A Unique Pressure Bandage Approach for the Prevention of Device Pocket Hematoma

One of the current challenges faced by electrophysiologists and allied professionals in the lab is preventing hematoma formation after cardiac device implantation. The increasingly prevalent use of anticoagulant therapy and/or antiplatelet agents in patients with cardiovascular disease increases this risk of procedural device pocket hematoma. Special attention needs to be paid to post-surgical care to prevent hematoma formation and ensure proper wound healing. 

Prevention of surgical pocket hematoma is important, because in our experience (and as reported in the literature), hematoma is the most common post-procedural complication.¹ Addressing this complication will not only help lessen pain in patients, but also can reduce hospital costs by avoiding reoperation for hematoma evacuation. 

Some investigators have demonstrated a possible correlation of pocket hematoma with infection, but their findings have not been conclusive.^2,3 In addition, sealant agents may be useful in the prevention of hematoma formation, but their efficacy is controversial, and there is concern about the potential increased risk of infection from these agents.³ While the focus of clinical investigation has been on anticoagulant management,⁵ there have been no significant studies using mechanical means to reduce hematoma formation. 

In my 17 years as a practicing physician assistant in the field of electrophysiology, I have had the opportunity to develop techniques that assist in preventing pocket hematoma and prevent these complications. We use readily available materials, but combine them in a unique fashion. In this article, I share my experience with post-operative wound care for implanted cardiac devices, and describe applying a pressure dressing with use of a unique skin-sensitive approach.

Our Approach

Our initial practice was routine placement of pressure dressings over surgical sites in patients at risk for hematoma formation. However, we noted adverse effects of the dressings, including skin tears, allergic or inflammatory reactions to the adhesive, and poorly adherent dressings that were unsuccessful in preventing hematoma formation. 

We experimented with some commercially available products, but found them to be ineffective and counterproductive. Elastic adhesive dressings frequently caused skin tears and irritation at sites of contact. Elastic nonstick bandages (e.g., ACE bandage) easily migrated from the site and did not provide adequate pressure. The addition of Tincture of Benzoin to secure the dressing appeared to increase skin irritation as well as cause topical dermatitis. 

We eventually developed a new approach for applying a pressure dressing over a cardiac device surgical site. In December of 2005, we encountered a difficult case with Dr. Yisachar Greenberg, Director of the Electrophysiology Lab. We were caring for a dialysis patient on aspirin who had a complicated case of pocket hematoma post-ICD implant. Despite standard pressure dressings and the addition of an intraoperative sealant agent, a pocket hematoma repeatedly formed. This was most likely secondary to platelet dysfunction. The patient required surgical hematoma evacuation on two separate occasions. The patient also had very delicate skin and a history of diabetes. Repeated efforts to apply a pressure dressing to this patient seemed futile. After much trial and error, we finally found a unique and effective method of applying a pressure bandage. 

Our approach, as described below, results in the firm adherence of the dressing with appropriate pressure to the surgical site, avoiding skin tears and irritation as well as protecting skin integrity. We used a combination of transparent skin dressings, elastic adhesive bandages, a sterile non-adherent dressing, and 4x4 gauze pads:

1. Apply a sterile (Primapore, Smith & Nephew) dressing to the incision site (Figure 1). 
2. Cover the fragile skin with transparent dressings around the device pocket incision (Figure 2). 
3. Use a stack of 4x4 gauze pads over the Primapore dressing directly over the device (Figure 3).
4. Cut a few strips of elastic adhesive bandage (Tensoplast^®, BSN medical) and stretch it over the 4x4 gauze pads, adhering it to the transparent dressing only and avoiding contact with skin (Figure 4A and 4B).
5. The edges of the elastic adhesive bandage can be secured with extra transparent dressing (Figure 5). 

The elastic adhesive dressing forms an incredible bond with the transparent dressing, holding it firmly in place without allowing interruption of skin integrity. The bond is secure, and the layers of the dressing will not separate under any circumstances. 

When removing the dressing, we have found it best to remove it as one unit starting with the transparent dressing layer. The dressing safely peels from the skin in one piece without causing tears or skin irritation. Not only did our initial patient heal nicely, but this method of dressing has proven to work best for all of our patients.

Acknowledgement. A special thanks to the entire EP lab staff that help with the post-op dressings on a daily basis, and who have helped this method to become the standard practice in our lab. 

Disclosures: The authors have no conflicts of interest to report regarding the content herein. 

References

1. Tompkins C, Cheng A, Dalal D, et al. Dual antiplatelet therapy and heparin ‘bridging’ significantly increase the risk of bleeding complications after pacemaker or implantable cardioverter-defibrillator device implantation. J Am Coll Cardiol. 2010;55:2376-2382.
2. Klug D, Balde M, Pavin D, et al; PEOPLE Study Group. Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators: results of a large prospective study. Circulation. 2007;116:1349-1355.
3. Lekkerkerker JC, van Nieuwkoop C, Trines SA, et al. Risk factors and time delay associated with cardiac device infections: Leiden device registry. Heart. 2009;95:715-720.
4. Ohlow MA, Lauer B, Buchter B, Schreiber M, Geller JC. Pocket related complications in 163 patients receiving anticoagulation or dual antiplatelet therapy: D-Stat Hemostat versus standard of care. Int J Cardiol. 2012;159(3):177-180.
5. Tischenko A, Gula LJ, Yee R, Klein GJ, Skanes AC, Krahn AD. Implantation of cardiac rhythm devices without interruption of oral anticoagulation compared to perioperative bridging with low-molecular weight heparin. Am Heart J. 2009;158:252-256.