What is the appropriate preoperative workup for a patient with a pacemaker (permanent artificial cardiac pacemaker) requiring general anesthesia (GA) for eyelid surgery?

Preoperative Workup for Patients with Pacemakers Requiring General Anesthesia for Eyelid Surgery

For patients with pacemakers requiring general anesthesia for eyelid surgery, a focused preoperative evaluation should include determining device type, pacemaker dependency status, and device function, with device evaluation within 3-6 months before surgery for pacemaker-dependent patients. 1

Initial Assessment

• Establish whether the patient has a cardiac implantable electronic device (CIED) through patient interview, medical records review, available chest x-rays, ECG review, and physical examination (checking for scars, palpating for device) 1
• Define the type of device by obtaining the manufacturer's identification card, ordering chest x-rays if no other data are available, or referring to supplemental resources (manufacturer's databases, pacemaker clinic records, consultation with a cardiologist) 1

Determining Pacemaker Dependency

Pacemaker dependency should be assessed through:

• Review of verbal history or medical record indicating bradyarrhythmia causing syncope or other symptoms requiring pacemaker implantation 1
• History of successful atrioventricular nodal ablation that resulted in pacemaker placement 1
• Evaluation showing no evidence of spontaneous ventricular activity when pacemaker is programmed to VVI mode at lowest programmable rate 1
• Chart review and examination of the ECG may be sufficient to determine dependency without requiring device interrogation 1

Device Evaluation

• For pacemaker-dependent patients, device evaluation should be performed within 3-6 months before surgery 1
• Assessment should include:
  • Determining device type 1
  • Confirming pacemaker dependency status 1
  • Checking device programmed settings and battery status 1
• If comprehensive evaluation is not possible, at minimum confirm whether pacing impulses are present and create a paced beat 1

Risk Assessment for Electromagnetic Interference (EMI)

• Determine whether EMI is likely to occur during eyelid surgery 1
• For eyelid surgery, the risk of EMI is lower compared to procedures involving the chest or abdomen since the surgical site is distant from the pacemaker 1
• When electrocautery is remote from the pacemaker and administered in brief bursts, the risk of interference is reduced 1

Preoperative Management Recommendations

For pacemaker-dependent patients:

• Consider reprogramming the device to an asynchronous mode (VOO or DOO) before surgery 1
• Alternatively, a magnet can be placed over the device during surgery to convert to asynchronous pacing, but verify this response before surgery as some devices can be programmed to not respond to magnets 1

For patients with ICDs:

• Consider deactivating antitachyarrhythmia functions before surgery to prevent inappropriate shocks 1
• If the ICD also provides pacing function for a pacemaker-dependent patient, reprogram to asynchronous mode 1

Intraoperative Considerations

• Advise the surgeon to consider using a bipolar electrocautery system or ultrasonic (harmonic) scalpel to minimize EMI 1
• Ensure availability of temporary pacing and defibrillation equipment 1
• Implement continuous ECG and pulse monitoring during surgery, as electrocautery may interfere with ECG monitoring 1
• Minimize EMI by using short, intermittent bursts of electrocautery at the lowest possible energy levels 1
• Maximize distance between electrocautery and the pacemaker device 1

Common Pitfalls and Caveats

• Failure to identify pacemaker dependency status can lead to adverse outcomes including asystole 1
• Routine use of magnets over ICDs is not recommended as effects vary by manufacturer and model 1
• Some pacemaker models can be programmed not to respond to magnets, so verify response before relying on this method 1
• After surgery, if the pacemaker or ICD was reprogrammed, it should be programmed back to original settings 1
• For ICDs, verify that antitachycardia function has been restored after surgery 1
• Consultation with a cardiologist or pacemaker/ICD service may be necessary for complex cases 1, 2