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July2017v1.8Reviewdate:2020
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British Society for Dermatological Surgery (BSDS) & British Heart
Rhythm Society (BHRS) Guidance on Implanted Devices &
DermatologicalSurgery
Contents
Page
1. Introduction
2. Summary&PPM
3. ICD&ILR
4. Cardiacphysiologyreports&bookings
5. References & Table: Types of electrosurgery with relevance to commonly used
Dermatologicalequipment
6. Flowchart
Glossary: Permanent Pacemakers (PPM), Implantable Cardiac Defibrillators (ICD),
ImplantableLoopRecorders(ILR),ElectromagneticInterference(EMI)
Introduction:
Atpresentthereisnospecificnationalsafetyguidanceavailableforclinicianswhoperform
cutaneoussurgeryonpatientswithcardiac rhythmdevices.The lowerriskofskinsurgery
proceduresandtheelectrosurgicaldevicesthataretypicallyusedmeanssomeofthegeneric
guidance is not so applicable to local anaesthetic skin surgery and may have significant
resourceimplications.Thisguidancehasthereforebeendevelopedtocomplementandclarify
thedetailedadvicepublishedbytheBHRS1andMHRA2thatwasdevisedprimarily forthe
generaltheatreandendoscopysetting,ratherthantheoutpatientprocedureroomorclinic
settinginwhichskinsurgeryisoftenperformed.
Skin surgery procedures are some of the commonest performed in the UK. A typical
Dermatologydepartment conductswell over 2000proceduresper year, and found2%of
these patients had implanted cardiac devices.3 Therefore any advice can have significant
ramificationsforpatientpathwaysandappropriateuseofresources,aswellassafety.
We reviewed the published literature, contacted the Medicines & Healthcare products
RegulatoryAgency (MHRA), and conducted a national survey ofmembers of theBSDS to
determineifelectromagneticinterferencehadbeenreportedinpracticeinthecontextofskin
surgery.Wefoundnoreportedorpublishedinstancesofanyadverseevents.Nevertheless
definiterisksstillexist.Itispossiblethatadverseeventshaveoccurredbuteithernotbeen
noticedimmediatelyornotbeenreported.Precautionsmuststillbetaken.
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Disclaimer:
This isaguideonlyandclinical judgementshouldultimatelydeterminethedegreeofrisk,
particularlyforcomplexpatients.Advicefromamultidisciplinaryteammayalsobehelpful.
LimitationsofGuidance:
ThisdocumenthasbeenpreparedonbehalfoftheBSDSandisbasedonthemostrelevant
data and expert opinion available when the document was prepared. A full systematic
literaturereviewhasnotbeenconducted.Itisrecognisedthatundercertainconditionsitmay
benecessarytodeviatefromtheguidelinesandthattheresultsoffuturestudiesmayrequire
someoftherecommendationshereintobechanged.Failuretoadheretotheseguidelines
should not necessarily be considered negligent, nor should adherence to these
recommendationsconstituteadefenceagainstaclaimofnegligence.Limitingthereviewto
English language referenceswas apragmatic decisionbut the authors recognise thismay
excludesomeimportantinformationpublishedinotherlanguages.
Summaryofkeypoints(alsoseeflowchart)
1. Monitor thepatient clinically andwithpulseoximeterwhilstusingbipolarelectrosurgery in
shortbursts>5cmawayfromaPPM.
2. Inadditionto(1)switchoffanyICDimmediatelypre-opandbackonimmediatelypost-op.
3. Bookingclerkorcliniciantocontactcardiacphysiologypre-op:
a. torequestdevicereport(seebelow)
b. toarrangevisittotheatreimmediatelypre-andpost-opifICD
c. torequestcardiacphysiologyhavesomeoneonstandbyontheproceduredateifthesurgical
siteiswithin5cmofthepacemakerbox
d. toallowanopportunityforILRdatatobedownloadedpre-opifrequired.
4. IfaPPMisunderregularroutinereviewbycardiacphysiologythennoadditionalpre-orpost-
opchecksareusuallyrequired.
5. IfthepatienthasanILRrecordtheprocedureinthepatient’seventdiary
Background
Electrosurgery passes electricity through tissue to cause coagulation, damage, or cutting. It can
interferewiththeusualrunningofsomeimplanteddevicesbyEMI.Queriesaboutthesedevicesmay
causeconcern,ortheremaybearisktothesafetyofthepatientorstaff.
Pacemakers(PPM)
Allpacemakers
Pacemakersmayregulateheartrhythminavarietyofways,butofmostrelevanceiswhenthepatient
is‘pacemakerdependent’i.e.theyhavenonaturalpacemakeroftheirown,ortheirheartratewithout
thepacemakeristoolow(leadingtoanyof:lightheadedness,fainting,shortnessofbreath,chestpain,
weakness,fatigue,collapse).Insomecasesthedevicecouldmistaketheelectrosurgerycurrentfor
heart activity and stop pacing temporarily. This effect is unlikely if using bipolar electrosurgery,
particularly if away from thedevice. Also shortpulses canbeused tominimise theeffectof this
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problem even if it does occur, as the device should resume pacing immediately after the
electrosurgerypulsestops.Ifthepatient’spulseremainssteadythroughtheelectrosurgerypulse,it
isobviouslynothavingthiseffectinanycase.Althoughtheoreticallypossible,anyreprogrammingof
thedevicebyelectrosurgeryEMIisnotconsideredarealrisk.
Pacemakerswithin5cmofsurgicalsite
Ifthesurgicalsiteiswithin5cmofthepacemakerbox(althoughtheriskisstilllowwithbipolar)the
pacing team shouldbe informedof thedate that thepatient is coming in to have someoneon
standby.Intheunlikelycasethatthebipolardiathermydoesinhibitthepacemaker(i.e.ifthepatient
becomessymptomaticduringelectrosurgeryuseorifsomeinhibitionisnotedviapulseoximeter)the
teamwill comeand re-programme thedevice to an ‘asynchronous’mode for thedurationof the
procedure.
Defibrillators(ICD)
ICDoftenlookandfeelsimilartoapacemaker,andareusually inthesamesite.Thereisagreater
danger as these devices are constantly sensing for odd electrical activitywhichmight indicate an
imminentcardiacarrest.Theythenadministerashockdirectlytotheheartviainternalelectrodes.
Again thedevicecouldmistake theelectrosurgerycurrent forheartactivityandshock thepatient
inappropriately. These therefore need to be switched off immediately before, and back on
immediatelyafter,proceduresinvolvingelectrosurgery.Thecardiacphysiologytechnicianswilldothis
intheoperatingtheatrebypriorarrangement.Thedeviceshouldbeofffortheminimumtimepossible
i.e.onlytheperiodwhenelectrosurgeryisneeded,notduringLAinfiltration,orrecovery.Itiscritical
thattheWHOchecklistisfollowedtopreventdevicesfrominadvertentlybeingleftswitchedoff.
Whenbooking surgery it is important to ask thepatient, study the case-notes, and contact the
cardiacphysiologydepartmentthatlooksafterthedevice,toensurewhatyoumaypresumetobe
a pacemaker is not also a defibrillator. The booking team should also obtain from the cardiac
physiologyteamasummaryofeverydeviceandthereasonitwasimplanted.
LoopRecorders(ILR)
ThesearedevicesimplantedusuallyinasimilarsitetorecordaconstantrunningECGwhilstinplace,
when cardiac arrhythmias are suspected but have been difficult to prove (e.g. syncope, falls,
palpitations).Theyarenota risk topatientorstaffas theywillmerelyshowsomeextraelectrical
activityfromtheelectrosurgeryintheirrecordingdata,andneitherarethedevicesatparticularrisk
fromtheelectrosurgeryitself.Thepatientkeepsadiaryofanysymptomsthattheyfeelduringthe
time thedevice is implanted, so theyshouldmerelyaddanotesaying theyhadaprocedurewith
electrosurgeryatthattime,tohelpthetechnicianstointerpretthefindingscorrectly.Thefollow-up
centreshouldbeinformedthataprocedureisplanned,togivethemtheopportunitytodownload
thestoreddatafromtherecorderbeforehand.
Otherdevices
Otherimplantedpumpsandbrainstimulatorsetcmayalsobepresent.Bevigilantandseekadvice
fromtherelevantdepartmentiffound.
Intra-operativemonitoring
ContinuousECGusingacardiacmonitorhaspreviouslybeensuggested,butisnotusuallyhelpfulin
theout-patientskinsurgerysetting.ThemonitoritselfreadilypicksupEMIfromtheelectrosurgery
whichobscuresthepatient’sheartrhythmattheverymomentthesurgeonwishestoseetheeffect.
Alsowith the surgeon busy, no anaesthetist, and not always a scrub nurse, themonitormay not
actually be checked during the procedure, even if attached. Although it might be useful for the
resuscitationteamtoviewtheaberrantrhythmquicklyifanICDpatientsufferedcardiacarrestwhilst
theirdevicewasswitchedoff,thisisextremelyunlikelyiftheproperprecautionsaretaken.Alsomany
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out-patientordaycasesurgeryunitsmayhaveanAutomatedExternalDefibrillator(AED)onthecrash
trolley,theuseofwhichdoesnotrequireviewingtheheartrhythm(andthecardiacmonitorleads
mayactuallyget in theway).Thecardiacmonitor isalsoslowto fitandprone to leadconnection
problems,whichcandelaysurgery.Insteadapulseoximetercanbeusedforheartratemonitoring,
is quick and unobtrusive to fit, often can be monitored audibly by the surgeon themselves if
necessary,andisnotsusceptibletoEMIfromelectrosurgery.
Devicereportsfromcardiacphysiologyteam
Asummaryofeverydeviceandthereasonitwasimplantedisneeded:
• ToidentifyICD+PPMdevices
• Toensuredevicestatusandindicationknown(especiallyifpatientfromoutofareaormovedsince
implantation)
• Toensuredeviceisnotnearingendoflife/batterychange• Togivethecardiacphysiologyteamanopportunitytoarrangeadevicecheckpre-opifrequired
• Togivecliniciandefinitiveinformationontheindicationforthedevice(thiswillnotusuallyaffect
theirperi-operativemanagement,butgivesanawarenessoflevelofrisk)
Organisationofbookings
• Bookingcliniciantoaskpatient“whereareyounormallyseenforyourPPM/ICD?”whencompleting
the electronic surgical booking form (to help obtain accurate device/indication report -may be
anotherhospital)
• Booking admin team to contact cardiac physiology to obtain device/indication report prior to
dating,andgivetobookingclinicianforcomment
• 1weekminimum notice needed for cardiac physiology team for routine ICD patient bookings
(otherwisebyspecialarrangementifpossible)
• CallcardiacphysiologyteamatendofcasepriortoICDpatienttoallowtimetoattenddepartment
(andupdatethemduringsurgeryifproceduredurationchanges)
Authors
DrAdamBray,ConsultantDermatologist,Dermatological&MohsSurgeon.BSDSGuidance
MrGarethDavies,LeadCardiacDevicesPhysiologist,BristolHeartInstitute.
DrBethWright,SpecialityRegistrar,Dermatology.
UniversityHospitalsBristolNHSFoundationTrust.
Acknowledgements:ManythankstotheBritishHeartRhythmSociety(BHRS)Council, the
ExecutiveCommitteeofTheBritishSocietyforDermatologicalSurgery(BSDS),andMrSimon
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Holmes SeniorMedicalDeviceSpecialist DeviceSafetyandSurveillance MHRA, for their
contributionstothisguidance.
References:
1. British Heart Rhythm Society Guidelines for the management of patients with
cardiacimplantableelectronicdevices(CEIDs)aroundthetimeofsurgery.
ThomasH,TurleyA,PlummerC,onbehalfofBHRSCouncil–January2016
http://www.bhrs.com/guidelines-informationAccessedon:7thMay2017
2. Guidelines for the perioperative management of patients with implantable
pacemakers or implantable cardioverter defibrillators, where the use of surgical
diathermy/electrocauteryisanticipated.
Medicines&HealthcareproductsRegulatoryAgency(MHRA)2006
3. BristolDermatologyCentre.Personalcorrespondence.
TypesofelectrosurgerywithrelevancetocommonlyusedDermatologicalequipment
TypeofElectrosurgery Equipmentcomments Description
Monopolarsingleelectrode ConmedHyfrecatorwithnormalhandleprobeattachment
Current passes from probe to
patient and disperses through
thebody(possibleasitisonlya
small amount of current and
tableisinsulated)
Bipolar CoaCompMunit
ConmedHyfrecatorwithbipolar
forcepsattachment
Current passes from 1 side of
forceps to the other through a
smallareaofthepatient’stissue
Monopolarwithreturnplate Unusual in Dermatological
surgery, commoner in main
theatres
Current passes from probe
through patient to a separate
plate (earth electrode)
connectedtomachine
Electrocautery Largely replaced by other
electrosurgery machines but
some older units may still be
used or battery powered e.g.
Bovie
Using current to heat a metal
probe (like a soldering iron) to
causecoagulationordamageto
tissue
