Electrocautery is the safest option in patients with implantable cardioverter-defibrillators (ICD) and cardiac pacemakers.
However, if electrocautery cannot control bleeding during the procedure, the use of bipolar forceps (bipolar electrocoagulation) may be considered. This confines the current to a very small area.
It is recommended that if using electrosurgery in a patient with an ICD or pacemaker, that only short bursts be
used at a low power setting and that they not be used around the
pacemaker/ICD. Furthermore, the cutting mode should never be used in these patients. Complications from electrosurgery in patients with pacemakers/ICD’s
are rare due to improved shielding technology of these devices, however,
complications can include the below: (
El-Gamal et al, Dermatol Surg 2001)
- Skipped beats
- Firing of an ICD
- Reprogramming of a
pacemaker
- Asystole
- Bradycardia
When electrosurgery is
required, bipolar forceps should be used to confine the current to a very small
area. When bipolar forceps connected to the active and dispersive electrode
termini on the device are being utilized, one is using a bipolar biterminal
electrosurgical treatment modality.
A review of electrosurgery terminology is included below:
- Monopolar electrosurgery: The current passes through a single
electrode through the tissue (only 1 tip projecting from surgical electrode).
The electron density diminishes rapidly with increasing distance from the
electrode. The current exits the patient in the path of least resistance (like
the ground).
- Bipolar electrosurgery: The current is confined to the tissue
between the two electrodes (2 tips projecting from the surgical electrode).
Grounding pads are not required as the current exits through the return
electrode. Bipolar forceps must be plugged into 2 ports on device.
- Biterminal circuits: Uses a treatment electrode with an
indifferent grounding dispersive electrode (2 wires are attached to the
machine). Grounding dispersive electrodes are not required for the unit to
function but they enhance the efficacy.
Energy passes through treatment electrode, through patient, to the
indifferent electrode. Examples of biterminal circuits include electrosection,
electrocoagulation, and electrosection with coagulation.
- Monoterminal Circuits: Uses a single treatment electrode
without a grounding dispersive electrode (the hand piece electrode is connected
to the machine via 1 wire and there is not a second grounding wire connected). Examples of monoterminal circuits include
electrodesiccation and electrofulguration. An example is the common wall mounted hyfrecator.
Common examples include:
- Bipolar electrocoagulation:
- Bipolar - 2 tips projecting from the surgical electrode (forceps)
- Biterminal - Bipolar forceps must be plugged into 2 ports on device. There is no grounding plate
- When electroautery fails to control bleeding in patients with implantable cardioverter-defibrillators and cardiac pacemakers, this is the next safest electrosurgical option
- Electrofulguration:
- Monopolar - 1 tip projecting from surgical electrode
- Monoterminal - No grounding device, i.e. the only cord attached to the machine is the surgical electrode cord
- Gap between electrode tip and tissue being fulgurated
- Electrodesiccation:
- Monopolor - 1 tip projecting from surgical electrode
- Monoterminal - No grounding device, i.e. the only cord attached to the machine is the surgical electrode cord
- Electrode tip makes contact with tissue being desiccated
- Biterminal electrocoagulation:
- Monopolar - 1 tip projecting from surgical electrode
- Biterminal - Grounding plate attached to machine with a 2nd cord
- Grounding plate is not required for the unit to function but enhances the efficacy.
- Electrosection:
- Monopolar - 1 tip projecting from surgical electrode
- Biterminal - Grounding plate attached to machine with a 2nd cord
- Surgical electrode tip cuts through tissue
Clinical Pearl: Electrosection should never be used in
patients with ICD’s or defibrillators. Electrocautery is the safest option in
these patients. If electrocautery cannot control bleeding, consider use of
bipolar forceps to confine the current to a very small area and avoid use over
the device, and only use very short bursts at a low power setting. Consider
consulting the patient’s cardiologist before and after the surgery to check the
patient’s device.
