Radiofrequency Scanning for Retained Surgical Items Can Cause Electromagnetic Interference and Pacing Inhibition if an Asynchronous Pacing Mode Is Not Applied

Abstract

Radiofrequency (RF) scanning is an increasingly popular method of detecting retained surgical items. RF systems are generally regarded as safe but have the potential to cause electrical interference with pacemakers. This may lead to serious adverse events, including asystole. We present a case of an RF system used with a temporary pacemaker resulting in asystole. With the use of RF devices becoming widespread, it is important for all operating room personnel to recognize the potential for pacemaker interference from RF scanning devices and the requirements for asynchronous pacing when these devices are in use.

Compatibility of Radiofrequency Surgical Sponge Detection Technology with Cardiac Implantable Electronic Devices and Temporary Pacemakers

“…A recent case report by Plakke et al . described an incident of pacing inhibition of a temporary epicardial pacing lead system (Medtronic 5388) during Wand scanning.…”

“…A recent case report by Plakke et al 7 described an incident of pacing inhibition of a temporary epicardial pacing lead system (Medtronic 5388) during Wand scanning. This was following coronary artery bypass surgery and a MAZE procedure where the patient came off of bypass with a junctional rhythm at 30 beats/min and required pacing.…”

Guideline for prevention of unintentionally retained surgical items

“…1 Because of the potential of electromagnetic interference with medical devices, perioperative team members should be verbally notified and verbally acknowledge the notification before adjunct technology devices that use radiofrequency and radiofrequency identification are used. 1,8 According to Cahn, there have been a few reported cases of temporary pacemaker inhibition associated with adjunct technology devices that use radiofrequency. "It has been suggested that this may be avoided if the temporary pacemakers are set to asynchronous mode before using these adjunct technology devices," she said.…”

“…Pacemakers and implantable cardioverter defibrillators should not be programmed when adjunctive technology with radiofrequency and radiofrequency identification is being used. 1,8 PERIOP BRIEFING…”

The Unstated Murphy’s Law of the Operating Room

“…In this issue of A&A Case Reports, Plakke et al 1 describe a new solution to an old problem that has created a new problem. As they report, technology involving RF identification (new solution) of retained surgical equipment (old problem) likely has improved surgical outcomes by decreasing the possibility of operative material accidentally remaining inside a patient after surgery.…”