Anaes · Perioperative medicine
Perioperative management of pacemakers and ICDs
Also known as CIED perioperative management · Pacemaker magnet mode · ICD disable for surgery · DDD pacing anaesthesia · Electromagnetic interference pacemaker
Exam-exhaustive CIED perioperative care: NBG modes at high level, pacing dependence, magnet behaviour (pacemaker vs ICD), diathermy EMI mitigation, reprogramming indications, ICD therapy suspension, external defibrillation readiness, and post-op interrogation for ANZCA Final and equivalents.
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Red flags
- Magnet on a pacemaker → asynchronous pacing; magnet on an ICD → suspends tachy therapy but does NOT make pacing asynchronous — know the difference.
- Monopolar diathermy can inhibit pacing or trigger inappropriate ICD shocks — prefer bipolar, short bursts, return pad path away from generator.
- Pacing-dependent + EMI without a plan = asystole. Have magnet, external pads, and cardiology contact before knife-to-skin.
- Suspending ICD therapy without external defibrillator capability is incomplete preparation.
- Post-op: re-enable ICD therapies and re-interrogate if settings changed or EMI exposure was significant.
Meet the patient
A 72-year-old with a dual-chamber pacemaker for complete heart block presents for laparoscopic hemicolectomy. The surgeon plans monopolar diathermy. The patient has no intrinsic rhythm — he is 100 percent pacing-dependent.[1]
Two questions decide whether this case is safe: will diathermy inhibit his pacing and cause asystole? (EMI risk plus dependence) and what is your plan to protect him? (magnet, reprogramming, or bipolar only). Answer both before the team brief.[1]
References3ShowHide
- [1]American Society of Anesthesiologists 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: Erratum Anesthesiology, 2020.PMID 32032098
- [2]Crossley GH, Poole JE, Rozner MA, et al. 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.PMID 21722856
- [3]Stone ME, Salter B, Fischer A Perioperative management of patients with cardiac implantable electronic devices Br J Anaesth, 2011.PMID 22156267