Authors' response: This case was used to illustrate the importance of nursing communication. The patient's ablation procedure took place in a cardiac catheterization laboratory. The code actually occurred later, while the patient was in a medical/surgical unit, not in the PACU. The ICD hadn't been interrogated or reprogrammed.
The current status of an ICD may not be apparent to the providers involved in a patient's periprocedural care. Our intent was to highlight a patient-safety issue and to ensure that these lifesaving devices can perform when needed. Clearly, patients require continuous cardiac monitoring with readily available emergency drugs and equipment while the ICD is deactivated.
The adverse event report that provided the basis for our article can be viewed at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.cfm?MDRFOI__ID=868724.
Roberta Sullivan RN, BSN, MPH
Ann Ferriter BS
1. Kluger MT, Bullock MF. Recovery room incidents: A review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia. 57(11):1060-1066, November 2002.
2. Practice advisory for the perioperative management of patients with cardiac rhythm management devices: Pacemakers and implantable cardioverter-defibrillators. Anesthesiology. 103(1):186-198, July 2005.
3. Hauser RG, Kallinen L. Deaths associated with implantable cardioverter defibrillator failure and deactivation reported in the United States Food and Drug Administration Manufacturer and User Facility Device Experience Database. Heart Rhythm. 1(4):399-405, October 2004.