survey Responses: Percent Agreement/Disagreement
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Table 4.  Consultant and Membership Survey Responses: Percent Agreement/Disagreement
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Table 4.  Continued
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Table 4.  Continued
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For the original Advisory, an additional survey was sent to the consultants asking them to indicate which, if any, of the evidence linkages would change their clinical practices if the Advisory was instituted. The rate of return was 39% (n = 16/41). The percent of responding Consultants expecting no change  associated with each linkage were as follows: preoperative evaluation, 67%; preoperative patient preparation, 67%; intraoperative monitoring of CIEDs, 67%; emergency defibrillation or cardioversion, 87%; postoperative monitoring of CIEDs, 73%; postoperative interrogation and restoration of CIED function, 60%; and intraoperative management of EMI during: electrocautery, 73%; radiofrequency ablation, 73%; lithotripsy, 80%; MRI, 80%; radiation therapy, 80%; and electroconvulsive therapy, 73%. Forty percent of the respondents indicated that the Advisory would have no effect  on the amount of time spent on a typical case. Nine respondents (60%) indicated that there would be an increase in the amount of time they would spend on a typical case with the implementation of this Advisory. The amount of increased time anticipated by these respondents ranged from 5–30 minutes.
Table 1.  Generic Pacemaker Code (NBG): NASPE/BPEG Revised (2002)
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Table 1.  Generic Pacemaker Code (NBG): NASPE/BPEG Revised (2002)
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Table 2.  Generic Defibrillator Code (NBD): NASPE/BPEG
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Table 2.  Generic Defibrillator Code (NBD): NASPE/BPEG
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Table 3.  Example of a Stepwise Approach to the Perioperative Management of the Patient with a Cardiac Implantable Electronic Device
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Table 3.  Example of a Stepwise Approach to the Perioperative Management of the Patient with a Cardiac Implantable Electronic Device
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Table 3.  Continued
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Table 3.  Continued
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Table 4.  Consultant and Membership Survey Responses: Percent Agreement/Disagreement
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Table 4.  Consultant and Membership Survey Responses: Percent Agreement/Disagreement
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Table 4.  Continued
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Table 4.  Continued
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