ORIGINAL ARTICLE

Electrosurgery in Patients With Pacemakers/Implanted

Cardioverter Defibrillators
Jeffrey C. Dawes, MD,* Raman C. Mahabir, MD,* Karen Hillier, RN,† Margaret Cassidy, BN,†
William de Haas, MD,* and Anne M. Gillis, MD†

Abstract: Despite improved protective mechanisms, pacemakers ELECTROSURGERY AS A SOURCE OF

and implanted cardioverter defibrillators are subject to interference ELECTROMAGNETIC INTERFERENCE (EMI)
from various sources. An effective means of hemostasis, electrocau- The terms electrocautery, electrosurgery, electrosection
tery generates electromagnetic interference and may be problematic (electrocutting), and electrocoagulation are not synonymous. By
in this patient population. Reported complication rates are low, but definition, electrocautery is the promotion of hemostasis by
the consequences can be serious. Recommendations regarding the heating a metal instrument. Electrosurgery can be monopolar
management of patients with implanted cardiac devices become (electrocutting or electrocoagulation) or bipolar. Electrocutting
increasingly significant both as the number of patients with devices uses continuous, high-voltage, high-frequency radiowave oscil-
increases and the number of out-of-hospital/minor surgery proce- lations with a variable power spectrum to produce a superheat-
dures performed increases. This article provides surgeons and anes- ing effect. This results in cell explosion and evaporation, with
thetists with practical recommendations for use of electrocautery in only mild thermal injury to adjacent tissue. Continuous energy is
patients with pacemakers or implantable cardiac defibrillators. more likely to cause interference than the intermittent current of
electrocoagulation. Electrocoagulation uses short bursts of a
Key Words: electrocautery, implantable cardioverter defibrillator,
lower voltage to produce tissue dehydration and vessel throm-
pacemaker
bosis with more extensive local thermal injury. In both cases,
(Ann Plast Surg 2006;57: 33–36) current in a monopolar configuration originates at the electro-
surgical tip and returns to the generator via a grounding pad. The
position of the grounding pad also influences the direction of
current flow through the patient. The longer the distance be-
E lectrocautery is an effective means of hemostasis. Rarely, its
use in patients with pacemakers or implantable cardioverter
defibrillators (ICDs) can result in serious complications.1–7 The
tween the instrument tip and the grounding pad, the larger the
generated electromagnetic field and the risk of EMI. Despite
this, the standard positions for the grounding pad are the dorsal
majority of the approximately 1 million paced individuals in thoracic spinal area or the medial thigh.
North America are over the age of 65, the most rapidly growing Occasionally, cautery is applied to a forceps or other
segment of the population.8 It follows that the overall number of instrument which is compressing the targeted vessel. When
paced patients requiring surgical procedures will increase pro- activated without first touching the forceps, current can arc
portionately, thereby increasing the likelihood of an adverse through the air and “demodulate,” resulting in varying and
event. While the interactions between electrocautery and im- unpredictable frequencies.
plantable pacemakers/defibrillators have been described,9 there Bipolar electrocautery poses less risk to the paced
are few perioperative recommendations to direct the surgeon or patient, and fewer adverse incidents have been reported.
anesthetist.10 –14 This article reviews the use of electrocautery in
Bipolar current flows only to the tissue between the tips of the
patients with pacemakers or ICDs and provides perioperative
instrument, limiting the dispersion of energy. It creates a
recommendations. Although this review is primarily directed to
local, low-intensity electromagnetic field approximately 15
plastic surgeons, it is applicable to all surgical disciplines.
cm in diameter and is therefore only an issue where coagu-
lation is necessary within that distance of the ICD or pace-
Received December 1, 2005 and accepted for publication January 21, 2006. maker leads. The use of bipolar cautery is limited by the
From the *Division of Plastic Surgery, Department of Surgery; and the extent of the operation and the caliber of the vessel. The
†Division of Cardiology, Department of Cardiac Sciences, Foothills surgeon must balance the risks of EMI due to each type of
Medical Center, Calgary, Alberta, Canada.
Presented at the Canadian Society of Plastic Surgeons meeting in Hamilton, cautery with the benefits of hemostasis.
Ontario, Canada; June 3, 2004. Other potential sources of EMI in the hospital include
Reprints: Anne M. Gillis, MD, Division of Cardiology, University of peripheral nerve stimulators, external cardioversion/defibril-
Calgary, 3330 Hospital Drive NW, Calgary, Alberta, Canada T2N 4N1. lation devices, strong magnetic fields (ie, magnetic reso-
E-mail: amgillis@ucalgary.ca.
Copyright © 2006 by Lippincott Williams & Wilkins
nance) and electronic security/surveillance systems.9 The
ISSN: 0148-7043/06/5701-0033 extent to which any of these EMI sources have had adverse
DOI: 10.1097/01.sap.0000208938.72409.06 effects on patients is uncertain. Further work is still required

Annals of Plastic Surgery • Volume 57, Number 1, July 2006 33

Dawes et al Annals of Plastic Surgery • Volume 57, Number 1, July 2006

to document the incidence, severity, and outcomes of com- ICDs

plications that arise from electrocautery generated EMI. ICDs are more complex devices and provide several
therapies: bradycardia pacing, ventricular antitachycardia pacing
for VT, synchronized cardioversion for sustained VT and defi-
PACEMAKERS brillation for rapid VT or VF. They accomplish this by detecting
The North American Society of Pacing and Electro- the onset of rapid ventricular rates, as well as monitoring
physiology/British Pacing and Electrophysiology Group Ge- ventricular electrogram morphology. The standardized code for
neric Code15 was created to standardize classification of ICDs16 is similar to the one for pacemakers (Table 1).
pacemakers (Table 1). Each device is assigned 5 letters. The In early generations of ICDs, EMI was sometimes de-
first describes the chamber(s) being paced, the second de- tected by the ICD as VT or VF, resulting in an inappropriate
scribes which chamber is being sensed, the third describes the therapy (cardioversion or shock). EMI perceived as “noise” may
programmed response to sensing, the fourth indicates only disable ventricular antitachycardia pacing therapies and repro-
whether adaptive-rate pacing (rate-modulation) is present or gram the device to a nominal pacing function (ie, VVIR at 60
absent, and the fifth indicates the presence of antitachycardia bpm). However, as with pacemakers, electrical filters have been
pacing therapies. Thus, VVIR describes a ventricular pace- incorporated into present ICDs, which effectively detect EMI.
maker with rate modulation and multisite ventricular pacing Now, even EMI secondary to electrocautery applied near the
that is inhibited when it senses intrinsic ventricular signals. ICD is usually, although not always, appropriately detected as
The first 3 letters are always required, but the last 2 may be such (Fig. 1). Nevertheless, protective mechanisms may differ
omitted if the features are absent. For example, AAI would be between manufacturers and appropriate precautions should be
an atrial pacing device inhibited by sensed spontaneous atrial undertaken during surgery to minimize EMI secondary to elec-
depolarizations with no rate modulation or multisite pacing. trocautery and thereby maximize patient safety. Future direc-
All pacemaker and ICD manufacturers provide patients with tions will include improvement in EMI protection and the use of
identification cards containing device, model, and serial num- advanced mathematic algorithms to more accurately detect EMI.
ber. The current programmed settings can be retrieved from
the pacemaker or ICD follow-up clinic where the patient is PERIOPERATIVE CONSIDERATIONS
normally followed. Larger institutions have dedicated clinics for pacemaker
In addition to a basic knowledge of pacemaker func- and ICD follow-up. The staff in those clinics can be consulted
tion, it is vital to know whether the patient is pacemaker for advice related to patient management perioperatively. Alter-
dependent prior to use of electrocautery. EMI in a pacemaker- natively, the patient’s cardiologist can be contacted. The follow-
dependent patient is potentially life threatening, whereas in a ing is a summary of the available recommendations,10 –14,17–20
nondependent patient, the issue will likely be less acute. Intra- as well as the opinion of the senior author (A.G.). A checklist is
operative EMI may inhibit older devices, resulting in increased provided for convenience (Table 2).
R-R intervals (time between heartbeats) to the point of asystole
Preoperative
in pacemaker-dependent patients. EMI may also be inappropri-
ately sensed as a noncardiac event and result in device repro- • Contact the pacemaker clinic, ICD clinic, or the patient’s
gramming to default pacing parameters or reversion to an asyn- cardiologist preoperatively and request information on the
chronous (nonsensing) pacing mode. If asynchronous pacing pacemaker/ICD, lead type, current programming parame-
occurs during ventricular repolarization (R on T phenomenon), ters, pulse generator location, and reset mode, as well as
there is a small chance that ventricular tachycardia (VT) or recommendations on perioperative programming
ventricular fibrillation (VF) may occur. Most commonly, old • Patients’ degree of dependence on the pacemaker can be
devices are simply reset to an asynchronous fixed-rate pacing determined by examining the preoperative ECG and noting
mode. More recent pacemakers are protected from EMI with pacing spikes. A spike prior to every beat indicates possible
electrical filters and shunting systems designed to detect and dependence. If this is the case, consult the pacemaker/ICD
direct inappropriate current flow away from the pacemakers’ clinic staff who can investigate further by inhibiting the
sensitive circuitry. device to determine whether an inherent rate is present

TABLE 1. North American Society of Pacing and Electrophysiology and British Pacing and Electrophysiology Group Generic
Code for Pacemakers and Implanted Cardioverted Devices15,16
Revised NASPE/BPEG Generic Code for Pacing
I II III IV V
Chamber(s) Paced Chamber(s) Sensed Response to Sensing Rate Modulation Antitachycardia Functions
O ⫽ None O ⫽ None O ⫽ None O ⫽ None O ⫽ None
A ⫽ Atrium A ⫽ Atrium T ⫽ Triggered R ⫽ Rate modulation P ⫽ Pacing
V ⫽ Ventricle V ⫽ Ventricle I ⫽ Inhibited S ⫽ Shock
D ⫽ Dual (A ⫹ V) D ⫽ Dual (A ⫹ V) D ⫽ Dual (A ⫹ V) D ⫽ Dual (P ⫹ S)

34 © 2006 Lippincott Williams & Wilkins

Annals of Plastic Surgery • Volume 57, Number 1, July 2006 Electrosurgery and Cardiac Devices

FIGURE 1. Electrograms and marker

channel annotations recorded intra-
operatively during electrocautery
use at the time of an ICD implanta-
tion. Upper Panel, Atrial electro-
gram. Middle Panel, Ventricular
electrogram. Lower Panel, Marker
channel which describes what the
ICD recognizes as detected or
paced events. The “noise” of the
electrocautery is detected as atrial
(AR, AS) or ventricular (VS, FS or
FD) events. The numbers indicate
timing intervals (ms) between de-
tected events.

• Communication with the operating room personnel is es-

TABLE 2. Perioperative Management of the Patient With a
Cardiac Device sential to preparedness
• Consider other means of electrosurgery, for example, bat-
Preoperative tery-operated cautery, ultrasonic or laser scalpel
□ Notify pacemaker/ICD clinic of pending surgery and ask for
recommendations
□ Identify device (location, type, manufacturer, programming Intraoperative
parameters)
□ Establish level of pacemaker dependence • Monitor patient’s ECG and oxygen saturation throughout
□ Consider an alternate means of hemostasis surgery, where possible
□ Communicate issue with operating room personnel • Have an alternate pacing system readily available (external
Intraoperative transthoracic, transvenous)
□ Monitor patient’s ECG and oxygen saturation • Use bipolar cautery whenever possible
□ Have alternate pacing readily available • If bipolar cautery is not an option, monopolar current
□ If possible, avoid electrocautery; otherwise use the lowest effective should travel perpendicular to the pacemaker lead system
settings • Electrocutting should be avoided
□ Use bipolar in place monopolar cautery where possible • Care must be taken to ensure that metal surfaces of the
□ Avoid electrocutting forceps and cautery are in contact before activating the
□ Cautery should be used for no more than 5 seconds with 10 seconds cautery to minimize the possibility of current demodula-
between uses
tion. This particularly applies to surgery conducted within
□ Ensure cautery tip and forceps are in contact before activating
cautery 10 –15 cm of the pacemaker/ICD
□ Ensure good contact between grounding plate and patient • Cautery current should not be used for more than 5 seconds
□ The ground plate should be placed in a way that minimizes current to at a time, with 10 seconds between use to allow resumption
the device and as close as possible to the operative site of rhythm and normal hemodynamics
□ The path between the grounding plate and the cautery tip should be • The lowest effective level should be used
at least 15 cm away from the pacemaker/ICD • The ground plate should be placed in a way that minimizes
□ Have emergency contact numbers readily available current to the pacemaker/ICD (ie, not in the path of current
Postoperative flow) and as close to the operative site as possible
□ Device function should be evaluated by the pacemaker/ICD clinic or • Good contact of the ground plate and patient is mandatory
cardiologist if there are any concerns • The path between the grounding plate and the cautery tip
□ Devices that have been temporarily reprogrammed should be restored should be at least 15 cm away from the pacemaker/ICD
to their preoperative settings prior to discontinuing monitoring
• Should electrocautery result in device malfunction in an
otherwise stable patient, the pacemaker clinic, ICD clinic,
• Not dependent—it is best not to change the programmed or a cardiologist should be contacted
mode • If EMI secondary to electrocautery triggers an inappropri-
• Dependent—should be reprogrammed to an asynchronous ate therapy (cardioversion, defibrillation, etc.) or the patient
mode above the intrinsic rate becomes unstable, the surgery should be suspended, emer-
• Chest x-ray will make known the location and orientation gency measures initiated, and a cardiologist consulted im-
of the pacing leads, which can assist in electrocautery setup mediately. A ring magnet placed over the device may reset

© 2006 Lippincott Williams & Wilkins 35

Dawes et al Annals of Plastic Surgery • Volume 57, Number 1, July 2006

the device. The patient will have to be continuously mon- 7. Peters RW, Gold MR. Reversible prolonged pacemaker failure due to
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36 © 2006 Lippincott Williams & Wilkins