You are excising a 1.2 cm squamous cell carcinoma from the lower leg of an 82-year-old patient with a dual-chamber pacemaker. Moderate bleeding occurs during the procedure.

Which of the following strategies are appropriate for achieving hemostasis? (Select all that apply.)

A. Use of bipolar electrosurgery
B. Use of monopolar electrosurgery with short bursts at the lowest effective power
C. Placement of the dispersive return pad near the surgical site
D. Use of aluminum chloride 35%
E. Use of monopolar electrosurgery with grounding pad placed on the upper back
F. Having emergency defibrillation equipment readily available

Rationale: 

Patients with pacemakers are at risk for electromagnetic interference during electrosurgical procedures, particularly when monopolar electrosurgery is used. Monopolar devices send current from an active electrode through the patient’s body to a dispersive grounding pad. Bipolar devices confine the electrical current between two prongs of the same instrument. 

Correct answers:

 A. Bipolar electrosurgery confines the current between the two prongs of the device and does not pass through the body, making it significantly safer in patients with pacemakers.

B. While monopolar should be used cautiously, using it in short bursts at low power minimizes electromagnetic interference and is considered acceptable with proper precautions.

C. Placing the return pad close to the surgical field (e.g., on the same leg) minimizes the current’s path through the torso and reduces the risk of pacemaker interference.

D. Aluminum chloride 35% is a topical hemostatic agent that poses no risk to pacemaker function and is often sufficient for low-volume bleeding.

F. Even with best practices, unintentional device interference or arrhythmia is possible. Having appropriate emergency equipment is important in any procedural encounter. 

Incorrect answer:

E. Placing the return pad near the chest increases the chance that current will pass through or near the pacemaker leads which increases the risk of interference. 

Additional reading at Procedural Dermatology Chapter 14: Electrosurgery