KRI STA HELD, RN BSN ( MOHS,

DERMATOLOGY)
Use of Electrocautery with
Implantable Devices
Learning Objectives
Describe how to recognize patients with implantable
devices (Pacemakers/Defibrillators)
Discuss the difference between mono polar cautery &
bi-polar cautery
Explain assessment and monitoring of patients with
implantable devices with the use of electrocautery.
Normal Electrical Conduction
SA Node
Intra-nodal pathways
AV node
Bundle of his
Left & Right bundle branches
Purkinje fibers

Pacemaker
Single and Dual chamber
Prevents bradycardia with programmable rates
Lower rate-device will not allow heart rates less than the
programmed rate
Upper rate- device will allow pacing up to a programmed higher
rate if the patient is dependent on the device (complete heart
block)
Sensor rate- device will pace to a programmed higher rate if the
patient is dependent on the device (sinus node dysfunction)
Response
to Sensing
III IV
NASPE / BPEG Generic (NBG) Code
Bernstein, A.D., et al. PACE 2002; 25:260-264
Letters Used:
O
R
None
Atrium
Ventricle
Dual A+V
O O None O None None O None
A A Atrium T Triggered
Rate
Modulation
A Atrium
V V Ventricle I Inhibited V Ventricle
D D Dual A+V D Dual T+I D Dual A+V
Chamber(s)
Paced
Chamber(s)
Sensed
Rate
Modulation
Multisite
Pacing
Category:
I II V
Position:
Single
A or V
S S
Single
A or V
Manufacturers Designation Only:
Code Combinations
Codes are combined to describe:
Mode of pacing Where is it pacing
Mode of sensing When will it pace
How the pacemaker will respond to the presence
or absence of intrinsic beats

What does an ICD do?
Monitors heart rhythms continuously
Provides therapy for ventricular tachycardia (VT)
Antitachycardia Pacing (ATP)
delivers a burst of low energy pacing impulses
Provides therapy for ventricular fibrillation (VF)
High energy shocks help restore a normal rhythm
Provides therapy for bradyarrhythmias (slow rates)
Low energy pacing impulses
Implantable Cardioverter-Defibrillator
Less common than pacemakers
Indicated in patients with high risk of ventricular
arrhythmia (ventricular tachycardia and ventricular
fibrillation)

Electrosurgery
Is a procedure that uses electrical energy to destroy
tissue in an effective, fast economical manner. In
dermatology, the procedure is used to achieve
hemostasis during surgery and to treat and destroy
malignant lesions.







Garcia-Bracamonte, B et al. Electrosurgery in Patients With Implantable Electronic Cardiac Devices (Pacemakers and
Defibrillators). Practical Dermatology 2013; 104:128-32.
Electrocautery
Uses thermal energy in a hand held wand to produce
hemostasis.






Howe, N. & Cherpelis, B. (2013) Obtaining rapid and effective hemostasis. Journal of the American Academy
of Dermatology, 69: 677

Figure 2 Bipolar circuit. The electric current flows between the 2 tines of the forceps (active electrode) without passing through the
patient.
B. Garca-Bracamonte , J. Rodriguez , R. Casado , F. Vanaclocha
Electrosurgery in Patients With Implantable Electronic Cardiac Devices (Pacemakers and Defibrillators)
Actas Dermo-Sifiliogrficas (English Edition), Volume 104, Issue 2, 2013, 128 - 132
http://dx.doi.org/10.1016/j.adengl.2012.09.020
Pacemakers: ICDs
All pacemakers will Asynchronously
pace at a set rate depending on the device
manufacturer.
Asynchronous pacing means that the
device is in a mode in which it is unable
to see what the intrinsic rhythm of the
heart is doing. Look at it as if the device
has blinders on, and it will march or pace
at that set rate no matter what.
Medtronic: 85bpm
Boston Scientific: 100bpm
St Jude: 98-100bpm
Devices set to pace a single chamber will
continue to only pace that chamber,
Devices set to pace dual chamber will
pace both chambers at the set rate.


A magnet will inhibit or
prevent tachy (shocking)
therapies from being
delivered.

What does a magnet do?
Recognizing Patients with Implantable Devices
Health history form
Pre-operative interview
Important ?s Pacemaker or Defibrillator
Pacemaker dependent loosely defined as the inability
to produce the intrinsic rhythm if stimulation is
interrupted. (Ventricular rhythm totally paced)

Place a screen shot of EPIC device clinic
Notes=> EPOP
Wrench in Flowsheet Amb Car Device
Assessment & Monitoring
Take pre-operative vital signs
Use bipolar cautery for all patients with implantable
devices
Monitor with continuous pulse oximetry during cautery
(look for red pulsating light on dynamap vital sign unit or
pleth wave)
Pulse oximeters measure pulsatile arterial blood in the
finger. (Confirms a perfusing pulse on the distal
extremity.)
A pleth wave is a graph that tells you how good the
pulsatile signal is.



Plethysmograph
Weak signal is indicated by the
amplitude of the wave form. It would
affect the accuracy & functioning of
the pulse oximeter
Cause of a weak signal
Poor perfusion
Dirty sensors
Improper positioning of the oximeter.

Pulse oxitmetry pleth (Pethsmograph) June 17,2014
Pleth is useful to detect irregular heart
rhythm.


Pulse oxitmetry pleth (Pethsmograph) June 17,2014

Assessment & Monitoring
Patients with a dependent pacemaker and or
defibrillator should Always have a magnet placed
over their device during cautery.
Surgeon should keep cautery to <3 sec bursts
Cautery tip should never be placed directly over
device and keep 15 cm from the pulse generator and
from the tip of the intracardiac pacemaker lead.
If using mono polar place return electrode
(grounding pad) under arm or shoulder
Left or right side depends on where device is located
Monitoring
Assess patient for poor profusion
Symptoms: heart rate, cold, clammy, lightheaded, dizziness
Monitor pleth wave or pulsating reading on Dynamap vital
signs machine
Take post-operative vital signs.
If stable safe to discharge home no need to interrogate or see
cardiologist.