Electromagnetic Interference with Protocolized Electrosurgery Dispersive Electrode Positioning in Patients with Implantable Cardioverter Defibrillators

Abstract

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background The goal of this study was to determine the occurrence of intraoperative electromagnetic interference from monopolar electrosurgery in patients with an implantable cardioverter defibrillator undergoing surgery. A protocolized approach was used to position the dispersive electrode. Methods This was a prospective cohort study including 144 patients with implantable cardioverter defibrillators undergoing surgery between May 2012 and September 2016 at an academic medical center. The primary objectives were to determine the occurrences of electromagnetic interference and clinically meaningful electromagnetic interference (interference that would have resulted in delivery of inappropriate antitachycardia therapy had the antitachycardia therapy not been programmed off) in noncardiac surgeries above the umbilicus, noncardiac surgeries at or below the umbilicus, and cardiac surgeries with the use of an underbody dispersive electrode. Results The risks of electromagnetic interference and clinically meaningful electromagnetic interference were 14 of 70 (20%) and 5 of 70 (7%) in above-the-umbilicus surgery, 1 of 40 (2.5%) and 0 of 40 (0%) in below-the-umbilicus surgery, and 23 of 34 (68%) and 10 of 34 (29%) in cardiac surgery. Had conservative programming strategies intended to reduce the risk of inappropriate antitachycardia therapy been employed, the occurrence of clinically meaningful electromagnetic interference would have been 2 of 70 (2.9%) in above-the-umbilicus surgery and 3 of 34 (8.8%) in cardiac surgery. Conclusions Despite protocolized dispersive electrode positioning, the risks of electromagnetic interference and clinically meaningful electromagnetic interference with surgery above the umbilicus were high, supporting published recommendations to suspend antitachycardia therapy whenever monopolar electrosurgery is used above the umbilicus. For surgery below the umbilicus, these risks were negligible, implying that suspending antitachycardia therapy is likely unnecessary in these patients. For cardiac surgery, the risks of electromagnetic interference and clinically meaningful electromagnetic interference with an underbody dispersive electrode were high. Conservative programming strategies would not have eliminated the risk of clinically meaningful electromagnetic interference in either noncardiac surgery above the umbilicus or cardiac surgery.

Consumer Electronics Show for the Anesthesiologist: Updates on Cardiac Implantable Electronic Devices

“…Regarding preoperative preparation, the updated advisory presents updates in the literature reporting significant EMI from electrosurgery above the umbilicus compared with below the umbilicus (category B1-H evidence). 15 As reported by Schulman et al from their 144-patient cohort, it was noted that the risk of clinically meaningful EMI in noncardiac surgery above the umbilicus was 7% compared with 0% below the umbilicus, and EMI was detected in 20% of all cardiac surgical cases. 15 Another area of advancement relates to behavior surrounding CIED management for patients undergoing MRI.…”

“…15 As reported by Schulman et al from their 144-patient cohort, it was noted that the risk of clinically meaningful EMI in noncardiac surgery above the umbilicus was 7% compared with 0% below the umbilicus, and EMI was detected in 20% of all cardiac surgical cases. 15 Another area of advancement relates to behavior surrounding CIED management for patients undergoing MRI. The previous advisory suggested that MRI generally is contraindicated in patients with CIEDs.…”

“…It highlights the fact that this remains a controversial issue. Several articles have been published suggesting that anesthesiologists do not need to turn off ICDs when the surgery is below the umbilicus; [15][16][17] however, there is a case report and clinical experiences suggesting otherwise. 18 Needless to say, consultants and anesthesiologists are ambiguous about what to do in this situation, and it suggests a need for more clinical research regarding this question.…”

“…1 Regarding managing sources of EMI from electrosurgery, there is still insufficient evidence evaluating the position of the dispersive electrode and its effects on CIED interference. 15 Furthermore, there are no controlled studies available evaluating the benefit of using low-energy and short bursts of electrocautery. Both methods are used routinely in practice.…”

A Review of Capacitive Return Electrodes in Electrosurgery

“…Incidence of EMI was not reported as related to the type of return electrode, and there were no inappropriate therapies or device resets. Schulman et al [13] evaluated the use of electrosurgery in 144 patients with ICDs. The Mega Soft return electrode was used in 34 subjects undergoing cardiac surgery.…”