In Response

In Response

We enthusiastically agree with Markan et al.¹ that training toward a basic working knowledge in the function and perioperative management of cardiovascular implantable electronic devices (CIEDs) should be a fundamental element of anesthesiology residency education. As perioperative physicians, anesthesiologists are managing CIEDs in the growing number of patients with cardiac devices who present for cardiac as well as noncardiac procedures. The sustained rates of device implantation combined with the increased survival in patients who benefit from the lifesaving functions of CIEDs will continue to challenge anesthesiologists who have not received formal instruction in the management of these devices. The challenge is more acute today since electrophysiologists and other trained personnel (manufacturer’s representatives) are increasingly not available to assist in the perioperative management of these patients, especially during emergency situations. Our editorial acknowledged the difficult situation anesthesiologists face in managing the wide range of cardiac devices with relatively little training and resources to consult for information.

Our recommendation is that each institution appoint at least 1 anesthesiologist to serve as a local resource and facilitator for education regarding perioperative management of CIEDs. Such source experts will have to engage electrophysiologists, general cardiologists, and technical support representatives to create a network to develop site-specific algorithms that take into account the local resources including trained personnel to assist in the management of CIEDs. Both routine as well as emergency CIED management algorithms should be developed as part of a comprehensive program of management for every institution.

National educational initiatives of multispecialty guideline development and CIED workshop training are another step toward informing residents and practicing anesthesiologists in perioperative device management but cannot realistically provide widespread training in their current formats. Future educational strategies such as Web-based perioperative CIED programs could more broadly provide training to residents and faculty, but would not provide the hands-on experience of working with programmers for implantable devices and temporary pacemakers. Another initiative to consider is the development of simulation modules that highlight the perioperative management and challenges of CIEDs. Simulation-based training in CIED management could be integrated into the existing simulation requirement for maintenance of certification as outlined by the American Board of Anesthesiology. Simulation-based training is ideal for introducing routine as well as emergency scenarios to refine perioperative CIED management. The interactive, tactile process of simulation training allows the participants to familiarize themselves with equipment such as temporary pacemaker generators. Such familiarity is important when a real-life crisis situation arises and is analogous to the needle thoracostomy or the emergency cricothyroidotomy that is routinely rehearsed in a simulated environment.

Annemarie Thompson, MD

Department of Anesthesiology

Vanderbilt University School of Medicine

Nashville, Tennessee

Aman Mahajan, MD, PhD, FAHA

Department of Anesthesiology

David Geffen School of Medicine at UCLA

Los Angeles, California

[email protected]