Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable Cardioverter–Defibrillators 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Implantable Electronic Devices^*

For this advisory, a cardiac implantable electronic device refers to any permanently implantable cardiac pacemaker or any implantable cardioverter–defibrillator. The term cardiac implantable electronic device also refers to any cardiac resynchronization therapy device.^†

The purposes of this advisory update are to: (1) facilitate safe and effective perioperative management of the patient with a cardiac implantable electronic device 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 cardiac implantable electronic device function 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, and inappropriate implantable cardioverter–defibrillator therapies.^‡

Adverse clinical outcomes include, but are not limited to, hypotension, tachyarrhythmia and bradyarrhythmia, myocardial tissue damage, and myocardial ischemia and infarction. Other related adverse outcomes may include extended hospital stay, delay and cancellation of surgery, readmission to manage device malfunction, and additional hospital resource utilization and cost.

This updated advisory focuses on the perioperative management of the patient who has a preexisting cardiac implantable electronic device for the treatment of bradyarrhythmia, tachyarrhythmia, or heart failure. This advisory applies to all cardiac implantable electronic device patients receiving general or regional anesthesia, sedation, or monitored anesthesia care. Both inpatient and outpatient procedures are addressed by this update.

This update does not address the perioperative management of the patient without a cardiac implantable electronic device, such as those (1) with only a temporary cardiac implantable electronic device; (2) with only a noncardiac implantable device (e.g., neurologic or spinal cord stimulator); (3) with only an implantable mechanical cardiac assist device (e.g., ventricular assist device); or (4) undergoing cardiac implantable electronic device implantation or revision. This update does not address procedures rarely involving anesthesia care (e.g., radiation therapy^§) or imaging modalities without known perioperative cardiac implantable electronic device concerns (e.g., diagnostic radiography or ultrasonography). In addition, this update does not address patient comfort or management of pain during a procedure.

This updated advisory is intended for use by anesthesiologists and all other individuals who deliver or who are responsible for anesthesia care. This update may also serve as a resource for other physicians and healthcare professionals who manage patients with cardiac implantable electronic devices.

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. In 2017, the ASA Committee on Standards and Practice Parameters requested that the advisory be updated. This update is a revision developed by an ASA-appointed task force of five members, including three anesthesiologists and two methodologists. Conflict-of-interest documentation regarding current or potential financial and other interests pertinent to the practice guideline were disclosed by all task force members and managed.

This updated advisory was developed by means of a five-step process. First, consensus was reached on the criteria for evidence. Second, original published articles from peer-reviewed journals relevant to the perioperative management of cardiac implantable electronic devices were evaluated and added to literature reported in the previous update. Third, consultants who had expertise or interest in cardiac implantable electronic devices and who practiced or worked in various settings (e.g., private and academic practice) were asked to participate in opinion surveys addressing the appropriateness, completeness, and feasibility of implementation of the draft recommendations and to review and comment on a draft of the Advisory. Fourth, additional opinions were solicited from random samples of active ASA members. Fifth, all available information was used to build consensus to finalize the advisory. A summary of recommendations can be found in appendix 1.

Preparation of this updated advisory followed a rigorous methodologic process. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. Detailed descriptions of the ASA process and methodology used in this Advisory may be found in other related publications.^2–5  Appendix 2 contains information on the evidence model, the literature search process, literature findings, and survey results.

Within the text of the advisory, literature classifications are reported for each intervention using the following classifications: category A, level 1: meta-analysis of randomized controlled trials; category A, level 2, multiple randomized controlled trials; category A, level 3: a single randomized controlled trial; category B, level 1: nonrandomized studies with group comparisons; category B, level 2: nonrandomized studies with associative findings; category B, level 3: nonrandomized studies with descriptive findings; and category B, level 4: case series or case reports. Outcomes are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E). Survey findings from task force–appointed expert consultants and a random sample of the ASA membership are fully reported in the text of these guidelines. Survey responses for each recommendation are reported using a five-point scale based on median values from “strongly agree” to “strongly disagree.”

A focused preoperative evaluation of the patient with a cardiac implantable electronic device consists of the following topics: (1) determining whether a patient has a cardiac implantable electronic device; (2) determining the cardiac implantable electronic device type, manufacturer, and primary indication for placement; (3) determining whether a patient is pacing-dependent; and (4) determining the cardiac implantable electronic device’s current settings and that it is functioning properly by interrogating the cardiac implantable electronic device or obtaining the most recent interrogation report.

Literature Findings. Although the literature is insufficient to evaluate the clinical benefit of performing a focused preoperative evaluation of patients with cardiac implantable electronic devices, case reports indicate that adverse outcomes (e.g., inappropriate shock, cardiac implantable electronic device switch to “end-of-life mode,” acute ventricular lead dysfunction, and corrupted device memory) may occur when a complete preoperative examination is not performed to determine whether the patient has a cardiac implantable electronic device (Category B4-H evidence).^6–9  The literature is insufficient to evaluate whether preoperatively determining the cardiac implantable electronic device type, manufacturer, and primary indication for placement or determining whether a patient is pacing-dependent affects perioperative outcomes. A case series reported inappropriate antitachycardia pacing or shocks, premature battery depletion, and cardiac implantable electronic device damage when the cardiac implantable electronic device’s settings were not adequately assessed preoperatively (Category B4-H evidence).¹⁰  The literature is insufficient to evaluate whether any particular time interval to determine recency for review of a previous cardiac implantable electronic device interrogation is most beneficial to the patient.

Survey Findings. The expert consultants and ASA members strongly agree with the recommendation that a preoperative evaluation should include determining whether a patient has a cardiac implantable electronic device, determining the cardiac implantable electronic device type (i.e., pacemaker, implantable cardioverter–defibrillator, cardiac resynchronization therapy), determining the primary indication for cardiac implantable electronic device placement, and determining whether the patient is pacing-dependent. The consultants strongly agree and ASA members agree that a preoperative evaluation should include determining the cardiac implantable electronic device manufacturer.

The consultants strongly agree and ASA members agree that a preoperative evaluation should include determining the cardiac implantable electronic device’s current settings and confirming that the cardiac implantable electronic device is functioning properly (i.e., by interrogating the cardiac implantable electronic device or obtaining the most recent interrogation report). The consultants selected preferred time spans for determining proper implantable cardioverter–defibrillator functioning before a procedure, as follows: immediately = 6% of consultants, at least 3 months before = 48% of consultants, at least 6 months before = 36% of consultants, and at least 12 months before = 6% of consultants. For a pacemaker the following time spans were selected by consultants: immediately = 3% of consultants, at least 3 months before = 39% of consultants, at least 6 months before = 30% of consultants, and at least 12 months before = 27% of consultants. The ASA members selected the following preferred time spans for determining proper functioning of an implantable cardioverter–defibrillator before the procedure: immediately = 10% of members, at least 3 months before = 39% of members, at least 6 months before = 44% of members, and at least 12 months before = 7% of members. For a pacemaker the following time spans were selected by members: immediately = 9% of members, at least 3 months before = 38%, at least 6 months before = 36%, and at least 12 months before = 18% of consultants.

• Determine whether a patient has a cardiac implantable electronic device

  • Conduct a focused history (e.g., interview the patient or other source, review medical record, chest x-ray, and electrocardiogram if available)

  • Perform a focused physical examination (e.g., check for scars, palpate for device)^‖

• Determine the cardiac implantable electronic device type, manufacturer, and primary indication for placement

  • Obtain the manufacturer’s identification card from the patient or other source

  • Review the medical record

  • Obtain and review the most recent cardiac implantable electronic device interrogation report^#

  • Refer to supplemental resources (e.g., manufacturer’s databases, cardiac implantable electronic device clinic records)

  • Order a chest x-ray if no other data are available^**

• Determine whether the patient is pacing-dependent^††

  • From the focused history and medical record, assess for one or more of the following indicators:

    • ▪

      Bradycardia that caused syncope or other symptoms resulting in cardiac implantable electronic device implantation

    • ▪

      Successful atrioventricular nodal ablation resulting in cardiac implantable electronic device implantation

    • ▪

      A cardiac implantable electronic device interrogation showing no evidence of spontaneous ventricular activity when the cardiac implantable electronic device’s pacing function is temporarily programmed to a nontracking mode (i.e., ventricular-only pacing and sensing) at the lowest programmable rate

• Determine the cardiac implantable electronic device’s current settings, that it is functioning properly (i.e., by interrogating the cardiac implantable electronic device or obtaining the most recent interrogation report), and that it is optimally programmed for the planned procedure ^‡‡§§

  • Reinterrogate the cardiac implantable electronic device if there is any question of proper function

Preoperative preparation for patient safety and proper maintenance of the cardiac implantable electronic device during a planned procedure includes the following topics: (1) sources of electromagnetic interference; (2) preoperative reprogramming of the cardiac implantable electronic device’s pacing function to an asynchronous pacing mode or disabling any special algorithms, including rate adaptive pacing functions; (3) suspending the antitachyarrhythmia functions for an implantable cardioverter–defibrillator; and (4) availability of temporary pacing and defibrillation equipment.

Literature Findings. The literature was evaluated for the following potential sources of electromagnetic interference: monopolar electrosurgery, bipolar electrosurgery, radiofrequency ablation, lithotripsy, external cardioversion or defibrillation, magnetic resonance imaging, radiation therapy, radiofrequency scanners, cardiac monitors, and electroconvulsive therapy.

Observational studies report that electromagnetic interference may occur during monopolar electrosurgery,^11–15  radiofrequency ablation,^16–21  magnetic resonance imaging,^22–35  and radiation therapy^36–42 (Category B3-H evidence). Case reports also indicate the occurrence of electromagnetic interference during monopolar electrosurgery,^43–50  bipolar electrosurgery,⁵¹  radiofrequency ablation,^52–54  magnetic resonance imaging,^6–9,55,56  and radiation therapy^57–59 (Category B4-H evidence).

Case reports indicate that inappropriately high pacing rates may occur due to electromagnetic interference from cardiac monitoring equipment in cardiac implantable electronic devices with active minute ventilation sensors (Category B4-H evidence).^60–62  An observational study of implantable cardioverter–defibrillators in the pectoral position reports a significantly higher occurrence of electromagnetic interference when electrosurgery above the umbilicus is performed compared with electrosurgery below the umbilicus (Category B1-H evidence).¹⁵  The literature is insufficient to evaluate the benefit of the availability of temporary pacing and defibrillation equipment during a procedure.

Survey Findings. The consultants and ASA members strongly agree that a preoperative evaluation should include determining whether electromagnetic interference from monopolar electrosurgery or other sources is likely to occur and strongly agree with the recommendation to alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient if monopolar electrosurgery (“bovie”) use is planned superior to the umbilicus. The consultants disagree and ASA members are equivocal with the recommendation to alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient if monopolar electrosurgery (bovie) use is planned inferior to the umbilicus. The consultants and ASA members strongly agree with the recommendation to suspend an implantable cardioverter–defibrillator’s antitachycardia function, when present, if monopolar electrosurgery (bovie) use is planned superior to the umbilicus. The consultants agree and ASA members are equivocal with the recommendation to suspend an implantable cardioverter–defibrillator’s antitachycardia function, when present, if monopolar electrosurgery (bovie) use is planned inferior to the umbilicus. The consultants and ASA members strongly agree with the recommendation to ensure that the patient is in a monitored environment before suspending the antitachycardia function of an implantable cardioverter–defibrillator. The consultants are equivocal and ASA members agree with the recommendation to avoid the routine use of a magnet over an implantable cardioverter–defibrillator. The consultants and ASA members strongly agree that if needed, a specialist should be consulted to alter the pacing function of a cardiac implantable electronic device or to suspend the antitachycardia function of an implantable cardioverter–defibrillator. The consultants and ASA members strongly agree that the proceduralist should be advised to use bipolar electrosurgery or an ultrasonic scalpel when feasible. The consultants and ASA members strongly agree with the recommendation that temporary pacing and defibrillation equipment should be immediately available before, during, and after all procedures with electromagnetic interference potential. Finally, the consultants and ASA members agree with the recommendation that a cardiac implantable electronic device’s active sensor for rate-responsive pacing should be suspended to prevent undesirable tachycardia.

• Determine whether intraoperative electromagnetic interference electromagnetic interference is likely to occur

• If electromagnetic interference is likely to occur (e.g., monopolar electrosurgery [bovie] use, or radiofrequency ablation is planned superior to the umbilicus), alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient^‖‖## and suspend an implantable cardioverter–defibrillator’s antitachycardia function, if present^***

  • Before suspending the antitachycardia function, ensure that the patient is in a monitored environment

  • Avoid the indiscriminate use of a magnet over an implantable cardioverter–defibrillator

  • If needed, consult a specialist to alter the pacing function of a cardiac implantable electronic device or to suspend the antitachycardia function of an implantable cardioverter–defibrillator

• Ensure that temporary pacing and defibrillation equipment are immediately available before, during, and after all procedures with electromagnetic interference potential

• Suspend a cardiac implantable electronic device’s active sensor for rate-responsive pacing to prevent undesirable tachycardia^†††

Intraoperative monitoring topics include (1) continuous electrocardiography monitoring; (2) continuous oxygen saturation measured by pulse oximetry (Spo₂) monitoring; and (3) peripheral pulse monitoring (e.g., pulse palpitation, pulse oximeter plethysmogram, or arterial line).

Literature Findings. Case reports indicate that continuous electrocardiography monitoring may detect electromagnetic interference-related pacemaker function abnormalities^49,56,63  and cardiac abnormalities^64,65  during a procedure (Category B4-B evidence). For cardiac implantable electronic device patients, the literature is insufficient to evaluate the clinical impact of continuous Spo₂ or perioperative peripheral pulse monitoring.

Survey Findings. The consultants and ASA members strongly agree with the recommendations to (1) continuously monitor and display a patient’s electrocardiogram as required by ASA standards from the beginning of anesthesia until the patient is transferred out of the anesthetizing location, with additional electrocardiography monitoring in the postoperative period as indicated by the patient’s medical condition; (2) perform continuous peripheral pulse monitoring for all cardiac implantable electronic device patients receiving anesthesia care; and (3) discontinue the procedure until the source of interference can be eliminated or managed if unanticipated cardiac implantable electronic device interactions occur.

• Continuously monitor and display a patient’s electrocardiogram and Spo₂ as required by ASA standards^66,67  from the beginning of anesthesia until the patient is transferred out of the anesthetizing location^‡‡‡

• Perform continuous peripheral pulse monitoring for all cardiac implantable electronic device patients receiving anesthesia care^§§§

• If unanticipated cardiac implantable electronic device interactions occur, temporarily suspend the procedure until the source of interference can be identified and eliminated or managed

Procedures using electrosurgery, radiofrequency ablation, radiofrequency identification devices, lithotripsy, magnetic resonance imaging, radiation therapy, nerve conduction studies, cardioversion, or electroconvulsive therapy may damage cardiac implantable electronic devices or interfere with cardiac implantable electronic device function, potentially resulting in severe adverse outcomes. Sources of electromagnetic interference are often unique to specific procedures, and the management of each of these potential electromagnetic interference sources is reported separately below.

Management of potential sources of electromagnetic interference associated with electrosurgery includes the following topics: (1) positioning the electrosurgical unit’s dispersive electrode so that the current pathway does not pass through or near the cardiac implantable electronic device generator and leads; (2) avoiding proximity of the electrosurgical unit’s electrical current to the generator or leads; (3) using intermittent and irregular bursts of monopolar electrosurgery at the lowest feasible energy levels; (4) using bipolar electrosurgery; and (5) using ultrasonic (harmonic) scalpel.

Literature Findings. The literature is insufficient to evaluate whether positioning the current pathway away from the cardiac implantable electronic device generator and leads reduces the occurrence of electromagnetic interference. A case report indicates that electromagnetic interference occurred when the electrosurgical unit’s electrical current was placed in proximity to the generator or leads (Category B4-H evidence).⁶⁸  An observational study reports that electromagnetic interference may occur in spite of positioning the dispersive electrode to divert the return path away from the generator and leads (Category B3-H evidence).¹⁵  Case reports also indicate that electromagnetic interference may still occur when proximity is avoided (Category B4-H evidence).^46,66  No controlled studies were found that examine the benefit of using short intermittent bursts of electrosurgery at the lowest feasible energy levels. One case report describes pacemaker failure when short bursts of current were used with a bipolar electrosurgery system (Category B4-H evidence).⁵¹ 

Case reports indicate that cardiac arrhythmias and asystole occurred when monopolar electrosurgery was initiated, and after changing to bipolar electrosurgery, the procedures proceeded uneventfully (Category B4-B evidence).^46,64,65  A case report indicated that dysrhythmias followed by asystole occurred when monopolar electrosurgery was initiated, and after changing to a harmonic scalpel, the procedure was completed successfully (Category B4-B evidence).⁴⁴ 

Survey Findings. The consultants and ASA members strongly agree with the recommendations to (1) minimize the risk of electromagnetic interference by positioning the electrosurgical instrument and dispersive electrode (bovie pad) so the current pathway does not pass through or near the cardiac implantable electronic device generator or leads; (2) avoid proximity of the electrosurgery electrical field to the generator and leads, including the avoidance of waving the activated electrode over the generator; and (3) use short, intermittent, and irregular bursts of electrosurgery at the lowest feasible energy levels. The consultants agree and ASA members strongly agree with the recommendations to use bipolar electrosurgery or an ultrasonic (harmonic) scalpel, if possible.

Management of potential sources of electromagnetic interference associated with radiofrequency ablation primarily involves keeping the radiofrequency current path (electrode tip to current return pad) as far away from the generator and leads as possible.

Literature Findings. The literature is insufficient to examine the benefit of avoiding direct contact between the ablation catheter and the generator and leads or of keeping the radiofrequency current path (electrode tip to current return pad) as far away from the generator and leads as possible.

Survey Findings. The consultants and ASA members strongly agree with the recommendations to avoid direct contact between the ablation catheter and the generator and leads and to keep the radiofrequency’s current path (electrode tip to current return pad) as far away from the generator and leads as possible.

Management of potential sources of electromagnetic interference associated with lithotripsy consists of avoiding focus of the lithotripsy beam near the generator.

Literature Findings. The literature insufficient to evaluate the benefits of focusing the lithotripsy beam away from the generator.

Survey Findings. The consultants and ASA members strongly agree with the recommendation to avoid focusing the lithotripsy beam near the generator.

Management of potential sources of electromagnetic interference associated with magnetic resonance imaging include the topics of (1) moving the patient outside of the immediate magnetic resonance imaging area when an external defibrillator/monitor, cardiac implantable electronic device programmer, or any other magnetic resonance imaging-unsafe equipment is used; (2) interrogating the cardiac implantable electronic device before the magnetic resonance imaging scan; (3) suspending the antitachycardia function of an implantable cardioverter–defibrillator before the magnetic resonance imaging scan; (4) altering the pacing function of the cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient before the magnetic resonance imaging scan; (5) ensuring that an individual capable of programming the cardiac implantable electronic device remains in attendance for the duration of the magnetic resonance imaging scan; and (6) reinterrogating the cardiac implantable electronic device and restoring its permanent settings after the magnetic resonance imaging is completed.^‖‖‖

Literature Findings. Observational studies evaluating the effects of suspending the antitachycardia function of an implantable cardioverter–defibrillator report that electromagnetic interference may still occur (Category B3-E evidence).^25,30,32,33  Observational studies of magnetic resonance imaging-conditional cardiac implantable electronic devices report that electromagnetic interference does not occur when a cardiac implantable electronic device is programed to “magnetic resonance imaging mode” and the antitachycardia function is suspended (Category B3-E evidence).^22–24 

The literature is insufficient to examine the necessity of: (1) moving the patient outside of the magnetic resonance imaging area when an external defibrillator/monitor, cardiac implantable electronic device programming system, or any other magnetic resonance imaging-unsafe equipment is used; (2) interrogating a cardiac implantable electronic device before magnetic resonance imaging is performed; (3) having an individual capable of programming the cardiac implantable electronic device remain in attendance for the duration of magnetic resonance imaging; and (4) reinterrogating the cardiac implantable electronic device and restoring its permanent settings after magnetic resonance imaging is completed.

Survey Findings. The consultants and ASA members strongly agree with the recommendations to move the patient outside of the immediate magnetic resonance imaging area when the use of an external defibrillator/monitor, cardiac implantable electronic device programmer, or any other magnetic resonance imaging-unsafe equipment is required and to monitor the patient’s electrocardiogram and/or Spo₂ continuously throughout the magnetic resonance imaging. The consultants agree and ASA members are equivocal regarding the recommendation to have an individual capable of programming the cardiac implantable electronic device remain in attendance for the duration of the magnetic resonance imaging.

For magnetic resonance imaging-conditional cardiac implantable electronic devices, the consultants strongly agree and ASA members agree with the recommendations to interrogate a cardiac implantable electronic device, program the cardiac implantable electronic device to magnetic resonance imaging mode, suspend the antitachycardia function of an implantable cardioverter–defibrillator, and alter the pacing function of the cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient before the magnetic resonance imaging. The consultants and ASA members strongly agree with the recommendation to reinterrogate the cardiac implantable electronic device and restore its permanent settings after the magnetic resonance imaging scan.

For magnetic resonance imaging nonconditional cardiac implantable electronic devices, the consultants strongly agree and ASA members agree with the recommendations to interrogate a cardiac implantable electronic device before the magnetic resonance imaging scan, alter the pacing function of the cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient, and suspend the antitachycardia function of an implantable cardioverter–defibrillator if present. The consultants and ASA members strongly agree with the recommendation to reinterrogate the cardiac implantable electronic device and restore its permanent settings after the magnetic resonance imaging scan.

Radiofrequency identification devices are scanners used to detect retained surgical items. Management of potential sources of electromagnetic interference associated with radiofrequency identification devices addresses the topic of avoiding the use of these devices in close proximity to a cardiac implantable electronic device.

Literature Findings. The literature is insufficient to evaluate either the impact of radiofrequency identification devices as a source of electromagnetic interference or to evaluate whether electromagnetic interference depends on the distance between the radiofrequency source and cardiac implantable electronic device in the perioperative setting.

Survey Findings. For radiofrequency identification devices, the consultants strongly agree and ASA members agree with the recommendations to avoid using radiofrequency identification devices in close proximity to the cardiac implantable electronic device whenever possible.

Management of potential sources of electromagnetic interference associated with electroconvulsive therapy includes the topics of altering the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient, suspending an implantable cardioverter–defibrillator’s antitachycardia functions, and monitoring and treating ventricular arrhythmias that may occur secondary to the hemodynamic effects of electroconvulsive therapy.

Literature Findings. The literature is insufficient to evaluate the effects of specific management activities related to electroconvulsive therapy.

Survey Findings. The consultants and ASA members agree with the recommendations to alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient and to suspend an implantable cardioverter–defibrillator’s antitachycardia functions, if present. The consultants and ASA members strongly agree with the recommendation to monitor for and treat ventricular arrhythmias that may occur secondary to the hemodynamic effects of electroconvulsive therapy.

• If monopolar electrosurgery is planned superior to the umbilicus, ensure that the pacing function of a cardiac implantable electronic device is altered to an asynchronous pacing mode in the pacing-dependent patient and suspend an implantable cardioverter–defibrillator’s antitachycardia function, if present

  • Before suspending the antitachycardia function of an implantable cardiovertor defibrillator, ensure that the patient is in a monitored environment

• Minimize the risk of electromagnetic interference from monopolar electrosurgery

  • Position the electrosurgical instrument and dispersive electrode (bovie pad) so the current pathway does not pass through or near the cardiac implantable electronic device generator or leads^###****

  • Avoid waving the activated electrode over the generator^††††

  • Use short, intermittent, and irregular bursts of electrosurgery at the lowest feasible energy levels

• Use bipolar electrosurgery or an ultrasonic (harmonic) scalpel, if possible

• If radiofrequency ablation is planned superior to the umbilicus, ensure that the pacing function of a cardiac implantable electronic device is altered to an asynchronous pacing mode in the pacing-dependent patient and suspend an implantable cardioverter–defibrillator’s antitachycardia function, if present

  • Before suspending the antitachycardia function, ensure that the patient is in a monitored environment

• Avoid direct contact between the ablation catheter and the generator and leads

• Keep the radiofrequency’s current path (electrode tip to current return pad) as far away from the generator and leads as possible

• Do not focus the lithotripsy beam near the generator

Magnetic Resonance Imaging^‡‡‡‡

• Ensure that a standardized workflow and/or institutional protocol is in place and followed

• Move the patient outside of the immediate magnetic resonance imaging area when the use of an external defibrillator/monitor, cardiac implantable electronic device programmer, or any other magnetic resonance imaging-unsafe equipment is required

• Before the magnetic resonance imaging scan, perform the following:

  • Interrogate the cardiac implantable electronic device

  • Suspend the antitachycardia function of an implantable cardioverter–defibrillator, if present

    • ▪

      For magnetic resonance imaging-conditional cardiac implantable electronic devices, adhere to all product labeling including activating magnetic resonance imaging mode to suspend the antitachycardia function of a magnetic resonance imaging-conditional implantable cardioverter–defibrillator^§§§§

    • ▪

      In the pacing-dependent patient, alter the pacing function of the cardiac implantable electronic device to an asynchronous pacing mode

• Ensure that an individual capable of performing advanced cardiac life support remains in attendance for the duration of the magnetic resonance imaging scan.

• Ensure that an individual capable of programming the cardiac implantable electronic device is readily available for consultation or remains in attendance for the duration of the magnetic resonance imaging scan whenever dictated by institutional policy

• After the magnetic resonance imaging scan is completed, reinterrogate the cardiac implantable electronic device and restore its permanent settings

• Avoid using radiofrequency identification devices in close proximity to the cardiac implantable electronic device whenever possible

• Monitor for signs of electromagnetic interference and be prepared to stop using the radiofrequency identification device if interference occurs

• Alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient

• Suspend an implantable cardioverter–defibrillator’s antitachycardia function, if present

• Monitor for and be prepared to manage postconvulsive sinus tachycardia

• Monitor for and treat ventricular arrhythmias that may occur secondary to the hemodynamic effects of electroconvulsive therapy

During the perioperative period, the cardiac implantable electronic device patient might require emergency external defibrillation or cardioversion. In this case, a concern is to minimize the current flowing through the pulse generator and leads.

Literature Findings. The literature is insufficient to evaluate the effects of specific management activities related to emergency defibrillation or cardioversion.

Survey Findings. The consultants and ASA members agree with the recommendation that before emergently defibrillating or cardioverting a patient with an implantable cardioverter–defibrillator and magnet-disabled therapies, all sources of electromagnetic interference should be terminated, and the magnet should be removed to reenable the implantable cardioverter–defibrillator’s antitachycardia therapies; then the patient should be observed for the delivery of appropriate antitachycardia therapy from the implantable cardioverter–defibrillator. The consultants agree and ASA members strongly agree with the recommendation to determine whether the antitachycardia therapy of an implantable cardioverter–defibrillator should be reenabled when it has been disabled by programming. The consultants and ASA members strongly agree that if the above activities fail to restore implantable cardioverter–defibrillator antitachycardia function, emergency external defibrillation or cardioversion should be performed when needed using advanced cardiac life support guidelines for delivered energy level and pad placement. The consultants and ASA members strongly agree with the recommendation to minimize the current flowing through the generator and leads by positioning the defibrillation or cardioversion pads so they are not directly over the cardiac implantable electronic device. The consultants strongly agree and ASA members agree with the recommendation to use anterior–posterior rather than anterior–lateral pad positioning whenever possible. The consultants and ASA members strongly agree with the recommendations to use a clinically appropriate energy output regardless of the presence of the cardiac implantable electronic device and to interrogate the cardiac implantable electronic device immediately after external cardioversion or defibrillation is performed.

• Before attempting to emergently externally cardiovert or defibrillate a patient with an implantable cardioverter–defibrillator and magnet-disabled therapies, terminate all sources of electromagnetic interference and remove the magnet to reenable the implantable cardioverter–defibrillator’s antitachycardia therapies

  • Observe the patient for appropriate antitachycardia therapy from the implantable cardioverter–defibrillator

  • Determine the need for reenabling an implantable cardioverter–defibrillator’s antitachycardia therapy if it was disabled by programming

• If the above activities fail to restore the implantable cardioverter’s antitachycardia therapy, or if the antitachycardia therapy cannot be restored expeditiously, proceed with emergency external cardioversion or defibrillation when needed.

  • Follow advanced cardiac life support guidelines for delivered energy level and pad placement

  • Position the cardioversion and defibrillation pads so they are not directly over the cardiac implantable electronic device generator to minimize the current flowing through the generator and leads

  • Use a clinically appropriate energy output regardless of the presence of a cardiac implantable electronic device

  • Interrogate the cardiac implantable electronic device immediately after external cardioversion or defibrillation is performed

Postoperative management of cardiac implantable electronic device patients primarily consists of interrogating and restoring cardiac implantable electronic device function.

Literature Findings. An observational study reports that postoperative interrogation revealed cardiac implantable electronic device malfunctions that occurred during a procedure (Category B3-B evidence).⁴¹  Case reports also indicate that postoperative interrogation may have revealed intraoperative changes to cardiac implantable electronic device settings; subsequently the devices were reprogrammed to their original settings, except in one case where the device was damaged to the point it had to be replaced (Category B4-B evidence).^10,52  The literature is insufficient to evaluate the benefits of: (1) continuing to monitor and display a patient’s electrocardiogram; (2) monitoring cardiac rate and rhythm throughout the immediate postoperative period; (3) ensuring that back-up pacing and cardioversion–defibrillation equipment are immediately available; and (4) restoring the cardiac implantable electronic device to its permanent setting before the patient is discharged from a monitored environment when the cardiac implantable electronic device has been reprogrammed pre- or intraoperatively.

Survey Findings. The consultants and ASA members strongly agree with the following recommendations: (1) continuously monitor cardiac rate and rhythm throughout the immediate postoperative period; (2) for a cardiac implantable electronic device that was reprogrammed pre- or intraoperatively, ensure that back-up pacing and cardioversion–defibrillation equipment is immediately available until the permanent settings are restored; (3) for a cardiac implantable electronic device that was reprogrammed pre- or intraoperatively, restore the cardiac implantable electronic device to its permanent settings before the patient is discharged from a monitored environment; (4) if interrogation determines that the cardiac implantable electronic device settings are inappropriate, then reprogram the cardiac implantable electronic device to newly appropriate settings; (5) perform a postoperative cardiac implantable electronic device interrogation if emergency surgery occurred without appropriate preoperative cardiac implantable electronic device evaluation; (6) perform a postoperative cardiac implantable electronic device interrogation if there is suspicion that antitachycardia therapy might have been disabled rather than temporarily suspended with magnet placement; (7) perform a postoperative cardiac implantable electronic device interrogation if significant electromagnetic interference occurred in close proximity to the cardiac implantable electronic device; and (8) perform a postoperative cardiac implantable electronic device interrogation if the delivery of antitachycardia therapy was observed or if there is concern for cardiac implantable electronic device malfunction. The consultants strongly agree and ASA members agree that if the cardiac implantable electronic device is not interrogated during the immediate postoperative period, interrogate it within 30 days after the procedure.

• Continue to monitor and display a patient’s cardiac rate and rhythm throughout the immediate postoperative period as required by ASA standards and as indicated by the patient’s medical condition

• For a cardiac implantable electronic device that was reprogrammed pre- or intraoperatively:

  • Ensure that back-up pacing and cardioversion–defibrillation equipment are immediately available until the cardiac implantable electronic device’s permanent settings are restored^‖‖‖‖

  • Ensure that the patient’s cardiac rate and rhythm are continuously monitored and displayed until the cardiac implantable electronic device’s permanent settings are restored^####

  • Ensure that the patient remains in a monitored environment until the cardiac implantable electronic device’s permanent settings are restored (e.g., until the antitachycardia function of an implantable cardioverter–defibrillator is reenabled)

• Perform a postoperative cardiac implantable electronic device interrogation whenever:

  • Emergency surgery occurs without appropriate preoperative cardiac implantable electronic device evaluation

  • There is suspicion that antitachycardia therapy might have been disabled rather than temporarily suspended with magnet placement^*****

  • The delivery of antitachycardia therapy was observed or suspected

  • There is concern for cardiac implantable electronic device malfunction (i.e., significant electromagnetic interference occurred in close proximity to the cardiac implantable electronic device, an invasive procedure was performed in close proximity to a cardiac implantable electronic device generator or lead, or large fluid shifts occurred)

• If interrogation determines that the cardiac implantable electronic device settings are inappropriate, reprogram to newly appropriate settings^{†††††}

• Determine whether a patient has a cardiac implantable electronic device (cardiac implantable electronic device)

  • Conduct a focused history (e.g., interview the patient or other source, review medical record, chest x-ray, and electrocardiogram if available)

  • Perform a focused physical examination (e.g., check for scars, palpate for device)^§§§§§

• Determine the cardiac implantable electronic device type, manufacturer, and primary indication for placement

  • Obtain the manufacturer’s identification card from the patient or other source

  • Review the medical record

  • Obtain and review the most recent cardiac implantable electronic device interrogation report^{‖‖‖‖‖}

  • Refer to supplemental resources (e.g., manufacturer’s databases, cardiac implantable electronic device clinic records)

  • Order a chest x-ray if no other data are available^#####

• Determine whether the patient is pacing-dependent^******

  • From the focused history and medical record, assess for one or more of the following indicators:

    • ▪

      Bradycardia that caused syncope or other symptoms resulting in cardiac implantable electronic device implantation

    • ▪

      Successful atrioventricular nodal ablation resulting in cardiac implantable electronic device implantation

    • ▪

      A cardiac implantable electronic device interrogation showing no evidence of spontaneous ventricular activity when the cardiac implantable electronic device’s pacing function is temporarily programed to a nontracking mode (i.e., ventricular-only pacing and sensing) at the lowest programmable rate

• Determine the cardiac implantable electronic device’s current settings, that it is functioning properly (i.e., by interrogating the cardiac implantable electronic device or obtaining the most recent interrogation report), and that it is optimally programed for the planned procedure^{‡‡‡‡‡‡§§§§§§}

  • Reinterrogate the cardiac implantable electronic device if there is any question of proper function

• Determine whether intraoperative electromagnetic interference is likely to occur.

• If electromagnetic interference is likely to occur (e.g., monopolar electrosurgery [“bovie”] use, or radiofrequency ablation is planned superior to the umbilicus), alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient^{‖‖‖‖‖‖######} and suspend an implantable cardioverter–defibrillator’s antitachycardia function, if present^*******

  • Before suspending the antitachycardia function, ensure that the patient is in a monitored environment

  • Avoid the indiscriminate use of a magnet over an implantable cardioverter–defibrillator

  • If needed, consult a specialist to alter the pacing function of a cardiac implantable electronic device or to suspend the antitachycardia function of an implantable cardioverter–defibrillator

• Ensure that temporary pacing and defibrillation equipment are immediately available before, during, and after all procedures with electromagnetic interference potential

• Suspend a cardiac implantable electronic device’s active sensor for rate-responsive pacing to prevent undesirable tachycardia^{†††††††}

• Continuously monitor and display a patient’s electrocardiogram and Spo₂ as required by American Society of Anesthesiologists (ASA) standards^66,67  from the beginning of anesthesia until the patient is transferred out of the anesthetizing location^{‡‡‡‡‡‡‡}

• Perform continuous peripheral pulse monitoring for all cardiac implantable electronic device patients receiving anesthesia care^{§§§§§§§}

• If unanticipated cardiac implantable electronic device interactions occur, temporarily suspend the procedure until the source of interference can be identified and eliminated or managed

• If monopolar electrosurgery is planned superior to the umbilicus, ensure that the pacing function of a cardiac implantable electronic device is altered to an asynchronous pacing mode in the pacing-dependent patient and suspend an implantable cardioverter–defibrillator’s antitachycardia function, if present

  • Before suspending the antitachycardia function, ensure that the patient is in a monitored environment

• Minimize the risk of electromagnetic interference from monopolar electrosurgery

  • Position the electrosurgical instrument and dispersive electrode (“bovie pad”) so the current pathway does not pass through or near the cardiac implantable electronic device generator or leads^{‖‖‖‖‖‖‖#######}

  • Avoid waving the activated electrode over the generator^********

  • Use short, intermittent, and irregular bursts of electrosurgery at the lowest feasible energy levels

• Use bipolar electrosurgery or an ultrasonic (harmonic) scalpel, if possible

• If radiofrequency ablation is planned superior to the umbilicus, ensure that the pacing function of a cardiac implantable electronic device is altered to an asynchronous pacing mode in the pacing-dependent patient and suspend an implantable cardioverter–defibrillator’s antitachycardia function, if present

  • Before suspending the antitachycardia function, ensure that the patient is in a monitored environment

• Avoid direct contact between the ablation catheter and the generator and leads

• Keep the radiofrequency’s current path (electrode tip to current return pad) as far away from the generator and leads as possible

• Do not focus the lithotripsy beam near the generator

• Ensure that a standardized workflow and/or institutional protocol is in place and followed

• Move the patient outside of the immediate magnetic resonance imaging area when the use of an external defibrillator/monitor, cardiac implantable electronic device programmer, or any other magnetic resonance imaging-unsafe equipment is required

• Before the magnetic resonance imaging scan, perform the following:

  • Interrogate the cardiac implantable electronic device

  • Suspend the antitachycardia function of an implantable cardioverter–defibrillator, if present

    • ▪

      For magnetic resonance imaging-conditional cardiac implantable electronic devices, adhere to all product labeling including activating “magnetic resonance imaging mode” to suspend the antitachycardia function of a magnetic resonance imaging-conditional implantable cardioverter–defibrillator^{‡‡‡‡‡‡‡‡}

    • ▪

      In the pacing-dependent patient, alter the pacing function of the cardiac implantable electronic device to an asynchronous pacing mode

• Ensure that an individual capable of performing advanced cardiac life support remains in attendance for the duration of the magnetic resonance imaging scan

• Ensure that an individual capable of programming the cardiac implantable electronic device is readily available for consultation or remains in attendance for the duration of the magnetic resonance imaging scan whenever dictated by institutional policy

• After the magnetic resonance imaging scan is completed, reinterrogate the cardiac implantable electronic device and restore its permanent settings

• Avoid using radiofrequency identification devices in close proximity to the cardiac implantable electronic device, whenever possible

• Monitor for signs of electromagnetic interference and be prepared to stop using the radiofrequency identification device if interference occurs

• Alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient

• Suspend an implantable cardioverter–defibrillator’s antitachycardia function, if present

• Monitor for and be prepared to manage postconvulsive sinus tachycardia

• Monitor for and treat ventricular arrhythmias that may occur secondary to the hemodynamic effects of electroconvulsive therapy

• Before attempting to emergently externally cardiovert or defibrillate a patient with an implantable cardioverter–defibrillator and magnet-disabled therapies, terminate all sources of electromagnetic interference and remove the magnet to reenable the implantable cardioverter–defibrillator’s antitachycardia therapies

  • Observe the patient for appropriate antitachycardia therapy from the implantable cardioverter–defibrillator

  • Determine the need for reenabling an implantable cardioverter–defibrillator’s antitachycardia therapy if it was disabled by programming

• If the above activities fail to restore the implantable cardioverter’s antitachycardia therapy, or if the antitachycardia therapy cannot be restored expeditiously, proceed with emergency external cardioversion or defibrillation when needed.

  • Follow advanced cardiac life support guidelines for delivered energy level and pad placement

  • Position the cardioversion and defibrillation pads so they are not directly over the cardiac implantable electronic device generator to minimize the current flowing through the generator and leads

  • Use a clinically appropriate energy output regardless of the presence of a cardiac implantable electronic device

  • Interrogate the cardiac implantable electronic device immediately after external cardioversion or defibrillation is performed

• Continue to monitor and display a patient’s cardiac rate and rhythm throughout the immediate postoperative period as required by ASA standards and as indicated by the patient’s medical condition

• For a cardiac implantable electronic device that was reprogrammed pre- or intraoperatively:

  • Ensure that back-up pacing and cardioversion–defibrillation equipment are immediately available until the cardiac implantable electronic device’s permanent settings are restored^{§§§§§§§§}

  • Ensure the patient’s cardiac rate and rhythm are continuously monitored and displayed until the cardiac implantable electronic device’s permanent settings are restored^{‖‖‖‖‖‖‖‖}

  • Ensure the patient remains in a monitored environment until the cardiac implantable electronic device’s permanent settings are restored (e.g., until the antitachycardia function of an implantable cardioverter–defibrillator is reenabled)

• Perform a postoperative cardiac implantable electronic device interrogation whenever:

  • Emergency surgery occurred without appropriate preoperative cardiac implantable electronic device evaluation

  • There is suspicion that antitachycardia therapy might have been disabled rather than temporarily suspended with magnet placement^########

  • The delivery of antitachycardia therapy was observed or suspected

  • There is concern for cardiac implantable electronic device malfunction (i.e., significant electromagnetic interference occurred in close proximity to the cardiac implantable electronic device, an invasive procedure was performed in close proximity to a cardiac implantable electronic device generator or lead, or large fluid shifts occurred)

• If interrogation determines that the cardiac implantable electronic device settings are inappropriate, reprogram to newly appropriate settings^*********

For this updated practice advisory, a systematic search and review of peer-reviewed published literature was conducted, with scientific findings summarized and reported below and in the document. Assessment of conceptual issues and the practicality and feasibility of the advisory recommendations were also evaluated, with opinion data collected from surveys and other sources. Both the systematic literature review and the opinion data are based on evidence linkages or statements regarding potential relationships between perioperative interventions and electromagnetic interference (electromagnetic interference) outcomes associated with cardiac implantable electronic devices (cardiac implantable electronic devices). The evidence linkage interventions are listed below. The evidence model below guided the search, providing inclusion and exclusion information regarding patients, procedures, practice settings, providers, clinical interventions, and outcomes. After review of all evidentiary information, the task force placed each recommendation into one of three categories: (1) provide the intervention or treatment; (2) the intervention or treatment may be provided to the patient based on circumstances of the case and the practitioner’s clinical judgment; or (3) do not provide the intervention or treatment. The American Society of Anesthesiologists (ASA) Committee on Standards and Practice Parameters reviews all practice parameters at the ASA annual meeting and determines update and revision timelines. The policy of the ASA Committee on Standards and Practice Parameters is to update practice guidelines every 5 yr.

• Inclusion criteria:

  • Patients with permanently implanted cardiac implantable electronic device for treatment of a bradyarrhythmia, tachyarrhythmia, or heart failure

    • ▪

      pacemakers

    • ▪

      Implantable cardioverter–defibrillators

    • ▪

      Cardiac resynchronization devices

• Exclusion criteria:

  • Patients undergoing cardiac implantable electronic device implantation or revision

  • Patients without a permanently implantable pacemaker or implantable cardioverter–defibrillator

  • Patients with a temporary cardiac implantable electronic device

• Inclusion criteria:

  • Inpatient procedures

  • Outpatient procedures

• Exclusion criteria:

  • Procedures without known perioperative cardiac implantable electronic device-related concerns

    • ▪

      Plain radiography

    • ▪

      Fluoroscopy

• Inclusion criteria:

  • Any perioperative setting in which an anesthesia provider will be delivering anesthesia care

    • ▪

      Preoperative settings

    • ▪

      Intraoperative settings

    • ▪

      Postoperative settings

    • ▪

      Recovery settings

• Exclusion criteria:

  • Nonperioperative settings

• Inclusion criteria:

  • Anesthesia care providers

    • ▪

      Anesthesiologists

    • ▪

      All other individuals who deliver or are responsible for anesthesia care

• Exclusion criteria:

  • Individuals who do not deliver or are responsible for anesthesia care

• Inclusion criteria:

  • Preoperative patient evaluation

    • ▪

      Establish whether a patient has a cardiac implantable device

      • Conduct a focused history

      • Obtain manufacturer’s identification card from patient or other source

      • Order chest x-ray if no other data are available

      • Refer to supplemental resources (e.g., manufacturer’s databases)

    • ▪

      Determine cardiac implantable electronic device dependency

    • ▪

      Determine cardiac implantable electronic device function

      • Determine whether a cardiac implantable electronic device will capture when it paces

      • Contact the manufacturer

  • Preoperative preparation

    • ▪

      Determine whether electromagnetic interference occurs during procedure

      • Electrosurgery

      • Radiofrequency ablation

      • Lithotripsy

      • External cardioversion or defibrillation

      • Magnetic resonance imaging

      • Electroconvulsive therapy

    • ▪

      Determine whether reprogramming a cardiac implantable electronic device to an asynchronous pacing mode is needed

      • Electrosurgery

      • Radiofrequency ablation

      • Lithotripsy

      • Magnetic resonance imaging

    • ▪

      Program antitachyarrhythmia therapy off

    • ▪

      Temporary pacing and cardioversion and defibrillation equipment immediately available

    • ▪

      bipolar electrosurgery or ultrasonic scalpel

  • Intraoperative management

    • ▪

      Monitor operation of the cardiovascular device

      • Electrocardiography monitoring (per ASA standard)

      • Monitor pulse wave form (e.g., pulse oximeter plethysmogram, intraarterial pressure)

    • ▪

      Management of potential cardiac implantable electronic device dysfunction due to electromagnetic interference

      • Electrosurgery

        • Position the dispersive electrode so that the current pathway does not pass through or near the cardiac electronic device generator and leads

        • Avoid direct contact with the generator or leads

        • Use short, intermittent, and irregular bursts at the lowest feasible energy levels

        • Use bipolar electrosurgery system or ultrasonic scalpel

        • Use an ultrasonic (harmonic) scalpel (an ultrasonic scalpel can be safely used without affecting a pacemaker or implantable cardioverter–defibrillator)

      • Radiofrequency ablation

        • Keep the current path as far away from the generator and leads as possible

        • Avoid proximity of the ablation catheter to the leads (intercardiac ablative procedures)

      • Lithotripsy

        • Avoid focusing the lithotripsy beam near the pulse generator

      • Magnetic resonance imaging

        • Move the patient outside of the immediate magnetic resonance imaging scan area when the use of an external monitor or cardioverter defibrillator, cardiac implantable electronic device programmer, or any other magnetic resonance imaging-unsafe equipment is required

        • Monitor the patient’s electrocardiogram and/or Spo₂ continuously throughout the magnetic resonance imaging scan

        • An individual capable of programming the cardiac implantable electronic device remaining in attendance for the duration of the magnetic resonance imaging scan

      • Magnetic resonance imaging-conditional cardiac implantable electronic devices

        • Before the magnetic resonance imaging, interrogate the cardiac implantable electronic device and program to “magnetic resonance imaging mode” to suspend the antitachycardia function or an implantable cardioverter–defibrillator

        • Alter the pacing function of the cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient

        • After the magnetic resonance imaging scan is completed, reinterrogate the cardiac implantable electronic device and restore its permanent settings

      • Magnetic resonance imaging nonconditional cardiac implantable electronic devices

        • Interrogate the cardiac implantable electronic device before and after the magnetic resonance imaging scan

        • Reprogram the cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient

        • Suspend the antitachycardia function of an implantable cardioverter–defibrillator, if present

        • After the magnetic resonance imaging scan is completed, reinterrogate the cardiac implantable electronic device and restore its permanent settings

      • Radiofrequency identification devices

        • Avoid using this equipment in close proximity to the cardiac implantable electronic device whenever possible

        • Monitor for signs of interference with the cardiac implantable electronic device and be prepared to stop using the radiofrequency identification device if interference occurs

      • Electroconvulsive therapy

        • Alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient

        • Suspend an implantable cardioverter–defibrillator’s antitachycardia therapy, if present

        • Monitor for and treat ventricular arrhythmias that may occur secondary to the hemodynamic effects of electroconvulsive therapy

  • Emergency cardioversion or defibrillation

    • ▪

      Patients with an implantable cardioverter–defibrillator and magnet-disabled therapies:

      • Remove the magnet to reenable antitachycardia therapy

      • Terminate all sources of electromagnetic interference after magnet is removed

      • Observe the patient for appropriate cardiac implantable electronic device antitachycardia therapy

    • ▪

      Patients with an implantable cardioverter–defibrillator and antitachycardia therapy that have been disabled by programming

      • Reenable antitachycardia therapy via programming

    • ▪

      Minimize the current flowing through the generator and leads

      • Position cardioversion and defibrillation pads as far as possible from the pulse generator

      • Use anterior–posterior position

      • Use a clinically appropriate energy output

  • Postoperative management

    • ▪

      Confirm or restore cardiac implantable electronic device function

      • Interrogate the implantable cardiac electronic device

      • Reprogram the implantable cardiac electronic device to appropriate settings

      • Restore therapy antiarrhythmic therapies

      • Patients with disabled implantable cardioverter–defibrillator antitachycardia functions

        • Continuously monitor cardiac function

        • Keep external cardioversion and defibrillation equipment immediately available until antitachycardia function has been restored

• Expected benefits:

  • Successful procedure

  • Reduced frequency/severity of adverse outcomes:

    • ▪

      Adverse outcomes associated with a cardiac implantable electronic device

      • Inability to deliver pacing or shocks

      • Lead-tissue interface damage

      • Changes in pacing behavior

      • Electrical reset to the backup pacing mode

      • Inappropriate implantable cardioverter–defibrillator antitachycardia therapy

    • ▪

      Adverse clinical outcomes

      • Hypotension

      • Tachyarrhythmia

      • Bradyarrhythmia

      • Myocardial tissue damage

• Literature inclusion criteria:

  • Randomized controlled trials

  • Prospective nonrandomized comparative studies (e.g., quasi-experimental, cohort)

  • Retrospective comparative studies (e.g., case-control)

  • Observational studies (e.g., correlational or descriptive statistics)

  • Case reports, case series

• Literature exclusion criteria (except to obtain new citations):

  • Editorials

  • Literature reviews

  • Meta-analyses conducted by others

  • Abstracts

  • Unpublished studies

  • Studies in non–peer-review journals

  • Newspaper articles

• Survey evidence:

  • Expert consultant survey

  • ASA membership survey

  • Other participating organization surveys

  • Reliability survey

  • Feasibility survey

For the systematic review, potentially relevant clinical studies were identified via electronic and manual searches. Healthcare database searches included PubMed, EMBASE, Web of Science, Google Books, and the Cochrane Central Register of Controlled Trials. The searches covered a 9.5-yr period from January 1, 2010, through July 1, 2019. Accepted studies from the previous advisory were also rereviewed, covering the period of January 1, 1990, through July 31, 2010. Only studies containing original findings from peer-reviewed journals were acceptable. Editorials, letters, and other articles without data were excluded. A literature search strategy and PRISMA^{†††††††††} flow diagram are available as Supplemental Digital Content 2 (https://links.lww.com/ALN/B980).

In total, 1,143 new citations were identified, with 810 articles assessed for eligibility. After review, 746 were excluded, with 24 new studies meeting the above stated criteria. These studies were combined with 40 pre-2010 articles used in the previous advisory and 8 provided by task force members, resulting in a total of 72 articles accepted as evidence for these guidelines. In this document, 63 peer-reviewed articles, 2 ASA standards, and 1 ASA practice advisory are referenced, with a complete bibliography of articles used to develop these guidelines, organized by section, available as Supplemental Digital Content 3 (https://links.lww.com/ALN/B981).

Each pertinent outcome reported in a study was classified by evidence category and level and designated as beneficial, harmful, or equivocal. Findings were then summarized for each evidence linkage and reported in the text of the updated advisory, with evidence tables available as Supplemental Digital Content 4 (https://links.lww.com/ALN/B982).

Evidence categories refer specifically to the strength and quality of the research design of the studies. Category A evidence represents results obtained from randomized controlled trials, and category B evidence represents observational results obtained from nonrandomized study designs or randomized controlled trials without pertinent comparison groups. When available, category A evidence is given precedence over category B evidence for any particular outcome. These evidence categories are further divided into evidence levels. Evidence levels refer specifically to the strength and quality of the summarized study findings (i.e., statistical findings, type of data, and the number of studies reporting/replicating the findings). In this document, only the highest level of evidence is included in the summary report for each intervention—outcome pair, including a directional designation of benefit, harm, or equivocality.

Category A. Randomized controlled trials report comparative findings between clinical interventions for specified outcomes. Statistically significant (P < 0.01) outcomes are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E).

Level 1. The literature contains a sufficient number of randomized controlled trials to conduct meta-analysis,^{‡‡‡‡‡‡‡‡‡} and meta-analytic findings from these aggregated studies are reported as evidence.

Level 2. The literature contains multiple randomized controlled trials, but the number of randomized controlled trials is not sufficient to conduct a viable meta-analysis for the purpose of these guidelines. Findings from these randomized controlled trials are reported separately as evidence.

Level 3. The literature contains a single randomized controlled trial, and findings from this study are reported as evidence.

Category B. Observational studies or randomized controlled trials without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. Inferred findings are given a directional designation of beneficial (B), harmful (H), or equivocal (E). For studies that report statistical findings, the threshold for significance is P < 0.01.

Level 1. The literature contains nonrandomized comparisons (e.g., quasiexperimental, cohort [prospective or retrospective], or case-control research designs) with comparative statistics between clinical interventions for a specified clinical outcome.

Level 2. The literature contains noncomparative observational studies with associative statistics (e.g., correlation, sensitivity, and specificity).

Level 3. The literature contains noncomparative observational studies with descriptive statistics (e.g., frequencies, percentages).

Level 4. The literature contains case reports.

Insufficient Literature. The lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable (i.e., no pertinent studies found) or inadequate. Inadequate literature cannot be used to assess relationships among clinical interventions and outcomes because a clear interpretation of findings is not obtained due to methodologic concerns (e.g., confounding of study design or implementation) or the study does not meet the criteria for content as defined in the “focus” of the guidelines.

Although interobserver agreement among task force members and two methodologists was not assessed for this update, the original guidelines reported agreement levels using a κ statistic for two-rater agreement pairs 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 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 Validation of the concepts addressed by this advisory and subsequent recommendations proposed was obtained by consensus from multiple sources, including: (1) survey opinions from consultants^{§§§§§§§§§} who were selected based on their knowledge or expertise in perioperative management of cardiac implantable electronic devices; (2) survey opinions from randomly selected samples of active members of the ASA; (3) testimony on the original advisory from attendees of two publicly held open forums at a national anesthesia meeting and at a major cardiology meeting; and (4) internet commentary. All opinion-based evidence relevant to each topic was considered in the development of these guidelines. However, only findings obtained from formal surveys are reported in the document. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. Identical surveys were distributed to expert consultants and a random sample of members of the participating organizations.

Survey responses were recorded using a five-point scale and summarized based on median values.^{‖‖‖‖‖‖‖‖‖}

Strongly agree: Median score of 5 (at least 50% of the responses are 5)

Agree: Median score of 4 (at least 50% of the responses are 4 or 4 and 5)

Equivocal: Median score of 3 (at least 50% of the responses are 3, or no other response category or combination of similar categories contain at least 50% of the responses)

Disagree: Median score of 2 (at least 50% of responses are 2 or 1 and 2)

Strongly disagree: Median score of 1 (at least 50% of responses are 1)

The survey rate of return was 34% (N = 32/94) for consultants, and 5% (N = 245/5,000) for the ASA membership. The results of the surveys are reported in tables 2 and 3 and are summarized in the text of the guidelines.^#########

An additional survey was sent to the consultants accompanied by a draft of the advisory asking them to indicate which, if any, of the evidence linkages would change their clinical practices if the advisory were instituted. The rate of return was 13% (N = 12 of 94). The percentage of responding consultants expecting no change associated with each linkage were as follows: preoperative evaluation (determining whether a patient has a cardiac implantable electronic device and that it is functioning properly), 83.3%; patient preparation (determining whether electromagnetic interference is likely to occur), 83.3%; consulting a specialist when needed to alter the pacing function of a cardiac implantable electronic device, 75.0%; having temporary pacing and defibrillation equipment immediately available before, during, and after procedures with electromagnetic interference potential, 91.7%; continuous monitoring of electrocardiography, Spo₂, and peripheral pulse, 91.7%; electrosurgery, 100%; radiofrequency ablation, 100%; lithotripsy, 91.7%; magnetic resonance imaging, 91.7%; radiation therapy, 100%; radiofrequency identification devices, 100%; electroconvulsive therapy, 100%; emergency defibrillation or cardioversion, 91.7%; postoperative management (continuing to monitor and display electrocardiogram, cardiac rate, and rhythm), 100%; postoperative management (for a cardiac implantable electronic device that was reprogrammed pre- or intraoperatively, restore the cardiac implantable electronic device to its permanent settings before the patient is discharged from a monitored environment), 83.3%; and postoperative cardiac implantable electronic device interrogation, 91.7%. In total, 67% of the respondents indicated that the advisory would have no effect on the amount of time spent on a typical case with the implementation of this advisory, 25% indicated that there would be an increase, and 8.3% indicated that there would be a decrease.

The authors are indebted to the late Dr. Marc A. Rozner for his service as the original chair of this Task Force and his invaluable contributions to the earlier versions of this advisory.

Support was provided solely by the American Society of Anesthesiologists (Schaumburg, Illinois).

The authors declare no competing interests.