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electrocardiogram (ECG) should be available. If appropriate CIED function has
been conrmed, no other special laboratory tests are needed. If a chest radiograph
(CXR) is available, the CIED location is noted. A CIED is typically in a pectoral
position, with leads from the device following the superior vena cava into the heart
and terminating in the right ventricle, right atrium, or coronary sinus (depending on
the device type). However, the pulse generator of newer ICDs might be implanted
subcutaneously in the left mid-axillary line, with subcutaneous lead(s) positioned
over the heart.
M. Sabra and M. M. Refaat
Device Interrogation
In the preoperative period, appropriate device interrogation by the CIED team is
performed to determine the patient’s underlying rhythm, appropriate function, and
programming of the CIED.The Heart Rhythm Society (HRS) recommends device
interrogation prior to scheduled surgery as follows [7]:
• Within 6months for an implantable cardioverter debrillator (ICD)
• Within 12months for a conventional pacemaker (PM)
• Within 3–6months for any cardiac resynchronization therapy (CRT) device
This is a very important step in the subsequent intraoperative management of
devices in case of malfunction.
Preoperatively, decision-making by the CIED care team should consider issues
that include:
• Determine whether a CIED is present and the functionality of the device
(Pacemaker or ICD, for example).
• Determine if a signicant EMI will be present during the surgical procedure that
may affect the function of the CIED and act accordingly.
– When EMI is likely, there is a risk of inappropriate shocks or anti-tachycardia
pacing in the presence of ICD. Hence, the pacing function of the ICD is disabled. In addition, the ICD or PM should be switched to asynchronous pacing
mode to avoid oversensing in patients who are pacing-dependent.
• Establish if the patient is pacing-dependent on anti-bradycardia pacing and
whether reprogramming of the pacemaker is required.
• Decide the ways in which anti-tachyarrhythmia therapy in the case of ICD shall
be suspended (reprogramming or magnet application).
• Make sure that the CIED is functioning as intended.
If unwanted patient movement can occur due to ICD shock, causing injury to the
patient or surgical team, the anti-tachyarrhythmias function of the ICD should be
disabled. Moreover, some CIED have mechanical or physiologic sensors that should
be disabled during a surgery to prevent undesirable tachycardia. Table8.1 summarizes the perioperative CIED—loop recorder, pacemaker (transvenous and
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Table 8.1 Perioperative CIED—loop recorder, Pacemaker (transvenous and leadless), ICD
(transvenous and subcutaneous), cardiac resynchronization therapy—management
recommendations
Elective surgery Emergency surgery
Check if the surgery is superior to the umbilicus Where possible, follow
elective surgery guidance
Check if the device is an ICD and the device manufacturer from
the patient-held card or by the radiological appearance of the
generator
Arrange interrogation of the CIED, if not performed within the
last 3–6months for any cardiac resynchronization therapy
device, 6months for ICD, and 12months for a conventional
pacemaker
Determine the need for asynchronous pacing if the patient is
pacing-dependent and the pacing rate needed
Position transcutaneous pacing/debrillator pads on the patient
and continuous monitoring with both ECG and pulse oximetry
plethysmography
If diathermy will be required, the diathermy cables and the
grounding electrode should be remote from the ICD
If reprogramming is necessary, reprogram the CIED
preoperatively to monitor mode and determine whether CIED
reprogramming with a programming machine or magnet
application is necessary (a magnet does not produce
asynchronous pacing in an ICD)
Position the current dispersion pad of the electrosurgical unit
(ESU) so the current path does not cross the CIED
Bipolar diathermy is preferred and low-energy short bursts are
desirable
If monopolar diathermy is essential, low-energy, short
intermittent and irregular bursts are preferred
Arrange for ICD interrogation postoperatively –
If the device can’t be
switched to monitor mode
preoperatively:
• Restrict diathermy
usage and where possible
use bipolar diathermy
• Ensure that
cardiopulmonary
resuscitation facilities are
available
If an appropriate CIED
shock occurs, correct any
reversible causes
If recurrent CIED shocks
occur, follow standard CPR
guidelines
Arrange for ICD
interrogation
postoperatively
–
–
–
–
–
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leadless), ICD (transvenous and subcutaneous), cardiac resynchronization therapy—management recommendations for elective and emergent surgeries.
Reprogramming oftheCIED
Formal reprogramming of a CIED is necessary and performed when the patient is
pacing-dependent and there is a signicant EMI exposure [8]. An ICD is usually
reprogrammed to suspend the anti-tachyarrhythmia function by using a
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programming machine or a magnet. Meanwhile, debrillator pads/transcutaneous
pacing are placed on the patient while the anti-tachyarrhythmia functions are
disabled.
M. Sabra and M. M. Refaat
Programming Machine
The importance of a programming machine is with ICDs. Several functions such as
switching to asynchronous mode or disabling a rate-responsive sensor can be done
by this machine [9]. Regarding pacemakers, a programming machine promises versatile options not found with the use of magnets, which might prove useful in a
patient with suboptimal cardiac function. The use of programming machines
requires the presence of specialized personnel before and after the procedure.
Furthermore, the changes made with a programming machine are not as fast as
those done by a magnet, and the reprogramming process takes several minutes as
well. Debrillator pads/transcutaneous pacing are always placed on the patient and
ready as a backup therapy [10].
Magnet Application
Magnet application is considered an alternative to the programming machine to
suspend anti-tachyarrhythmia function in ICD. Preoperatively, the response of the
CIED to the magnet should be tested by the CIED care team. There are several scenarios where the magnet function on the CIED might be disabled or the CIED is on
“power on reset” mode where the magnet function is disabled [11].
Magnet application on pacemakers will initiate asynchronous pacing at a xed
rate as well as a xed AV delay. Magnet application on ICDs will suspend tachyarrhythmia detection and therapy, but has no effect on the pacing mode.
In pacing-dependent patient with ICDs, magnet application does not cause asynchronous pacing. If pacing is inhibited by EMI, profound bradycardia or asystole
may occur. Also, it may be difcult to maintain the magnet over the pulse generator
if the patient is in prone or lateral position. Magnet application may risk the eld
sterility if the incision is near the magnet location. In addition, magnet-induced
asynchronous pacing in patients with pacemakers may compromise cardiac function, causing morbidity [12].
Intraoperative Management
Intraoperatively, the management of patients with CIED requires careful monitoring
and continuous assessment since this patient population is at risk of life-threatening
arrhythmias. Continuous monitoring of the cardiac rhythm and rate (through ECG)
and the peripheral pulse is required. Providers should be alert to any electrical
changes observed on the ECG and hemodynamic instability due to EMI and act
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accordingly though stopping the ESU.Furthermore, providers within the operating
room should be aware of any changes in pacing (adverse pacing behavior or inhibition of pacing) and apply magnet on pulse generator to switch to asynchronous
mode of the ICD [8]. Surgical and anesthesia teams should always consider the
possibility of cardioversion and debrillation during a surgical procedure, and thus
should always be prepared in patients with CIEDs.
Transcutaneous pacing/debrillator pads are placed on the patient before reprogramming/ magnet application and before surgical prepping and draping. It is
important to consider the positioning of the debrillator pads to avoid any damage
to the CIED.Generally, an anteroposterior pad position is preferred for patients with
left-sided CIED.Anterolateral pad position is used when the anteroposterior position is not feasible [3].
During the surgical procedure for patients with CIED, it is imperative to have
continuous monitoring of both ECG and arterial pulse. Continuous ECG monitoring
requires reconguration to clearly display pacing pulses. In addition, it is important
to distinguish pacing artifacts from “true” QRS complexes by the clinicians [13].
Continuous monitoring of arterial pulse through pulse oximetry plethysmography
or invasive intra-arterial pressure monitoring to detect a mechanical systole by the
heart [14].
During central venous catheterization insertion for patients with CIED, special
precautions should be taken. Guidewires insertion may alter the CIED function
through inhibition of pacing or inappropriate shock delivery. In addition to continuous ECG and pulse oximetry monitoring, anti-tachycardia functions must be suspended for patients with ICD.In the rst 3months of CIED insertion, there is a
signicant risk of lead dislodgement during a central line insertion. Caution must be
taken through performing a CXR before the line insertion to locate the position of
the coronary sinus since that lead is predisposed to dislodgement [7].
Anesthetic agents do not in general affect CIED.In patients with bradycardia,
drugs that may cause decreased heart rate should be avoided (fentanyl, dexamethasone) to prevent pacing dependence [15, 16]. Moreover, agents that prolong the QT
interval should be avoided in patients with CIED due to long QT syndrome.
When there is a need for emergency external debrillation or cardioversion during a surgery, several measures should be taken. The magnet should be removed
from the ICD to allow the anti-tachyarrhythmia function. In addition, all sources of
EMI should be removed to allow correct interpretation of rhythm. Sometimes, the
magnet cannot be immediately removed and, in that case, external debrillators
should be used via the transcutaneous pacing/debrillator pads that were placed
before the procedure.
When such events happen, there is a need for proper recording of ECG on the
bedside monitor to allow future interrogation of the cardiac rhythm and the presence
of ventricular tachycardia. It is important to record the ventricular rate since it may
be lower than the minimum threshold of the anti-tachyarrhythmia function of the
CIED.In that case, future reprogramming is needed.
Even when older CIEDs are used, intraoperative failure of those devices is rare
when exposed to EMI.When it happens, failure can manifest as absence of any
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response or as inappropriate therapy, such as repeated shock delivery or “runaway”
high-rate pacing (typically 180–200 beats/min) [6]. Discovery or even suspicion of
cessation of inappropriate therapy requires prompt or immediate termination of the
surgery, removal of all EMI sources, and investigation of the CIED.
M. Sabra and M. M. Refaat
Emergent Surgery
For emergency surgery with potential for EMI superior to the umbilicus, a magnet
is placed over a pacemaker in a pacing-dependent patient to initiate asynchronous
pacing, or over an ICD to disable anti-tachyarrhythmia therapy. However, a magnet
will not result in asynchronous pacing in an ICD, and profound bradycardia or asystole may still occur due to EMI-induced pacing inhibition. Thus, it may be necessary to minimize EMI by use of bipolar instead of monopolar ESU, or use monopolar
ESU in short, intermittent, and irregular bursts at the lowest feasible energy levels.
Evaluation
During physical examination, the presence of a scar may indicate the presence of a
CIED. Further history taking from the patient or family member may reveal the
manufacturer’s identication card that contains the type of device, model, and current settings. A 12-lead ECG should be obtained from the patient. In the case where
an ECG was not obtained, the anesthesia monitoring equipment may be used to
generate a paced rhythm strip at multiple leads. Next, the ECG needs to be examined to determine the presence of atrial and/or ventricular pacing. When identiable
pacing artifacts are absent, a consistently regular rhythm at 60, 65, or 70bpm usually indicates pacing [17].
When a chest radiograph is obtained, the type of the device (ICD versus pacemaker) can be identied. If the time allows before the emergency surgery, a magnet
should be applied to the CIED to determine if it will produce the desired effect. This
can be performed in the operating room after continuous monitoring of ECG and
pulse oximeter plethysmography has been established. After the magnet is applied,
the ECG response and the intra-arterial waveform are compared to the expected
response from magnet application to the device (PM or ICD) [18]. However, magnet
response does not always occur, due to the previous disabling of the magnet switch
from the device. When this happens, future interrogation of the CIED is indicated to
determine if it is functioning properly.
Management
In the case of an emergency surgery where there is no time for adequate preoperative device interrogation and reprogramming and EMI is likely, transcutaneous pacing/debrillator pads should be placed. Also, continuous ECG monitoring and pulse
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oximeter plethysmography are indicated. Furthermore, a magnet should be applied
prior to the use of ESU or EMI-producing device. If necessary, the nonsterile magnet can be placed in a plastic sterile bag and placed over the CIED.
For patients with a pacemaker, magnet application will almost always initiate
asynchronous pacing at a xed rate with a xed atrioventricular (AV) delay. It is
important to observe the ECG rhythm to ensure that the asynchronous pacing is not
competing with the patient’s intrinsic rhythm [19].
For patients with an ICD, magnet application will cause suspension of the tachyarrhythmia detection and the anti-tachyarrhythmia function. Nonetheless, EMI may
still cause ventricular oversensing and pacing inhibition. It is important to keep
observing the ECG rhythm to ensure that profound bradycardia or asystole occur [19].
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Postoperative Management
CIEDs that were reprogrammed preoperatively require the reactivation of the previous settings before the patient leaves the recovery unit where they are closely monitored. Sometimes, changes in the patient’s condition, such as hemodynamic
instability, may necessitate changes in the CIED function. For example, the use of
more optimal atrioventricular delay or the use of higher paced rate in patients with
hemodynamic instability.
Until the CIED original settings are restored, the patient should be continuously
monitored with continuous ECG monitoring and pulse oximetry plethysmography.
In addition, the transcutaneous/debrillator pads should not be removed with the
presence of an external debrillator with pacing capabilities.
There are several recommendations regarding the postoperative management of
patients with CIED.The Heart Rhythm Society recommends immediate postoperative interrogation is needed only for hemodynamically unstable patients or when a
CIED is exposed to signicant EMI (e.g., monopolar electrosurgery superior to the
umbilicus) [7]. The Canadian Anesthesiologists’ Society and Canadian Cardiovascular
Society guidelines recommend monitoring the patient until hemodynamic stability is
assured, and suggest that postoperative device interrogation is routinely required only
after thoracotomy [20]. The British Medicines and Healthcare products Regulatory
Agency recommends contacting the patient’s CIED clinic for support in order to conrm device functionality shortly after surgery (timeframe unspecied) [18].
Postoperative interrogation of CIED is preferred when the patient underwent an
emergent surgery without appropriate preoperative CIED evaluation.
Conclusion
The high prevalence of cardiac implantable electronic devices (CIEDs), along with
their increased use in patients who have cardiac indications, make the understanding of CIED’s preoperative, intraoperative, and postoperative management of high
importance.
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M. Sabra and M. M. Refaat
References
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Rhythm. 2013;10(4):e59–65.
2. Pokorney SD, Miller AL, Chen AY, Thomas L, Fonarow GC, De Lemos JA, etal. Implantable
cardioverter-debrillator use among Medicare patients with low ejection fraction after acute
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3. Rooke GA, Bowdle TA. Perioperative management of pacemakers and implantable cardioverter debrillators: it’s not just about the magnet. Anesth Analg. 2013;117(2):292–4.
4. Schulman PM, Rozner MA, Sera V, Stecker EC. Patients with pacemaker or implantable
cardioverter- debrillator. Med Clin. 2013;97(6):1051–75.
5. Misiri J, Kusumoto F, Goldschlager N.Electromagnetic interference and implanted cardiac
devices: the nonmedical environment (part I). Clin Cardiol. 2012;35(5):276–80.
6. Lau W, Corcoran SJ, Mond HG.Pacemaker tachycardia in a minute ventilation rate- adaptive
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of transcutaneous electrical nerve stimulation with permanent ventricular stimulation: a new
clinical problem? Europace. 2008;11(3):364–9.
11. Plakke MJ, Maisonave Y, Daley SM.Radiofrequency scanning for retained surgical items can
cause electromagnetic interference and pacing inhibition if an asynchronous pacing mode is
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Miller’s anesthesia. Philadelphia: Elsevier Health Sciences; 2014.
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Percutaneous implantation of an entirely intracardiac leadless pacemaker. N Engl J Med.
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Traffic, Attire, andDistractions
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intheOperating Room
ChrysanthosD.Christou, JamalJ.Hoballah,
andGeorgiosTsoulfas
Introduction
The operating room (OR) is undeniably among the most challenging workplaces. It
is a resource-dense environment that requires advanced infrastructure, utilizes new
technologies, and employs specialized, multidisciplinary human resources.
Communication in the OR can be challenging since most surgical teams are ad hoc
teams whose members have no previous experience working together and are
assembled for the task on hand [1]. Nowadays, failure to coordinate care and lack of
effective communication are the leading causes of medical errors [2]. Even though
reports support surgical teams’ consistency since it increases their efciency through
cumulative team experience, this concept has not yet been widely embraced [3, 4].
The modern OR is a unique workplace with specic, often conicting, environmental requirements for its inhabitants. Even minor uctuations of its internal environment could substantially impact patient care and the surgical team members’
safety and comfort. Therefore, in the OR lurk various potential hazards. These hazards include surgical smoke, infectious materials, hazardous drugs with carcinogenic and teratogenic toxicity, hazardous disinfecting chemicals and waste, waste
anesthesia gases, aerosols, radiation, ergonomic hazards, work-related injuries,
noise, and electrical and re hazards [5–9].
9
C. D. Christou · G. Tsoulfas (*)
Center for Research and Innovation in Solid Organ Transplantation, Department of
Transplantation Surgery, Aristotle University School of Medicine, Thessaloniki, Greece
J. J. Hoballah
Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
© Springer Nature Switzerland AG 2024
J. J. Hoballah et al. (eds.), Principles of Perioperative Safety and Efciency,
https://doi.org/10.1007/978-3-031-41089-5_9
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Studies have reported that surgical smoke from 1g of cauterized tissue has the
mutagenic and toxic effects of six cigarettes, while the total exposure in a day is the
mutagenic equivalent of 27–30 cigarettes [10, 11] Even though most of the OR
personnel acknowledge adverse symptoms from surgical smoke, only a few were
adequate personal protective equipment (PPE), and only 14% always use local
exhaust ventilation during electrosurgery [12, 13]. In surgery ergonomics, 19% of
surgeons report a work-related injury [14], 84% consider their working posture as
uncomfortable and painful [6], and up to 73% had at a point suffered from musculoskeletal conditions [15] that could even lead to early retirement [16].
Ensuring a safe, comfortable, and efcient working environment for all OR team
members can be challenging. Trafc, attire, and distractions are all an integral part
of the OR and play a crucial role in addressing all the above challenges. This chapter
aims to provide insight into their role in creating a safe, efcient environment in the
OR that is directly linked to the surgical outcome and the patient’s well-being.
Before discussing the role of trafc, attire, and distractions in the OR, we present
the surgical suite’s main features, particularly the different designated areas of
movement and the OR’s main ventilation features. The knowledge regarding these
main aspects of the surgical suite facilitates an understating of how the surgical
suite’s design contributes to a safe, efcient environment. We then demonstrate how
OR trafc affects the surgical outcome and, specically, the development of surgical site infections (SSIs). Thirdly, we present the controversies surrounding our current practices regarding the appropriate attire in the OR and summarize the current
recommendations. Finally, we demonstrate how distractions, particularly personal
electronic devices, noise, and disruptive behavior, could compromise surgical care
quality and jeopardize patient safety.
C. D. Christou et al.
The Surgical Suite
The surgical suite is divided into three designated areas: the unrestricted, the semirestricted, and the restricted. This classication is based on access to each area, the
activities performed, and the appropriate attire and PPE required in each area.
First, the unrestricted areas include a central control point where the designated
personnel monitors patients, staff, and materials’ trafc into the semi-restricted
areas [17]. Unrestricted areas are isolated from the main hospital, and they include
locker rooms, ofces, break rooms, and waiting rooms [17]. Public access to these
areas could be restricted based on each healthcare facility’s protocols and
regulations.
The semi-restricted areas provide peripheral support to the OR and are accessible from unrestricted areas and restricted areas. These include storages for clean
and sterile materials, sterilization processing areas, scrub sink areas, corridors
that connect unrestricted and restricted areas, and preoperative admission
areas [17].
Lastly, restricted areas are designated areas conned within semi-restricted areas
that are accessible only through semi-restricted areas. The restricted areas include
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the OR and other rooms where surgical or other invasive procedures are performed
[17]. Typically, sterile and clean materials are introduced into the OR from a clean
core corridor and are contained and transported, following decontamination, through
peripheral corridors. In principle, as we progress from the unrestricted to the surgical suite’s restricted areas, regulations regarding environmental control, attire policies, and personnel/material trafc become stricter.
135
Ventilation
The OR’s ventilation is designed to provide a comfortable, safe environment for the
patient and the surgical team by controlling the temperature, the humidity, and the
circulation of various potential biological and chemical pollutants [18]. Also, it
aims to prevent SSIs through sufcient air exchange [19]. Air exchange is commonly expressed as air exchanges per hour, and a standard recommendation is
20–25 air exchanges per hour with at least three to four air exchanges per hour from
outdoor air [18, 20]. Positive pressure must be maintained regarding corridors and
adjacent to the OR areas, while the OR doors should remain closed except from
essential trafc [21]. The surgical suite utilizes either a conventional (turbulent)
ventilation system or a laminar ow air (unidirectional–LAF) ventilation system or,
nally, a combination of the above schemes [22].
Regarding the conventional system, the air is supplied from a high level and
exhausted at a low level, typically on two sides [23]. On the other hand, LAF ventilation systems provide a uniform, directional airow that aims to move oating
particles from the areas that should remain contaminant-free toward the return ducts
and ltration systems [24]. All of these airow control systems are quite sensitive to
introducing new air into the OR, which disrupts the ventilation patterns. As a result,
these systems’ ability to remove contaminants and skin scales away from the sterile
eld is compromised.
Traffic intheOR
Trafc in the OR regards the patterns of movement of materials and personnel
among the surgical suite’s three designated areas. Navigating these areas has several
restrictions. While unrestricted areas could allow public access, unrestricted and
restricted areas should strictly be accessible only to authorized personnel and
patients accompanied by authorized personnel [17].
Door Openings
Door openings in the OR are surprisingly high. A study in orthopedics reported that
during 100 primary total joint arthroplasty operations, with an average operation
time of 111.9min, 35–176 door openings were counted per case, with an average of
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