Pacemaker / ICD Generator Change
Patient phenotype
Battery depletion (5-10 yr life). HF with CRT/ICD. Prior MI. AF with VVI. Comorbidities significant in this population.
Procedure
L (or R) pectoral pocket reopened, generator replaced (leads usually retained), wound closed. ~30-60 min. Outpatient or short stay.
Anesthetic plan
MAC + local typical. GA reserved for anxious/uncooperative or new lead complexity. Disable ICD shock function before electrocautery (magnet OR program).
Setup
- ·Standard monitors
- ·PIV
- ·Magnet (donut style) at hand
- ·Defib pads on patient (anterior-posterior, not L pectoral)
- ·Cardiology/EP nurse for device interrogation
- ·Atropine, isoproterenol, transcutaneous pacing available
Biggest concerns by phase
Device interrogation + management plan
Cardiology interrogates device — type (PPM, ICD, CRT), lead state, dependency, programming. ICD: disable shock (magnet or reprogram) before bovie use. Pacemaker-dependent: program asynchronous (DOO, VOO) for bovie.
Electromagnetic interference (EMI) from electrocautery
Bipolar > monopolar (less EMI). If monopolar: short bursts, ground pad far from device. EMI on ICD → inappropriate shock. EMI on PPM → inhibition + asystole (in dependent patient).
Magnet behavior
Magnet on PPM → asynchronous (rate varies by manufacturer). Magnet on ICD → SUSPENDS shock (does NOT change pacing). Magnet placement is reversible — remove for normal function.
Reactivate device + interrogate post-op
Cardiology reinterrogates + restores original programming. Document. Patient teach post-discharge — may have driving restrictions if ICD was tested.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
78-yo M with prior CRT-D for ICM (EF 25%), VOO-pacing dependent, generator EOL replacement. Plan?
What an examiner probes for
- ▹Pre-op cardiology interrogation
- ▹Reprogram to asynchronous pacing OR magnet
- ▹Disable ICD shocks (magnet or program)
- ▹Bipolar cautery preferred
- ▹Defib pads on, post-op interrogation
Sources
- ASA Practice Advisory: Cardiac Implantable Electronic Devices 2020
- Heart Rhythm Society EHRA Guidelines
Anatomy reference
Sourced reference images. 4 matches for "heart conduction chambers".
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