DS21: How can skin surgery outcomes be improved for patients with implanted devices?

Cheuk Yin Chow and Rhonda Meys

Royal Free Hospital, London, UK

A proportion of patients who undergo skin surgery have implanted cardiac devices and the vast majority have no complications when electrocautery is used. We were alerted to a lack of knowledge in our department by a no-harm clinical incident in a patient with a permanent pacemaker (PPM) involving monopolar electrosurgery. There were also several avoidable cases of the rescheduling of surgeries in patients with implantable cardioverter defibrillators (ICDs). There was a perceived lack of dermatology registrar teaching on implanted devices. Via questionnaires, we tested the knowledge of our dermatologists and surgical nurse specialists performing skin surgery in our department. From the preintervention questionnaires, only an average of three out of seven questions were answered correctly, highlighting the gap in knowledge. Our aim was to produce up-to-date and easy-to-follow guidelines tailored and endorsed by our trust. There are national guidelines for implanted cardiac devices, including ICDs and PPMs from the British Society for Dermatological Surgery and British Heart Rhythm Society. We collaborated with the cardiac pacing team and implemented a modified guideline in our department. Information about other implanted devices is limited, so we undertook literature research and covered them in our guideline. The variations from the national guidance that were negotiated with the cardiac devices team were as follows. If the PPM or ICD has had a review by cardiac physiology within 12 months, no extra checks are required. A documented report should be made available during the procedure in case the pacing team has to attend for device malfunction. Deep brain stimulators, intrathecal pumps and insulin pumps may have temporary interruption of therapeutic benefit, but no other concerns were identified. For cochlear implants, there is potential irreversible damage to basilar membrane with monopolar cautery and bipolar should be used. We were able to agree that intraoperative monitoring with a pulse oximeter (set to audible) and blood pressure monitoring should be mandatory for all devices. We presented the guideline in our local meeting to educate our staff. After our intervention, we reassessed with the same questionnaires. On average, six out of seven questions were answered correctly. We conclude that with our interventions, clinicians have better knowledge about implanted devices and skin surgery, resulting in better patient outcomes.