围手术期间心脏植入装置的管理 专家共识.ppt

围手术期间心脏植入装置的管理专家共识解读南昌大学第二附属医院鲍慧慧,TheHeartRhythmSocietyExpertConsensus（2011AHA/ACC/ASA/STS）,CommitteeStaff8AHA/ACC/4ASA/1STS,Nashville,TN；Seattle,WA；Houston；TX,Rochester,MNBaltimore；Cleveland,OHGreenville,NC；Hanover,NHCharleston,SC；WestDesMoines,IACleveland,OH；Jacksonville,FLCharlottesville,VA；Nashville,TN,Engineersfrom：,概要,介绍医疗操作期间可能出现的问题ProblemsthatcanoccurduringmedicalproceduresPreoperativeevaluationofapatientwitha心脏植入性电子装置（CIED）患者术前评估心脏植入性电子装置（CIED）患者手术中管理与思考Intraoperativemanagementandconsiderations心脏植入性电子装置术中的评估IntraoperativeevaluationofCIEDs,Abbreviations,CIED：CardiovascularimplantableelectronicdevicesEMI：ElectromagneticinterferenceECT：ElectroconvulsivetherapyCIEDteam：Physician,nurse,andtechniciansPerioperativeteam：Anesthesiologist,surgeon，physician,nurse,Morethan3,000,000deviceswereimplantedintheglobe全球约有三百万以上患者心脏植入装置700,000deviceswasimplantedin20092009年有700,000患者心脏植入装置Increasingattherateof15%everyyear每年以15%速度递增,Introduction,EnsurepatientswithdevicessafeinperioperativeperiodNeedforaconsistentstatement1、RapidchangesinCIEDtechnology2、ExpandinguseofEMI3、Confusingrecommendations,Introduction,Problemsthatcanoccurduringmedicalprocedures,EMIElectrosurgicalenergy,EMIandCIEDsElectrosurgicalenergy,IdentificationofproblemsspecifictopatientswithCIEDduringmedicalprocedures,OversensingRateresponsivealgorithmsResetPulsegeneratordamageLead-tissueinterfacedamage,EMIandCIEDs,Transienteffectionsuchas：PacinginhibitionInappropriatetrackingofelectricalnoiseDamageatthelead-tissueinterfacePulsegeneratordamageElectricalresetmodeRateresponsivealgorithms,Extentofabnormalbehaviordependson：StrengthDurationParticulartypeofinterferenceClinicalimpactdependson：PatientsintrinsicrateandrhythmPacingmodeFunctioningofprotectivecircuitryengineeredtofilteroutextraneouselectricalcurrents,EMIandCIEDs,Electrosurgicalenergy,Bipolarelectrosurgery：(e.g.electricalforceps）UsedfarlesscommonlyonlyforcoagulationandnotdissectionMonopolarelectrosurgeryUtilizedformostsurgicalproceduresElectrode：“Penorstylus”totheoperativesiteReturnelectrode：patientsbody,InteractionswithCIEDsincluding：InhibitionTriggeringunneededtachyarrhythmiatherapyElectricalresetOversensing,Electrosurgicalenergy,DirectlytothepulsegeneratororsystemelectrodePermanentdamageoftheCIEDpulsegeneratorDamagetothelead-myocardialinterfacecausinganincreaseofpacingthresholdsNodamageifthedistanceis6inches,Electrosurgicalenergy,Determineconsequencesofoversensing：DurationofexposurePathofthecurrentPatientsunderlyingrhythmOversensinginICDsresultsin：inhibitionofpacingATPtherapyICDshocks,Oversensing,ICDrequireacertaindurationofcontinuoushigh-ratesensingtofulfillarrhythmiadetectioncriteriaAnapproachthatlimitselectrosurgeryusagetoshortburstsmaybeasaferapproachtopatient-CIEDmanagementthaneitherreprogrammingtheCIEDorplacementofamagnetoverthepulsegenerator,Oversensing,CIEDusesaminute-ventilationsensorforrateresponseRateresponsivealgorithmsoccursbecausetheimpedancemeasurementismiscalculatedduetothecurrentfromtheelectrosurgery.AlsoinsomeCIEDs,themagneticswitchcanbeactivatedbyelectrosurgery,causingrapidpacing,Rateresponsivealgorithms,DeviceresetismorecausedbytherapeuticionizingradiationthanEMIcorruptionofthememoryinthecircuitry(2)asurgeofenergycoursingthroughthepulsegeneratorthatsimulatestheinitialconnectionofthepowersourceWerecommendcontactingthetechnicalsupportserviceofthemanufacturer,Reset,Pacingandantitachycardiatherapyparametersareuniquetoeachmanufacturer,SomenewerBostonScientificICDshaveSafetyCoreSafetyCoreisaback-upmodeintendedformajorhardwarefailuresthatprovideshigh-voltagetherapywithasimpleunipolarVVIpacing,Reset,Electricalenergycanenterthepulsegenerator：BreachofleadinsulationCorruptionofthesealingringswithconductivefluidbridgetotheleadconnector,Pulsegeneratordamage,SurgeriesclosetotheCIEDshouldbedonewithbipolarratherthanmonopolarelectrosurgery（e.g.breast,shoulder,headandneck,pulsegeneratorreplacement,orcarotidprocedures）Surgeryontheipsilateralhand,thereturnelectrodeshouldbeontheipsilateralarm1,Pulsegeneratordamage,Leadtissueinterfacedamage,Electrosurgicalcollateraldamagetothelead-myocardialinterfaceResultingin：IncreaseinpacingthresholdLossofcaptureInductionofarrhythmias,Howtomitigatetherisk（1）,KeepingthecurrentpathawayfromCIEDdiminishesthepotentialforadverseinteractionwiththeCIEDForexample：belowtheumbilicusislesslikelytocauseinterferencethanabovetheumbilicusUsingbipolarelectrosurgerywheneverpossibleMinimizingthelengthofmonopolarelectrosurgeryburststo5secondsorless,CardioversionCatheterablationforcardiacarrhythmiasDiagnosticradiationTherapeuticradiationElectroconvulsiveTherapyTransurethralneedleablation(TUNA)Transurethralresectionoftheprostate(TURP)GastroenterologyproceduresTissueexpandersStimulatorsRadiofrequencyidentificationdevices(RFID)OtherwirelesstechnologyLithotripsyIontophoresisPhotodynamictherapyDentalprocedures,Specialsituations,Cardioversion,ExternalcardioversionwasassociatedwithtransientdysfunctionofolderCIEDs,particularlyusedunipolarleadsusingananterior-lateralelectrodeposition：transientlossofcaptureandelectricalresetInarecentclinicalstudy，44patientswithCIEDsUsingananterior-posteriorelectrode，positionedwith8cmbetweentheanteriorelectrodeandtheCIEDNoCIEDmalfunction,Inacase-seriesofthreepatients,highpacingthresholdsafterthecardioversionExperienceofseveralcommitteemembers：pulsegeneratorreset,Cardioversion,RadiofrequencyenergydeliverynearCIEDsmayresultin：ElectricalresetReprogrammingOversensingInappropriateinhibitionUndersensingInappropriatearrhythmiadetection（ICD）pulsegeneratormalfunction,Catheterablationforcardiacarrhythmias,HouseholdmicrowaveenergyhasnosignificantimpactonpacemakersandICDsNospecificstudiesareavailableintermsofmicrowaveablation,whethertheenergyisdeliveredtotheepicardiumorendocardium,Catheterablationforcardiacarrhythmias,Diagnosticradiation,DiagnosticradiationgenerallydoesnothaveanysignificantadverseeffectonCIEDsWiththenewestgenerationofmultislicecomputedtomographymachinesthatusehigherradiationdoses,transienteffectsonCIEDsduetooversensing,TherapeuticradiationcandamageCIEDfunctionModernCIEDsutilizemetaloxidesemiconductorsintheintegratedcircuitryWhenthesemiconductorsareexposedtoionizingradiation,damageoccurstothesiliconandthesiliconoxideinsulatorswithinthesemiconductorSuddenoutputfailureorrunawaypacinghasbeenreported,Therapeuticradiation,DirectradiationofpacemakersandICDsshouldbestrictlyavoidedandaccumulateddoses5GyScatterneutronmayoccurelectricalresetImportantly,theuseofconventionalx-rayshieldingduringradiotherapydoesnotprotectthepulsegeneratorfromtheeffectsofthescatteredneutronsIfthephotonbeamenergyexceeds10MV,evaluationofCIEDfunctionimmediately,Therapeuticradiation,InECT,anelectriccurrentisdeliveredtothebrain,triggeringabriefseizureDamagetoCIEDfunction：NoisereversionmodeMyopotentialoversensingBradycardiaInappropriateICDshocks,Electroconvulsivetherapy（ECT）,ThephysicianneedstoknowtheICDtachycardiadetectionrateandshouldhaveamagnethandyincasethesinusrategetsnearthatratePretreatmentwithshort-actingbeta-blockersmightalsobeconsideredinsuchpatients,Electroconvulsivetherapy,Transurethralresectionoftheprostate(TURP),PlacingthepatientreturnelectrodeonalegLimitingapplicationsofTURP-relatedelectrosurgeryto1to2secondsevery10secondsReducetheriskofinhibitioninindividualswhoarepacemakerdependentAvoidICDinappropriatedetections,Colonoscopy、gastrocopyandCapsuleendoscopy：NoreportingcauseinterferenceTissueexpanders：DevicescalledtissueexpandersareusedbyplasticsurgeonstoprepareforreconstructivebreastsurgeryReceivetissueexpanderswithoutmagneticaimingguides,Radiofrequencyidentificationdevices(RFID)：avoidplacingidentificationtagsclosetothepulsegeneratorOtherwirelesstechnology：SeveralstudieshaveevaluatedinteractionofGSMwithCIEDsandfoundinterferencewhenthewirelessdeviceiscloserthan10cmtotheCIEDpocket,Transurethralneedleablation(TUNA)Electromyelograms(EMGs)andnerveconductiontestingIontophoresisPhotodynamictherapyDentalprocedures,TherearenoreportsofthistechnologyinalteringCIEDfunctionality,PreoperativeevaluationofapatientwithaCIED,Timely,thoroughpreoperativeevaluationisessentialforthesafeperioperativemanagementofpatientswithCIEDsandshouldincludeamultidisciplinaryandsystematicapproachCIEDteamANDperioperativeteamThemosteffectiveprescriptionfortheperioperativecareofapatientwithaCIED,Preoperativerecommendations,TheProcedureteammustadvisetheCIEDteamaboutthenatureoftheplannedprocedureGeneralprinciplesguidinginclude:InactivationofICDdetectionisnotauniversalrequirementforallprocedures.RenderingPMsasynchronousinpacemaker-dependentpatientsisnotauniversal,Pacemakersthatneedtobeprotectedfrominhibitionmaybemadeasynchronousbyprogrammingorbyplacementofamagnetappliedoverthepulsegenerator,providedthepulsegeneratorisaccessible.ICDarrhythmiadetectioncanbesuspendedbyplacementofamagnetoverthepulsegeneratorAmagnetplacedoveranICDgeneratorwillnotrenderpacemakerfunctioninanICDasynchronous.,Preoperativerecommendations,RenderingaPMasynchronousinaPM-dependentpatientispreferableformostproceduresabovetheumbilicus.Inpacemakerpatients,noreprogrammingisusuallyneededifbelowtheleveloftheumbilicus.Patientswithpacemakersundergoingelectivesurgeryshouldhavehadadevicecheckaspartofroutinecarewithinthepast12monthspatientswithICDsundergoingelectivesurgeryshouldhavehadadevicecheckaspartofroutinecarewithinthepast6months,Preoperativerecommendations,PreoperativeevaluationofapatientwithaCIED,EssentialelementsoftheinformationgiventotheCIEDphysicianEssentialelementsofthepreoperativeCIEDevaluation,EssentialelementsoftheinformationgiventotheCIEDphysician,EssentialelementsofthepreoperativeCIEDevaluationtobeprovidedtotheoperativeteam,EssentialelementsofthepreoperativeCIEDevaluationtobeprovidedtotheoperativeteam,Approachtoemergentprocedures,1、IdentifythetypeofdeviceEvaluatethemedicalrecordExaminethepatientregistrationcardTelephonethecompanytoclarifydevicetypeExaminethechestradiograph2、DetermineifthepatientispacingObtaina12-leadECGorrhythmstripdocumentationIftherearepacemakerspikesinfrontofallormostPwaveand/orQRScomplexes,assumepacemakerdependency,Approachtoemergentprocedures,3、Pacemakerdependent?Yes:pacemaker(notICD)，Useshortelectrosurgicalbursts,placemagnetoverdeviceforproceduresaboveumbilicusorextensiveelectrosurgery,havemagnetimmediatelyavailableforproceduresbelowumbilicusMonitorpatientwithplethysmography