What to keep in mind
By Stuart Steichen, Do
From Minnesota Healthcare News
The world of medicine has changed dramatically with the introduction of medical devices, such as pacemakers, artificial joints, targeted drug delivery systems, and eye lenses. Family medicine physicians are often the first providers to recognize the need for such devices. But more important, once patients start feeling better, they often don’t follow up with their specialists, instead choosing to see their family physician for ongoing medical care. Here are some things we need to keep in mind when treating patients who have medical devices.
The heart is a prime location for implanted medical devices. From pacemakers and stents to implantable cardioverter defibrillators, cardiac resynchronization therapy devices, mechanical heart valves, and even left ventricular assist devices (LVADs), these medical therapies have become more prevalent, especially in older patients. We should be especially vigilant with patients who have cardiovascular disease, helping them learn to listen to their bodies and watch for signs of difficulty breathing, fainting or dizziness, weight gain, edema in the legs and ankles, and any heart rate changes.
Total joint replacement is one of the most common, and most successful, orthopedic surgeries. Today, many younger, active patients receive new joints and may need to have them replaced during the course of their lifetime. Watch for obvious signs that a joint replacement might be failing, such as increased pain or reduced range of motion. Also, watch for signs of deep vein thrombosis (DVT) in patients with joint replacements. Pain in the leg or arm, accompanied by redness or warmth, could signal a DVT.
Imaging and procedure safety
Before scheduling imaging studies, make sure the patient’s device is MRI-safe. Today, more devices are MRI-friendly than before. Even patients with some pacemakers can have an MRI safely, but it’s important to check on the model of device before suggesting an MRI study or check with a radiologist. Radiologists are a good source of information about what imaging is safe for patients with medical devices. They typically err on the side of safety if they can’t find specific information, especially when it comes to spinal implants.
While some pacemakers and defibrillators today are MRI-safe, patients with metal implants, including pacemakers, defibrillators, insulin pumps, spinal implants, pain management systems, or deep brain stimulation devices, generally should not receive the following medical procedures:
Catheter microwave ablation
Diathermy treatment (high frequency, short wave, or microwave)
MRI (magnetic resonance imaging)—unless specifically noted to be safe
MRA (magnetic resonance angiography) scan
Transurethral needle ablation (TUNA)
Procedures such as CT scans, ultrasound, electrocautery, high-energy radiation therapy, radiofrequency ablation, and transcutaneous electrical nerve stimulation (TENS) usually can be performed safely, if the proper precautions are taken to avoid direct interference with the device itself.
Many patients are on new prescriptions for medications after a device implant. Some will remember to tell you. Some will wait for you to ask. It is an important question. Patients who have received a mechanical heart valve, for example, will most likely be on blood thinners that need to be monitored regularly. We have a special anticoagulation clinic that monitors a patient’s INR and provides immediate results. Remember that patients on blood thinners are more susceptible to injury if they fall, and blood thinners may need to be stopped prior to a patient’s surgical procedure.
Don’t let chronic pain relief lead to narcotic addiction for your patients. Devices that control pain, either through spinal cord stimulation that blocks pain signals to the brain or targeted drug delivery that delivers pain medication through a catheter to the spinal area, are wonderful devices to help patients suffering from chronic pain. Sometimes, however, the devices lessen the pain but don’t take it away completely. Patients may request narcotic pain medications to bridge the gap. Be cautious of patients who “doctor shop” to receive multiple prescriptions for painkillers. The most common requests are for hydrocodone, oxycodone, morphine, and codeine. Also, be wary of prescribing painkillers that might heighten the dosage or interfere with medications patients are already receiving.
Due to the increased issue with opioid dependence and the drug’s addictive potential, alternatives such as Gabapentin and Lyrica have been shown to help with neuropathic pain. Also, the NSAID Meloxicam has continued to gain popularity for appropriate patients. Alternatives to opioid medications also include holistic therapies, meditation, physical therapy, drug patches, and acupuncture. Medical cannabis has also been gaining in popularity. This is a controversial issue that will continue to be in the news and have a political undertone.
The Centers for Disease Control and Prevention suggests that physicians use prescription drug monitoring programs to identify patients who might be at higher risk for overdose or those with substance abuse problems. Try to avoid combinations of prescription painkillers and sedatives, unless medically indicated, and always prescribe the lowest effective dose and quantity needed.
Infections aren’t as frequent as one might think, but they can be deadly, and we need to be vigilant. Medical devices implanted under the skin, even intraocular eye lenses, can create pockets of infection. If not caught early, they can lead to systemic infections, including sepsis. Patients may not know an infection is starting, so make a point to check the implant site during regular office visits to look for redness, inflammation, seepage at the incision site, or fever. A patient with a serious infection also might present with clammy or sweaty skin, confusion, shortness of breath, or a high heart rate.
It also is important to know when a patient needs to take antibiotics before a dental appointment to prevent an infection. Those with artificial knees and hips usually don’t need to, but other device implants may require them. Be wary of the dangers of overuse. Dentists can prescribe an antibiotic if they feel it is necessary, as well.
Depression may be more prevalent after a medical device implant. Watch for signs of depression in patients with medical devices, especially cardiovascular devices, deep brain stimulators, or new joints. While studies have not shown any direct cause and effect relationship, physicians have reported an increase in patients exhibiting signs of depression after these kinds of implants. It may be a short-term reaction to a new medical condition, or it may be something else. Screen your patient for depression if you sense a change.
Exercise is still important. Regardless of which medical device a patient has had implanted, exercise is still important. Individuals with joint replacements usually leave the hospital with a regimen for physical and occupational therapy. Helping them keep up with their therapy is important. Likewise, individuals with cardiovascular devices need to keep their hearts working strongly, but they should stay away from heavy lifting or anything that puts a strain on the heart. There’s no excuse for not exercising, but you may need to help your patients find new ways to stay in shape. I tell my patients to try for 30 minutes of exercise at least five times a week, if they can. Walking and water aerobics can wear off calories, but make sure any implanted medical device is water-safe.
As people age and need medical devices, they frequently have comorbidities. Physicians with patients who have cardiovascular devices should be on the lookout for other conditions, such as high blood pressure, diabetes, and congestive heart failure. The patient may not recognize the symptoms of these comorbidities, as they are often subtle at first, but taking time to check for them will help to avoid serious problems down the road.
Today, many patients wear an implantable insulin pump to help manage their diabetes. Patients with diabetes are at a higher risk for cardiovascular diseases, kidney disease, blindness, neuropathy, retinopathy, obesity, high blood pressure, obstructive sleep apnea, fatty liver disease, cancer, and fractures. We need to make sure that we are taking all the necessary steps to prevent the onset of these comorbidities in our patients with diabetes.
Medical devices are becoming more prevalent. Technological advances are increasing rapidly, making it likely that we will see more and more patients with implanted medical devices. While this article didn’t address all of the medical devices we see in our patients, it is meant to be a reminder that while a patient may come to us for a sore throat, we need to be mindful of the whole patient, including any implanted medical device, in order to provide a high standard of care.