KEY POINTS

1. Have the pacemaker or defibrillator interrogated by a competent authority shortly before the anesthetic is delivered.
2. Obtain a copy of this interrogation, and ensure that the device will pace the heart.
3. Consider replacing any device near its elective replacement period in a patient scheduled to undergo major surgery or surgery within 15 cm (6 in.) of the generator.
4. Preoperatively determine the patient's underlying rate and rhythm, which then determines the need for backup (external) pacing support.
5. Identify the magnet rate and rhythm, if present.
6. Program minute ventilation rate responsiveness off, if present.
7. Program all rate enhancements off.
8. Consider increasing the lower rate limit rate to optimize oxygen delivery to tissues for major cases.
9. Disable antitachycardia therapy if using a defibrillator.
10. Intraoperatively, monitor cardiac rhythm with pulse oximeter (plethysmography) or arterial waveform.
11. Ask the surgeon to operate without the monopolar electrosurgical unit (ESU).
12. Use bipolar ESU if possible; if not possible, pure cut is better than "blend" or "coag."
13. Place the ESU return pad in such a way to prevent electricity from crossing the generator-heart circuit, even if the pad must be placed on the distal forearm and the wire covered with sterile drape.
14. If the ESU causes ventricular oversensing and pacer quiescence, limit the periods of asystole.
15. Have the device interrogated by a competent authority immediately postoperatively. Some rate enhancements can be reinitiated, and a determination of optimal heart rate and pacing parameters should be made. Any patient with a disabled antitachycardia therapy must be monitored until the antitachycardia therapy is restored.