Safety of epinephrine-containing local anaesthesia in CIED implantations
Authors: Lau Y , Kong Q G , Ang D T Y , Peck O , Tun T , Hood S , Peat E 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Cardiac implantable electronic devices (CIED) are common. Permanent pacemaker implantations can improve quality of life of patients with sick-sinus syndrome and prolong survival in those with infranodal high-grade AV block. Nonetheless, pocket haemathoma can be problematic post CIED implantation, especially with the increasing use of oral anticoagulants and antiplatelet agents (especially P2Y12 inhibitors) in the at-risk population. The use of epinephrine in local anaesthetic is common in UK but remains controvesial with 2021 EHRA consensus statement recommending its avoidance(1).

Aim
To compare the rate of pocket haemathoma and subsequent haemathoma drainage and pocket revisions in CIED patients who have received epinephrine-containing local anaesthetia versus local anesthesia without epinephrine.

Methods
Retrospective, observational studies across a disctrict general hospital and tertiary cardiology hospital, involving a total of 377 consecutive CIED patients over the course of 2021 - 2022. Patients' demographics, comorbidities, peri-procedural medication use and complication events were retrived from electronic data base. Types of local anaesthesia were recorded.

Results and Outcomes
Out of 377 patients, 184 patients received 1% epinephrine-containing local anaesthesia (Group 1) and 193 patients received plain local anesthesia only (Group 2).
In terms of baseline demographics (age and gender distribution), associated comorbidities (treated hypertension, diabetes type 2, ischaemic heart disease, hypercholesterolemia, smoker) were not statistically different between both groups. Number of leads implanted (DDD vs VVI vs ILR) were not statistically different (26.6% DDD pacemaker and 65.8% VVI pacemaker in Group 1 versus 34.8% DDD and 57.0% VVI in Group 2, p=0.143).
Periprocedural usage of oral anticoagulations (38.6% vs 30.5%,p=0.102) and single or dual antiplatelet agents (31.5% vs 29.0%, p=0.796) were not different between both groups.
Overall complication rates were low and not statistically different between both groups: 4.35% in Group 1 versus 6.74% in Group2.
Only 1 patient received epinephine-containing local anesthesia experienced pocket haemathoma against 6 patients who received plain local anaesthsia (0.543% vs 3.11%,p=0.122). No patients require evacuation of haemathoma, drainage or subsequent pocket revision (p= 1.0).
Summary: The results of this retrospective observational study demonstrated that 1% epinephrine-containing local anesthesia for CIED implantation is not associated with increased risk of pocket haemathoma, no increased risk of haemathoma evacuation, drainage or pocket revision. This is despite peri-procedural anticoagulation or antiplatelet use exceeding 70%. This "real-life" result is incongruent with the published MAITRE study which formed the basis for the 2021 EHRA expert consensus statement.
Recommendation surrounding epinephrine-containing local anaesthesia in CIED implantation may need to be reviewed.