Practical Dermatology
Electrosurgery in Patients With Implantable Electronic Cardiac Devices (Pacemakers and Defibrillators)
Electrocirugía y dispositivos electrónicos cardiacos implantables (marcapasos y desfibriladores)
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García-Bracamonte, J. Rodriguez, R. Casado, F. Vanaclocha" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "García-Bracamonte" "email" => array:1 [ 0 => "beagarcia50@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Rodriguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "R." "apellidos" => "Casado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Vanaclocha" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Marcapasos, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesia, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Electrocirugía y dispositivos electrónicos cardiacos implantables (marcapasos y desfibriladores)" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 791 "Ancho" => 1670 "Tamanyo" => 77824 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Monopolar circuit consisting of an electrosurgical unit, active electrode, and patient return electrode. The electric current flows through the patient.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">It is increasingly common in clinical practice to encounter patients with surgically treatable skin lesions who have a pacemaker or other implantable electronic cardiac device (IECD). The presence of such devices has classically been considered to contraindicate the use of the electrosurgical unit. However, owing to improved engineering, the resistance of these implantable devices to electromagnetic interference is constantly increasing. Some studies report a high level of safety for the use of the electrosurgical unit in dermatological surgery<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> and, with certain exceptions, the fact that a patient is carrying an IECD should not substantially alter our surgery guidelines.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The goal of this article is to discuss the interference capacity of the different waves generated by an electrosurgical unit, and to explain the basic features of the different types of IECD, with a practical focus on highlighting the precautions that should be taken in this setting.</p><p id="par0015" class="elsevierStylePara elsevierViewall">When dealing with a patient with an IECD, we need to know the answers to a number of questions (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">We will begin by defining some important concepts and discussing the consequences of electromagnetic interference, and go on to discuss the preoperative, perioperative, and postoperative management of these patients.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Definitions</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Electrosurgery</span><p id="par0025" class="elsevierStylePara elsevierViewall">Electrosurgery is a procedure that uses electrical energy to destroy tissue in an effective, fast, and economical manner, with immediately visible results. The procedure is performed using an electrosurgical unit, a device that transforms standard 60<span class="elsevierStyleHsp" style=""></span>cycle current into a high-frequency current alternating at more than 200 000<span class="elsevierStyleHsp" style=""></span>Hz.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> In dermatology, the procedure is used to achieve hemostasis during surgery and to treat and destroy benign and malignant lesions.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Types of Circuit</span><p id="par0030" class="elsevierStylePara elsevierViewall">The circuit can be bipolar or monopolar. The most common practice is to use the electrosurgical unit with a monopolar circuit, in which case the patient forms part of the electrical circuit and the current passes through the patient's body (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In this configuration, the circuit comprises 4 elements: the generator, the active electrode, the patient, and the return electrode. The return electrode is extremely important because it completes the circuit, ensures patient safety, and prevents burns.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,6</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The use of bipolar electrosurgery is less common (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In the bipolar configuration, a special forceps is used and the current flows between the 2 tines, which serve as the active and return electrodes, allowing a complete circuit. The bipolar configuration is normally used in ophthalmology and neurosurgery and no patient return electrode is required.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Types of Waveform</span><p id="par0040" class="elsevierStylePara elsevierViewall">The electrosurgical unit can modify the waveform and voltage of the electrical current, thereby changing its effect on tissue and the speed at which heat is produced. The 3 standard waveforms used are a cutting current, a coagulation current, and a blended current. The power can also be adjusted.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Interference Capacity</span><p id="par0045" class="elsevierStylePara elsevierViewall">All electrical currents can interfere with the function of a pacemaker. The only technique that does not pose this problem is electrocautery, which, strictly speaking, is not a type of electrosurgery because no electric current passes through the patient's body. The instrument used in electrocautery is a filament heated to incandescence by means of a direct electric current; the technique can therefore be used safely in patients with pacemakers.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7,8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The safest modality for electrosurgery is a bipolar circuit with a forceps because in this configuration the current does not flow through the patient's body and is therefore unlikely to interfere with the IECD.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,7–10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In the case of monopolar electrosurgery, there is some disagreement in the literature regarding the levels of interference associated with the different modes. In the opinion of some authors, the desiccation-fulguration mode is the least likely to interfere, followed by electrocoagulation and finally cutting.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> Other authors, however, consider the interference capacity of the cutting mode to be lower than that of the coagulation mode, as the voltage is lower.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Implantable Electronic Cardiac Devices</span><p id="par0060" class="elsevierStylePara elsevierViewall">There are essentially 2 types of devices that we should be familiar with: pacemakers and automatic implantable cardioverter-defibrillators (AICD). Both detect intrinsic cardiac activity and respond according to a specific program.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacemakers</span><p id="par0065" class="elsevierStylePara elsevierViewall">Pacemakers are most often indicated in symptomatic bradycardia due to sinus node dysfunction or atrial ventricular block. They are identified by a code consisting of 3 to 5 letters(<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), in which each position relates to a specific type of information as follows: the first letter indicates the chamber paced, the second letter the chamber where the intrinsic rhythm is sensed, and the third the type of response to a sensed event. A fourth letter indicates programmability (whether the device has a rate modulation sensor), and the fifth indicates the chamber where multisite pacing is performed in implantable cardioverter-defibrillators.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,12,13</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Pacemakers can be single-chamber or dual-chamber. Furthermore, they can be unipolar or bipolar.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In bipolar devices the anode and cathode are located very close to each other on the distal end of the intracardiac lead. Pacemakers with bipolar leads, currently the most common type, have the advantage of being more resistant to electromagnetic interference.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In unipolar devices, the anode is located at the tip of the intracardiac lead and the cathode is the casing of the pulse generator.</p><p id="par0080" class="elsevierStylePara elsevierViewall">It is very important to determine whether the patient is pacemaker dependent (5%-10% of patients).<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,10</span></a> Pacemaker dependency can be loosely defined as the inability to produce the intrinsic rhythm if stimulation is interrupted. Pacemaker dependent patients may experience problems if the delivery of impulses is inhibited or interrupted during surgery.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7,12</span></a> Pacemaker dependency is normally indicated in the patient's cardiology report and on the European health care card of patients who have a pacemaker or AICD.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Automatic Implantable Cardioverter-Defibrillators</span><p id="par0085" class="elsevierStylePara elsevierViewall">AICDs are less common than pacemakers (only 1 in 500 devices) and are indicated in patients with a high risk of severe ventricular arrhythmia (ventricular tachycardia and ventricular fibrillation)<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,12</span></a>; they detect these arrhythmias and correct them by delivering bursts of high-energy electric shocks to defibrillate the heart. AICDs require particular care because malfunction could result in the delivery of inappropriate shocks with fatal consequences. In each case, it is essential to find out whether the device has been activated recently and when the last activation occurred.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,12</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Consequences of Interference</span><p id="par0090" class="elsevierStylePara elsevierViewall">In order to function correctly, modern pacemakers and AICDs have to detect intrinsic heart activity. Consequently, electrical signals from other sources, such as those generated by an electrosurgical unit, may be incorrectly interpreted by these devices as cardiac activity. This can provoke an inappropriate response, such as the inhibition of stimulus emissions (the problem most often observed). More rarely, with dual-chamber pacemakers, ventricular pacing may occur at a higher frequency than normal if the interference is interpreted as atrial activity. Asynchronous pacing can also occur (emission of stimuli at a fixed frequency regardless of cardiac activity) or response algorithms may be activated, leading the device to switch to automatic mode or ventricular safety pacing. Exceptionally, direct contact between the electrosurgical energy source and the pacemaker's pulse generator casing may damage the circuits or, if the current should pass through the pacemaker leads, cause heat injury to the heart and loss of stimulation.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6,7,12,13,15</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In AICDs, interference could provoke the inappropriate delivery of impulses or inhibition of the pacing system, which would leave the patient without protection in the event of asystole.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,12,15</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Location of the Lesion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The location of the skin lesion to be treated is a very important aspect that must be taken into account when considering electrosurgery in patients with IECDs. Use of an electrosurgical unit is not recommended in the immediate proximity of the device casing, that is, near the chest area.</p><p id="par0105" class="elsevierStylePara elsevierViewall">When the electrosurgical unit is used in monopolar configuration, the electric current flows from the unit through the tip of the active electrode into the patient and returns to the unit via the patient return electrode. This return electrode should be placed close to the lesion and away from the cardiac device to ensure that the pathway followed by the current is short and directed away from the heart and the implanted device.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,6,10,12</span></a> For example, problems are unlikely to arise when the lesion is located below the umbilicus and the return electrode is placed under the patient's leg.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,12</span></a> In our patients, most of whom have lesions on the head and neck, we place the return electrode under the arm, shoulder or back.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The choice of the right or left arm depends on which side the cardiac device is located. The tip of the active electrode should never be activated over the pacemaker and every effort should be made to keep it at least 15<span class="elsevierStyleHsp" style=""></span>cm from the pulse generator and from the tip of the intracardiac pacemaker lead.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,14,15</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Preoperative, Perioperative, and Postoperative Precautions</span><p id="par0110" class="elsevierStylePara elsevierViewall">The patient should be assessed by the anesthesia and/or cardiology services. Before the operation, factors that might favor cardiac instability (anemia, abnormal electrolytes, etc.) should be investigated and any abnormalities found should be treated.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6,11</span></a> The date on which the patient's device was last monitored should be ascertained. An electrocardiogram (ECG) and chest radiograph should be obtained. The ECG will provide indirect information regarding the patient's dependence and the configuration of the device (large spikes indicate a unipolar pacemaker).<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,12</span></a> The chest radiograph will show whether the pacemaker is single-chamber or dual-chamber, the location of the leads, and whether they are unipolar or bipolar.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,10,12</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Recommendations</span><p id="par0115" class="elsevierStylePara elsevierViewall">Patients with IECDs undergoing electrosurgery must be monitored under the supervision of an anesthesiologist. The ECG should have at least 1 lead where the spike and/or QRS complex are fully visible and identifiable. The ECG should be complemented by a second monitoring method that is not affected by electrical interference (pulse oximetry).<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,12</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">A bipolar configuration should be used when possible.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,6–9,12</span></a> The monopolar configuration should be used with moderation using the lowest power possible and brief, intermittent bursts to minimize the hemodynamic repercussions of any effect on the pacemaker.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6,7,9,10,14</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The locations of the lesions to be treated and their relation to that of the IECD should always be taken into account and the placement of the return electrode should be chosen to ensure that the current flows away from the heart and the device.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7,10,12</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">When the unit is used to promote hemostasis, the current should not be activated until the electrode is in contact with the hemostat in order to prevent electric arcing.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,10,14</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In pacemaker-dependent patients who have no intrinsic cardiac rhythm, if the pacemaker stops every time the electrosurgical unit is used a magnet can be applied that will cause most devices to switch to a fixed pace (asynchronous mode) and emit continuous pulses.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,9,11,14</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In AICDs, a specialist in arrhythmias should be consulted and a request should be made to deprogram the device and reprogram it after the risk of electromagnetic interference has passed. The function that senses an arrhythmia and delivers corrective pulses should be deactivated and the pacemaker function should be maintained. The patient should be monitored and the adhesive paddles of an external defibrillator should be put in position so that an external defibrillator can be used if necessary.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,12</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical Disclosures</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of Human and Animal Subjects</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of Data</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors state that no patient details appear in this article.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to Privacy and Informed Consent</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data are disclosed in this article.</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres97864" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec85020" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres97865" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec85021" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Definitions" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Electrosurgery" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Types of Circuit" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Types of Waveform" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Interference Capacity" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Implantable Electronic Cardiac Devices" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Pacemakers" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Automatic Implantable Cardioverter-Defibrillators" ] ] ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Consequences of Interference" ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Location of the Lesion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Preoperative, Perioperative, and Postoperative Precautions" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Recommendations" ] 10 => array:3 [ "identificador" => "sec0070" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Protection of Human and Animal Subjects" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "Confidentiality of Data" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "Right to Privacy and Informed Consent" ] ] ] 11 => array:2 [ "identificador" => "sec0090" "titulo" => "Conflicts of Interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-05-24" "fechaAceptado" => "2012-09-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec85020" "palabras" => array:5 [ 0 => "Electrosurgical unit" 1 => "Electrosurgery" 2 => "Electromagnetic interference" 3 => "Pacemaker" 4 => "Defibrillator" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec85021" "palabras" => array:5 [ 0 => "Electrobisturí" 1 => "electrocirugía" 2 => "interferencias electromagnéticas" 3 => "marcapasos" 4 => "desfibrilador" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The electrosurgical unit is a very useful tool widely used in dermatology to treat benign and malignant skin lesions and to achieve hemostasis during surgery. However, precautions are required when this technique is used in patients with implantable electronic cardiac devices (IECD), such as pacemakers and defibrillators, because electromagnetic interference produced by the tool may cause such devices to malfunction. Before using electrosurgery in patients with IECDs, it is essential to ascertain the type of implanted device and the patient's level of dependence on it. The location of the skin lesion to be treated with respect to the device should also be assessed. Bipolar pacemakers are more resistant to interference. Appropriate monitoring and the use of bipolar forceps are recommended.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El electrobisturí es una herramienta muy útil y ampliamente utilizada en dermatología para el tratamiento de lesiones benignas y malignas cutáneas, y para la hemostasia durante la cirugía dermatológica. Su uso en pacientes con dispositivos electrónicos cardiacos implantables (marcapasos y desfibriladores) requiere tomar ciertas precauciones ya que puede producir interferencias electromagnéticas capaces de provocar su malfuncionamiento. Ante un paciente con uno de estos dispositivos se debe conocer el tipo de dispositivo que presenta, la dependencia del paciente, y valorar la localización tanto del dispositivo como de la lesión cutánea a tratar. El marcapasos en configuración bipolar es el más resistente a la interferencia. Se aconseja la monitorización adecuada del paciente y el uso de la pinza bipolar.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: García Bracamonte B, et al. Electrocirugía y dispositivos electrónicos cardiacos implantables (marcapasos y desfibriladores). Actas Dermosifiliogr. 2013;104:128-32.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 791 "Ancho" => 1670 "Tamanyo" => 77824 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Monopolar circuit consisting of an electrosurgical unit, active electrode, and patient return electrode. The electric current flows through the patient.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 902 "Ancho" => 1670 "Tamanyo" => 68223 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Bipolar circuit. The electric current flows between the 2 tines of the forceps (active electrode) without passing through the patient.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Abbreviation: AICD, automatic implantable cardioverter-defibrillator.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Does the patient wear a pacemaker or an AICD? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">When was the device last monitored? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Is the patient dependent on the pacemaker? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Is the pacemaker single-chamber, dual-chamber, or triple-chamber? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Are the leads unipolar or bipolar? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In the case of an AICD, has the defibrillator function been activated recently? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Where is the lesion located? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">When was the device implanted? \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab183291.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Questions That Must be Answered for Patients With Implantable Electronic Cardiac Devices.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Source: Madigan et al.,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Dawes et al.,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and Stone et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Letter 1Chamber paced \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Letter 2Chamber sensed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Letter 3Type of response \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Letter 4Rate modulation sensor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Letter 5Multisite pacing chamber \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>atrium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>atrium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>inhibited \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>rate adaptive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">V<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>ventricle \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">V<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>ventricle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">V<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>ventricle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>triggered \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">O<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>none \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>atrium \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>dual (A + V) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>dual (A + V)O<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>none \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>dual (I or T)O<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>none \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>dual (A+ V)O<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>none \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab183290.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Pacemaker Codes.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Electrosurgery, pacemakers and ICDs: a survey of precautions and complications experienced by cutaneous surgeons" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.M. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 39 | 15 | 54 |
| 2024 Octubre | 205 | 67 | 272 |
| 2024 Septiembre | 226 | 42 | 268 |
| 2024 Agosto | 254 | 85 | 339 |
| 2024 Julio | 273 | 51 | 324 |
| 2024 Junio | 263 | 47 | 310 |
| 2024 Mayo | 212 | 49 | 261 |
| 2024 Abril | 187 | 28 | 215 |
| 2024 Marzo | 171 | 35 | 206 |
| 2024 Febrero | 139 | 28 | 167 |
| 2024 Enero | 140 | 39 | 179 |
| 2023 Diciembre | 169 | 23 | 192 |
| 2023 Noviembre | 157 | 34 | 191 |
| 2023 Octubre | 131 | 32 | 163 |
| 2023 Septiembre | 138 | 36 | 174 |
| 2023 Agosto | 139 | 22 | 161 |
| 2023 Julio | 95 | 39 | 134 |
| 2023 Junio | 122 | 30 | 152 |
| 2023 Mayo | 143 | 34 | 177 |
| 2023 Abril | 84 | 35 | 119 |
| 2023 Marzo | 118 | 42 | 160 |
| 2023 Febrero | 133 | 24 | 157 |
| 2023 Enero | 112 | 32 | 144 |
| 2022 Diciembre | 89 | 49 | 138 |
| 2022 Noviembre | 60 | 34 | 94 |
| 2022 Octubre | 66 | 28 | 94 |
| 2022 Septiembre | 43 | 47 | 90 |
| 2022 Agosto | 39 | 32 | 71 |
| 2022 Julio | 25 | 46 | 71 |
| 2022 Junio | 36 | 29 | 65 |
| 2022 Mayo | 199 | 52 | 251 |
| 2022 Abril | 235 | 58 | 293 |
| 2022 Marzo | 256 | 59 | 315 |
| 2022 Febrero | 228 | 43 | 271 |
| 2022 Enero | 248 | 46 | 294 |
| 2021 Diciembre | 172 | 41 | 213 |
| 2021 Noviembre | 211 | 54 | 265 |
| 2021 Octubre | 174 | 52 | 226 |
| 2021 Septiembre | 131 | 44 | 175 |
| 2021 Agosto | 100 | 26 | 126 |
| 2021 Julio | 111 | 33 | 144 |
| 2021 Junio | 125 | 35 | 160 |
| 2021 Mayo | 122 | 35 | 157 |
| 2021 Abril | 188 | 69 | 257 |
| 2021 Marzo | 120 | 32 | 152 |
| 2021 Febrero | 111 | 34 | 145 |
| 2021 Enero | 79 | 31 | 110 |
| 2020 Diciembre | 94 | 30 | 124 |
| 2020 Noviembre | 70 | 21 | 91 |
| 2020 Octubre | 40 | 22 | 62 |
| 2020 Septiembre | 46 | 21 | 67 |
| 2020 Agosto | 63 | 32 | 95 |
| 2020 Julio | 62 | 13 | 75 |
| 2020 Junio | 47 | 18 | 65 |
| 2020 Mayo | 47 | 18 | 65 |
| 2020 Abril | 51 | 19 | 70 |
| 2020 Marzo | 37 | 25 | 62 |
| 2020 Febrero | 5 | 7 | 12 |
| 2020 Enero | 4 | 1 | 5 |
| 2019 Diciembre | 8 | 3 | 11 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Octubre | 1 | 2 | 3 |
| 2019 Septiembre | 10 | 0 | 10 |
| 2019 Agosto | 7 | 5 | 12 |
| 2019 Julio | 4 | 4 | 8 |
| 2019 Junio | 4 | 21 | 25 |
| 2019 Mayo | 7 | 31 | 38 |
| 2019 Abril | 2 | 9 | 11 |
| 2019 Marzo | 2 | 7 | 9 |
| 2019 Febrero | 2 | 4 | 6 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 2 | 1 | 3 |
| 2018 Noviembre | 2 | 4 | 6 |
| 2018 Octubre | 3 | 1 | 4 |
| 2018 Septiembre | 2 | 0 | 2 |
| 2018 Marzo | 26 | 2 | 28 |
| 2018 Febrero | 95 | 8 | 103 |
| 2018 Enero | 146 | 9 | 155 |
| 2017 Diciembre | 116 | 8 | 124 |
| 2017 Noviembre | 138 | 10 | 148 |
| 2017 Octubre | 143 | 3 | 146 |
| 2017 Septiembre | 103 | 9 | 112 |
| 2017 Agosto | 111 | 18 | 129 |
| 2017 Julio | 115 | 7 | 122 |
| 2017 Junio | 143 | 14 | 157 |
| 2017 Mayo | 105 | 11 | 116 |
| 2017 Abril | 90 | 4 | 94 |
| 2017 Marzo | 117 | 9 | 126 |
| 2017 Febrero | 362 | 7 | 369 |
| 2017 Enero | 89 | 9 | 98 |
| 2016 Diciembre | 115 | 18 | 133 |
| 2016 Noviembre | 136 | 17 | 153 |
| 2016 Octubre | 158 | 15 | 173 |
| 2016 Septiembre | 250 | 14 | 264 |
| 2016 Agosto | 209 | 31 | 240 |
| 2016 Julio | 103 | 23 | 126 |
| 2016 Junio | 5 | 19 | 24 |
| 2016 Mayo | 9 | 17 | 26 |
| 2016 Abril | 4 | 2 | 6 |
| 2016 Marzo | 6 | 7 | 13 |
| 2016 Febrero | 9 | 2 | 11 |
| 2016 Enero | 9 | 1 | 10 |
| 2015 Diciembre | 6 | 4 | 10 |
| 2015 Noviembre | 14 | 2 | 16 |
| 2015 Octubre | 7 | 1 | 8 |
| 2015 Septiembre | 7 | 3 | 10 |
| 2015 Agosto | 13 | 1 | 14 |
| 2015 Julio | 86 | 1 | 87 |
| 2015 Junio | 100 | 13 | 113 |
| 2015 Mayo | 137 | 22 | 159 |
| 2015 Abril | 139 | 19 | 158 |
| 2015 Marzo | 77 | 24 | 101 |
| 2015 Febrero | 59 | 10 | 69 |
| 2015 Enero | 61 | 6 | 67 |
| 2014 Diciembre | 44 | 4 | 48 |
| 2014 Noviembre | 41 | 7 | 48 |
| 2014 Octubre | 46 | 7 | 53 |
| 2014 Septiembre | 61 | 11 | 72 |
| 2014 Agosto | 55 | 9 | 64 |
| 2014 Julio | 50 | 9 | 59 |
| 2014 Junio | 42 | 4 | 46 |
| 2014 Mayo | 54 | 10 | 64 |
| 2014 Abril | 36 | 6 | 42 |
| 2014 Marzo | 53 | 22 | 75 |
| 2014 Febrero | 41 | 15 | 56 |
| 2014 Enero | 49 | 14 | 63 |
| 2013 Diciembre | 43 | 19 | 62 |
| 2013 Noviembre | 14 | 4 | 18 |
| 2013 Octubre | 10 | 13 | 23 |
| 2013 Septiembre | 9 | 23 | 32 |
| 2013 Agosto | 7 | 28 | 35 |
| 2013 Julio | 6 | 16 | 22 |
| 2013 Junio | 6 | 19 | 25 |
| 2013 Mayo | 13 | 23 | 36 |
| 2013 Abril | 19 | 18 | 37 |
| 2013 Marzo | 9 | 10 | 19 |
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