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Sowerby et al., 2019: Routine pre-operative electrocardiograms in patients at low risk for cardiac complications during shockwave lithotripsy: are they useful?

Sowerby R, Lantz AG, Ghiculete D, Hong A, Farcas M, Barrett K, Lee JY, Ordon M, Pace K, Honey JD

Abstract

INTRODUCTION Routine pre-operative electrocardiogram (ECG) before shockwave lithotripsy (SWL) is frequently performed despite recommendations against its use in asymptomatic patients undergoing low risk surgical procedures. This study assesses if routine pre-operative ECG prior to SWL is useful in patients at low risk for cardiac complications. MATERIALS AND METHODS A retrospective study of SWL at our centre (2003-2013) reviewed all cardiac-related pre-operative cancellations, intra-operative complications, post-operative admissions, and emergency department presentations in patients at low risk for cardiac complications. Patients received SWL with sedation and continuous 5-lead ECG monitoring. RESULTS Of 30,892 referrals, pre-operative ECG triggered 13 (0.04%) cancelations in low risk patients (1 with new atrial fibrillation and 12 with ischemia/previous infarction). Of these patients, 1 had a subsequent abnormal cardiac workup and 11 underwent uncomplicated SWL without cardiac intervention (2 history unknown). Of 27,722 treatments, 5 (0.02%) were stopped prematurely in low risk patients due to arrhythmia (3 had normal pre-operative ECG, 1 had abnormal ECG, and 1 did not complete ECG). Three patients developed an arrhythmia with sedation and 2 patients were admitted post-operatively due to cardiac complications (1 for atrial fibrillation and 1 for hypertension) of which all had normal pre-operative ECG. No patients presented to our emergency department with cardiac complications after SWL. CONCLUSIONS In patients at low risk for cardiac complications, pre-operative ECG triggered very few cancellations and did not predict early termination of treatment or cardiac complications after SWL. These findings suggest that in low risk patients routine pre-operative ECG has little effect on treatment or complication rate and should be omitted.

J Endourol. 2019 Feb 6. doi: 10.1089/end.2019.0053. [Epub ahead of print]

 

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Comments 1

Hans-Göran Tiselius on Monday, 01 July 2019 08:30

Pre-SWL ECG recording in low risk patients is not recommended. The need of this extra examination has been questioned, but according to this article, many stone centers still apply this routine.

In my own experience ECG recording always should be carried out during SWL; three-lead monitoring. When placing the patient on the therapy table and preparing for SWL any abnormalities can be recorded and appropriate steps taken. Pre-treatment ECG has never been the routine in my own department apart from ECG recordings that have been carried out as part of cardiological controls by other specialists.

Gated administration of shockwaves was the rule and frequently necessary when using electrohydraulic lithotripters, Appearance of VES during SWL with modern electromagnetic devices is so uncommon that personally, I only have found gating necessary in less than a handful of more than 12-13,000 treatments. ECG recording during SWL is, however, necessary. Pain treatment with analgesics and sedatives as well as the direct action by shock waves not infrequently causes bradycardia, a condition that can be dealt with by administration of 0.5 mg of atropine. This requirement occasionally is necessary.
Despite the fact that ECG is not recommended as pre-treatment examination it is of fundamental importance to continuously observe what happens with the cardiac rhythm during SWL.

Pre-SWL ECG recording in low risk patients is not recommended. The need of this extra examination has been questioned, but according to this article, many stone centers still apply this routine. In my own experience ECG recording always should be carried out during SWL; three-lead monitoring. When placing the patient on the therapy table and preparing for SWL any abnormalities can be recorded and appropriate steps taken. Pre-treatment ECG has never been the routine in my own department apart from ECG recordings that have been carried out as part of cardiological controls by other specialists. Gated administration of shockwaves was the rule and frequently necessary when using electrohydraulic lithotripters, Appearance of VES during SWL with modern electromagnetic devices is so uncommon that personally, I only have found gating necessary in less than a handful of more than 12-13,000 treatments. ECG recording during SWL is, however, necessary. Pain treatment with analgesics and sedatives as well as the direct action by shock waves not infrequently causes bradycardia, a condition that can be dealt with by administration of 0.5 mg of atropine. This requirement occasionally is necessary. Despite the fact that ECG is not recommended as pre-treatment examination it is of fundamental importance to continuously observe what happens with the cardiac rhythm during SWL.
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