E Letters to the Editor 2. Haridas RP, Mifflin JA. Researches regarding the Morton ether inhaler at Massachusetts General Hospital, Boston. Anesth Analg 2013;117:1230–5 3. Haridas RP, Bause GS. Correspondence by Charles T. Jackson containing the earliest known illustrations of a Morton ether inhaler. Anesth Analg 2013;117:1236–40 4. Juvin P, Desmonts JM. The ancestors of inhalational anesthesia: the Soporific Sponges (XIth-XVIIth centuries): how a universally recommended medical technique was abruptly discarded. Anesthesiology 2000;93:265–9 5. Rice NP. Trials of a Public Benefactor, as Illustrated in the Discovery of Etherization. New York, NY: Pudney & Russell, 1859:173, 187 6. Morton WTG. Letter from Dr. Morton, of Boston, U.S. Lancet 1847;ii:80–1 7. Smith T. Oleum ethereum, with ether, in surgical operations. London Medical Gazette 1847;4:395 8. Warren JM. Inhalation of ether. Boston Med Surg J 1847;36:149–62

cardiologist, electrophysiologist, surgeon, and anesthesiologist. This collaboration should produce a recommended individualized prescription for management of the device during the perioperative period. While it is appropriate for anesthesiologists, as the perioperative physicians, to take ownership of the process of creating this collaboration, it is inappropriate for anesthesiologists, even if specially trained, to take complete control over the management. As Rooke and Bowdle state,2 “there are too many exceptions to allow formulation of simple rules for straightforward management.” Only through collaboration will the patient be given the safest and most optimal care. Menachem M. Weiner, MD Department of Anesthesiology Icahn School of Medicine at Mount Sinai New York, New York [email protected]

DOI: 10.1213/ANE.0000000000000154

Preoperative Evaluation of Patients with Pacemakers and Implanted Cardioverter Defibrillators To the Editor

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chulman and Rozner1 recently issued a warning regarding the harmful consequences of applying a magnet to a cardiac implanted electronic device (CIED) without having a clear understanding of magnet function. They describe 3 cases in which inadequate preoperative assessment of the CIED combined with magnet application to the device contributed to patient injury or CIED damage. They instead advocate for a timely preoperative evaluation and reprogramming of the CIED as necessary for the surgical procedure. The accompanying editorial by Rooke and Bowdle2 laments the lack of clear ownership over the process of perioperative management of the devices and describes 2 approaches to dealing with the problem used in various hospitals. I suggest that it is imperative that anesthesiologists, as perioperative physicians, have an expertise in the function and management of CIEDs. Unfortunately, as the number of patients presenting for surgery with a CIED has increased at a rapid pace, anesthesiologist education has lagged behind. This educational gap and suggested remedies were the subject of a recent letter to the editor3 and author responses. To address this, many institutions have instituted algorithms for perioperative management of these devices.4 Many of these algorithms would likely have recommended placement of a magnet in the cases reviewed by Schulman and Rozner,1 further highlighting a growing issue. While it is unquestionable that the perioperative team needs to be educated to have a clear understanding of the CIED status and function to guide perioperative management, particularly in an emergent or unforeseen situation,5 neither the case report of Schulman and Rozner1 nor the editorial by Rooke and Bowdle2 are in line with the guidelines from the Heart Rhythm Society and American Society of Anesthesiologists.6 The guidelines advocate a multidisciplinary approach with collaboration between the patient’s

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REFERENCES 1. Schulman PM, Rozner MA. Case report: use caution when applying magnets to pacemakers or defibrillators for surgery. Anesth Analg 2013;117:422–7 2. Rooke GA, Bowdle TA. Perioperative management of pacemakers and implantable cardioverter defibrillators: it’s not just about the magnet. Anesth Analg 2013;117:292–4 3. Markan S, Youngblood S, Wright C, Palvadi RR, Porter J. Paucity of education regarding pacemakers/cardiovascular implantable electronic devices in anesthesiology training programs is a patient safety hazard. Anesth Analg 2013;117:746–7 4. Thompson A, Mahajan A. Perioperative management of cardiovascular implantable electronic devices: what every anesthesiologist needs to know. Anesth Analg 2013;116:276–7 5. Izrailtyan I, Schiller RJ, Katz RI, Almasry IO. Case report: Perioperative pacemaker-mediated tachycardia in the patient with a dual chamber implantable cardioverter-defibrillator. Anesth Analg 2013;116:307–10 6. Crossley GH, Poole JE, Rozner MA, Asirvatham SJ, Cheng A, Chung MK, Ferguson TB Jr, Gallagher JD, Gold MR, Hoyt RH, Irefin S, Kusumoto FM, Moorman LP, Thompson A. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management this document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Heart Rhythm 2011;8:1114–54 DOI: 10.1213/ANE.0000000000000149

We Need to Understand Our Electronics! To the Editor

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e agree with Schulman and Rozner1 regarding the importance of preoperative evaluation of Cardiac Implantable Electronic Devices (CIEDs) and wish to share our experience on management of CIEDs pre-, intra-, and postoperatively by anesthesiologists in a tertiary care community hospital. Collaborating with our electrophysiology cardiologists, we provided a 1-day education for

anesthesia & analgesia

Letters to the Editor

anesthesiologists on basic principles and ­hands-on training with 4 major CIEDs in the United States, that is, Medtronic, Biotronic, St. Jude, and Boston Scientific. Instruction included turning on/off defibrillator function, identifying pacer dependency, switching pacing mode from/to asynchronous (atrium-paced, no-chamber-sensed, no-sensing-fixed mode; ventricle-paced, ­no-chamber-sensed, no-sensing-fixed mode; asynchronous pacing; etc.), and changing the pacing rate and printing reports. At the end of the training, each anesthesiologist was asked to perform turning on/off tachycardia therapy, identify pacer dependency, and change pacer mode/rate independently to verify their skills. An education seminar every 6 months is planned. Each company provided their respective CIED programmer, and a CIED cart was assembled with all 4 programmers available. The cart remains in the operating room (OR) area. A perioperative CIEDs clinic was established to ensure maximal safety for CIED patients undergoing surgery. This clinic was led by a cardiac anesthesiologist, staffed by anesthesiologists, with available consultation from an electrophysiology cardiologist, and supported by CIED manufacture representatives. When a patient with a CIED presents to the preoperative area, the CIED clinic anesthesiologist will be notified. CIEDs are interrogated in the preoperative area, magnet response is assessed, and settings are changed if necessary (turn on/ off tachycardia therapy or change pacemaker mode and rate for patients who are pacer-dependent) in the OR after standard monitors are applied. There must be a magnet in the OR and a defibrillator immediately available. The anesthesiologist must document the following information in each patient’s chart and communicate to the entire OR/Anesthesia team. 1.  Date and time device setting is changed. 2.  Changes made on the device including turning on/ off tachycardia therapy or changing pacemaker mode and rate. 3.  The name and cell phone number of the anesthesiologist who makes the changes. CIEDs must be restored to the original settings by the CIED anesthesiologist before the patient leaves the OR. The CIED anesthesiologist reports to recovery room physicians and nurses regarding each patient’s CIED status. The CIED manufacturer’s representatives are called to interrogate the device before the patient leaves a cardiac telemetry environment if reprogramming has occurred or if the patient meets one of the criteria listed below.2 1.  Patients in whom the CIED was reprogrammed before the procedure that left the device nonfunctional such as disabling tachycardia detection. 2.  Patients with a CIED and who underwent surgery during which hemodynamic instability may have occurred. 3.  Patients with a CIED and who experienced significant intraoperative events including cardiac arrest requiring temporary pacing or cardiopulmonary

May 2014 • Volume 118 • Number 5

resuscitation and those who required external electrical cardioversion. 4.  Emergent surgery wherein the site of electromagnetic interference exposure was above the umbilicus. 5.  Cardiothoracic surgery. 6.  Patients with a CIED and who underwent a procedure (external cardioversion, radiofrequency ablation, and therapeutic radiation) that emits electromagnetic interference with a greater probability of affecting device function. 7.  Patients with a CIED who have logistical limitations preventing reliable device evaluation within 1 month from their procedure. All other patients will be scheduled for outpatient evaluation within 1 month of the procedure. An example of how such expertise was used is represented by the following case: A 58-year-old man with a history of diabetes, morbid obesity (Body Mass Index 39 kg/m2), hypertension, sleep apnea, and gout presented for left ventricular assist device exchange because of pump malfunction. A Medtonic CIED was in place for his ischemic cardiomyopathy. Adhesive defibrillation pads were placed on right shoulder and left lateral chest before draping and connected to a functional external defibrillator. The CIED was interrogated by a CIED cardiac anesthesiologist and determined that ventricular fibrillation and ventricular tachycardia (VT) detection and therapy were functional. The pacing mode was dual mode, dual chamber, and dual sensing 70 bpm. The tachy therapy was then turned off, and the mode changed to asynchronous pacing at 85 beats per minute, and atrial and ventricular capture verified. The left ventricular assist device was successfully changed through a left subcostal incision during femoral vein to artery cardiopulmonary bypass. The patient was separated from bypass, and when the surgeon used unipolar electrocoagulation (Unipolar Bovie, Bovie Medical Corporation, Clearwater, FL) near the heart to stop bleeding, the cardiac rhythm suddenly deteriorated to VT and then ventricular fibrillation. External transcutaneous defibrillation was performed multiple times without success, presumably from the increased distance between pads and the heart because of his morbid obesity. The mean blood pressure decreased to the low 40s. The subcostal incision/ exposure prevented us from using internal defibrillating paddles in the surgical field directly on the heart. Since the external transcutaneous defibrillator was not effective and CIED was turned off, the CIED programmer and the implantable cardioverter defibrillator therapies were turned back on after which the implantable cardioverter defibrillators shocked the heart twice; the rhythm went into VT after the first shock and returned to sinus rhythm after the second shock. Amiodarone infusion was started, and the remainder of the procedure was uneventful. As described by Schulman and Rozner,1 a magnet alone is inadequate to manage CIEDs perioperatively. Education and establishment of a formal CIED clinic by anesthesiologists are feasible and useful in a community tertiary care hospital.

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E Letters to the Editor Jiapeng Huang, MD, PhD Department of Anesthesiology Jewish Hospital Louisville, KY [email protected] Michael Springer, MD Department of Electrophysiology Cardiology Jewish Hospital Louisville, Kentucky REFERENCES 1. Schulman PM, Rozner MA. Case report: use caution when applying magnets to pacemakers or defibrillators for surgery. Anesth Analg 2013;117:422–7 2. Crossley GH, Poole JE, Rozner MA, Asirvatham SJ, Cheng A, Chung MK, Ferguson TB Jr, Gallagher JD, Gold MR, Hoyt RH, Irefin S, Kusumoto FM, Moorman LP, Thompson A. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management this document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Heart Rhythm 2011;8:1114–54 DOI: 10.1213/ANE.0000000000000150

In Response We thank Dr. Weiner1 for his interest in the important topic of perioperative cardiovascular implantable electronic device (CIED) management. One of his major concerns was the need for greater education among anesthesiologists, and on this point, we enthusiastically agree. Concern was also expressed as to whether the anesthesiologist-based program for device management ­ described in our editorial2 provides the level of collaboration among referring cardiologist, anesthesiology, surgeon, and electrophysiologist/cardiology as recommended by the Heart Rhythm Society (HRS)/American Society of Anesthesiologists expert consensus statement.3 In fact our program was designed specifically to be in accord with those guidelines. Dr. Jeanne Poole, the electrophysiologist who was instrumental in the creation of our program, was cochair of the consensus panel of experts that wrote the HRS guidelines. We actually delayed implementing our program to be sure that the structure of the program matched the final version of the HRS guidelines. Our program began providing clinical care in September 2010 with direct supervision by electrophysiology cardiologists for every case but has evolved to the point that most interrogations are now handled entirely by the anesthesia service. Yet the electrophysiology service is still frequently called on for advice and for clinical follow-up of devices perioperatively. The most common example of our collaboration involves patients who undergo placement of left ventricular assist devices. At the time of surgery, the CIED often suffers adverse changes in lead sensitivity and capture thresholds and subsequent follow up is necessary. This task is deferred to cardiology as we consider such care beyond our level of training. Furthermore, if the anesthesiologist is at any time not comfortable with the interrogation results or

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the decision-making process regarding suitable device programming, then help is obtained from electrophysiology/ cardiology. We hope this clarifies how our anesthesia-based CIED management program functions. We want to emphasize that our program may not be suitable for all practice settings. Local needs and resources will ultimately determine how CIEDs are best managed in a particular hospital. Conflicts of Interest: G. Alec Rooke reported a conflict of interest with Medtronic. G. Alec Rooke is an investigator on a study of electromagnetic interference and cardiovascular implantable electronic devices that is funded by Medtronic. G. Alec Rooke, MD, PhD T. Andrew Bowdle, MD, PhD Department of Anesthesiology University of Washington School of Medicine Seattle, Washington [email protected] REFERENCES 1. Weiner MM. Preoperative evaluation of patients with pacemakers and implanted cardioverter defibrillators. Anesth Analg 2014;118:1138 2. Rooke GA, Bowdle TA. Perioperative management of pacemakers and implantable cardioverter defibrillators: it’s not just about the magnet. Anesth Analg 2013;117:292–4 3. The Heart Rhythm Society Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: Facilities and patient management. Heart Rhythm 2011;8:1114–52 DOI: 10.1213/ANE.0000000000000151

In Response

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e thank Dr. Weiner1 as well as Drs. Huang and Springer2 for their interest in our case report,3 and we clearly agree that anesthesiologists must develop expertise in the function and management of cardiac implanted electronic devices (CIEDs). We also agree with Dr. Weiner1 that the apparent knowledge gap among anesthesiologists and likely other medical professionals regarding appropriate perioperative management of patients with CIEDs constitutes an important safety issue. However, as we are both Testamurs of the International Board of Heart Rhythm Examinersa as well as anesthesiologists who routinely provide comprehensive CIED management, we strongly disagree with Dr. Weiner that anesthesiologists should not assume complete perioperative care of these patients. Although we concur that collaboration and a multidisciplinary approach contribute to safe and optimal care, we see no reason that appropriately trained anesthesiologists should shy away from managing these devices. Rozner4 initially raised this point in this journal after incorrect CIED information was provided by a cardiologist to anesthesiologists.5 Furthermore, we believe that anesthesiologists are best suited and positioned to acquire requisite skills and provide this care when needed, just as we do with transesophageal echocardiography, intensive http://www.ibhre.org/Certification/IBHRE-Recipients/Physician-Pacing

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We need to understand our electronics!

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