*2.5.1 Pediatric*

The number of pediatric device patients is a relatively small subset of the device population, but babies, as well as children and adolescents, may be recipients of CIEDs. Nerve blocks have been effectively used in pediatric patients undergoing implantation of a subcutaneous ICD [23]. In this case series of 10 patients, the combination of bilateral parasternal blocks with a left erector spinae plane block provided good pain control. Pectoral nerve blocks have been shown to reduce perioperative anesthetic requirements and postoperative pain in children undergoing transvenous ICD implantation [24].

#### *2.5.2 Women*

A study of 180 men and 60 women, who had a *de novo* ICD implantation, found that women were statistically significantly more likely to be younger and less likely to be married or have a history of coronary artery disease than men [25]. However, women had lower functional status, reported more intense pain, and had more sleep problems than men. Men and women were similar in terms of symptoms of anxiety and depression [25]. A study of 179 consecutive ICD outpatients (mean age 60.5 ± 15.9 years) found women reported significantly more intense pain than men [26].

Women have been historically under-represented in ICD clinical trials and historically were sometimes overlooked in consideration for ICD implantation. In a retrospective study of 5156 outpatients with an ejection fraction ≤35%, 25.0% of women had received an ICD compared to 36.3% men (*p* < 0.01) [27]. In an observational study based on Get with the Guidelines-Heart Failure Program, 21,059 patients with an ejection fraction ≤35%, were evaluated in the time frame from 2011 to 2014. During this time, women were less likely to be counseled about ICD therapy than men (19.3% vs. 24.6%, *p* < 0.001) [28]. It may be that women who receive ICDs are not adequately counseled about what to expect from surgery or treated for pain.

#### *2.5.3 Overweight*

Studies suggest that obese patients, defined as a body mass index >30 kg/m<sup>2</sup> , are at an elevated risk for inappropriate shock and failed defibrillation testing when a subcutaneous device is implanted [29, 30]. Electrocardiographic testing before implant and appropriate patient selection may reduce such risks [10]. It is unknown whether obese patients experience more pain or more intense pain than normalweight patients.

#### *2.5.4 Racial/ethnic groups*

In a retrospective analysis of 5156 outpatients with an ejection fraction ≤35%, 28.0% of Black compared to 33.2% of White patients had an ICD, *p* = 0.02 [27]. Although this difference was statistically significant, it was less pronounced than sex-based differences in ICD implantation, where men were more likely to receive an ICD than women [27]. Since Blacks Americans are less likely to have health insurance than Whites, it might be speculated that part of this difference can be traced back to differences in health coverage. However, a study from the United Kingdom found that despite free, universal healthcare, there were racial disparities

#### *Postoperative Pain Control Following Cardiac Implantable Electronic Device Implantation DOI: http://dx.doi.org/10.5772/intechopen.101517*

in ICD implantations; ICDs in the United Kingdom were significantly more likely to be implanted in White than South Indian residents [31]. Although the population of Caucasians in the area of Leicestershire was 77.7% and South Asians made up 15.9% of the population, 91.9% of all ICDs in that areas were implanted in Caucasians compared to 8.1% South Asians. These differences persisted for primary- and secondary-prevention patients although the gap between Caucasians and South Asians was even wider for secondary-prevention treatment [31]. It is unclear, why this marked difference occurs. The lower rate of Black patients for ICD therapy is particularly concerning because Blacks are at greater risk than Whites for sudden cardiac death [32]. However, in the United States, Blacks also had a higher ICD refusal rate than other groups when ICD therapy was presented to them as a consideration [32]. Among patients who are at higher risk of sudden cardiac death, Blacks had significantly less probability of getting an ICD [33].

### *2.5.5 Geriatric*

Advanced age and frailty have been associated with less-frequent use of ICD systems and indications require the patient have a reasonable expectation to live at least one more year after device implant [34]. This life expectancy requirement is not always taken into account. In a survey of 386 physicians who refer selected patients for possible ICD implantation, 23% said that they do not consider life expectancy and 13% have knowingly referred patients with a life expectancy of under one year [35]. However, there is no specific age cutoff for ICD indications. More than 40% of all first implants of ICD systems occur in patients over the age of 70, and *de novo* patients over age 80 are not uncommon [36]. Biological age may be more important than chronological age in this regard [37].

Postsurgical pain in geriatric device patients is not well studied; indeed, elderly patients are often under-represented in clinical trials, if they are included at all. In a study of 150,264 primary-prevention patients, there were significantly more adverse events in the oldest patients (4.5% in those ≥80 years) compared to the youngest group (2.8% in those <65 years) [38]. This rate of adverse events plateaued at about 4.5% at age 80 and beyond. Comorbid conditions were stronger predictors for complications than age [38]. However, the proportions of older and younger patients who specifically experienced pain were not reported.

The control of postsurgical pain in geriatric patients can be challenging due to comorbid conditions, concurrent drug therapies (polypharmacy), and age-related pharmacokinetic and pharmacodynamic alterations [39]. Pain assessment maybe even more challenging in elderly patients with impaired communication skills or cognitive deficits. Because elderly patients may get benefit from ICD therapy and may have special limitations with respect to pain therapy, further study is much needed.

### **2.6 Opioid considerations**

Opioids have come under increasing scrutiny as routine analgesics since the Centers for Disease Control and Prevention (CDC) published guidance to limit their use because of growing concerns for their risks, opioid-associated side effects, and opioid use disorder (OUD). In addition, opioids may increase the risk of atrial fibrillation or other arrhythmias [40]. Nevertheless, opioids are effective analgesic agents and are often used for appropriate patients under clinical supervision to manage the acute pain associated with surgery.

In a retrospective analysis of all CIED procedures done at the three Mayo Clinics in Minnesota, Arizona, and Florida, from 2010 to early 2018, opioids were prescribed to 20.2% of the 16,517 patients (mean age 70 ± 15 years) after device

implantation. Of this group, 80% were opioid naïve. Of the opioid-naïve patients, 9.4% refilled their opioid prescription at least once and 38.8% of patients received >200 oral morphine equivalents (ME) [17]. The mean amount of ME prescribed was 243 ± 346 overall. Opioid-experienced patients were prescribed significantly more opioids than opioid-naïve patients with 335 ME compared to 219 ME for the opioid-naïve patients (*p* < 0.001) [17].

Opioids are associated with many well-known side effects, including nausea, somnolence, mental fogginess, pruritus, and constipation [41]. In most cases, these side effects are mild to moderate although they can in some instances be severe and even treatment-limiting. A short course of postsurgical opioids typically does not result in treatment-limiting side effects, although some patients find opioid analgesics unpleasant. In a study of 250 surgical inpatients, who had a variety of different types of surgery, 25% of those who had received some form of analgesic reported having side effects, although 90% said that they were satisfied with the pain control medications they were administered [42].

#### **2.7 Clinical strategies: Preoperative, perioperative, postoperative**

Although this chapter deals with postoperative pain control following device implant, it is difficult to discuss pain management isolated to the specific postoperative period without describing preoperative and perioperative techniques, which can affect the pain experienced by the patient when the procedure has ended and the patient enters recovery.

#### *2.7.1 Preoperative*

The implant of an ICD or any CIED can be associated with severe acute pain. The pain is most intense immediately after the implant procedure and diminished gradually over the next few days as the implant site heals. Postoperative pain should be managed with preoperative, perioperative, and postoperative strategies. In discussing the device implant with the patient, the clinical team should educate the patient on pain control goals and available options with their risks and benefits. It is important to manage the patient's expectations because complete pain eradication is likely not possible. It has been found that oral gabapentin (600–1200 mg) or pregabalin (150–300 mg) administered an hour or two before surgery can reduce postsurgical opioid consumption [43, 44]. Likewise, oral celecoxib (200–400 mg) 30 minutes to 1 hour before surgery can likewise diminish the need for postoperative opioids [43, 45]. Note that the individual patient must be considered in any analgesic regimen; nonsteroidal anti-inflammatory drugs such as celecoxib may be contraindicated in certain cardiology patients.

A structured plan to help to reduce the pain associated with CIED implantation and other related procedures, such as catheter ablation, could significantly reduce pain up to 8–24 hours after the procedure [46]. The elements of such programs include patient education, regular pain assessments, analgesic protocols, and prompt referrals to pain specialists if the pain becomes severe or cannot be managed.

It is concerning that many device patients do not receive any preoperative analgesics. In a study from Croatia, it was found that 75% of patients undergoing CIED implantation received no preoperative pain medications at all [4].

#### *2.7.2 Perioperative*

Perioperative pain control is typically managed by local medications and/or regional anesthesia [4]. Proper device placement in the fascia and good hemostasis

#### *Postoperative Pain Control Following Cardiac Implantable Electronic Device Implantation DOI: http://dx.doi.org/10.5772/intechopen.101517*

during the procedure may reduce pain following the operation. Liposomal bupivacaine extended-release formulation may provide good anesthetic infiltration with an effect that can last up to 72 hours [47]. In some cases, general anesthesia is used but truncal plane blocks may also provide adequate anesthesia for difficult procedures or those involving a subcutaneous device [12]. For conventional ICDs and devices with transvenous lead systems, local anesthetic infiltration is probably adequate, but sometimes cervical or pectoral nerve block may be employed [48, 49]. Intravenous ketamine is not recommended because of the potential for myoclonus, which can interfere with device function and cause double-counting [17].
