What are the implications of a hematoma under a pacemaker (pacer) site?

From the Guidelines

A hematoma under a pacemaker site should be monitored closely but typically resolves on its own within 1-2 weeks, and evacuation should only be considered when there is increased tension on the skin, as indicated by recent data 1. The management of a hematoma under a pacemaker site is crucial to prevent further complications, such as infection or device malfunction.

• Apply gentle pressure to the site for 10-15 minutes if actively bleeding, and use cold compresses for 15-20 minutes several times daily during the first 48 hours to reduce swelling and pain.
• After 48 hours, switch to warm compresses to help with absorption.
• Take acetaminophen (Tylenol) 650mg every 6 hours as needed for pain.
• Keep the site clean and dry, and avoid manipulating or massaging the hematoma.
• Contact your healthcare provider immediately if you notice increasing swelling, severe pain, skin discoloration spreading beyond the initial area, fever above 100.4°F, or if the incision opens. These complications occur because blood vessels can be damaged during pacemaker insertion, allowing blood to collect in the surrounding tissue. Most hematomas are minor and self-limiting, but larger ones may occasionally require drainage if they cause significant discomfort or put pressure on the device, as supported by a study published in Circulation 1. It is also essential to note that the prevention of hematoma during the procedure is desirable, and several interventions have been used, such as meticulous cautery of bleeding sites, consideration of packing the pocket with antibiotic-soaked sponges, and the application of topical thrombin, particularly in anticoagulated patients 1. Additionally, a recent study published in Ca-A Cancer Journal for Clinicians highlights the importance of identifying modifiable risk factors for CIED infections, including measures to decrease the risk of pocket hematoma, such as increasing platelet count, discontinuation of antiplatelet medications, and avoidance of therapeutic low-molecular-weight heparin 1.

From the Research

Implications of a Hematoma under a Pacemaker Site

The implications of a hematoma under a pacemaker site can be significant, leading to:

• Prolonged hospitalization 2, 3
• Reoperation for pocket hematoma 2, 4
• Increased risk of pocket infection 5
• Increased length of hospital stay 3, 5
• Re-operation rate 5

Risk Factors for Hematoma Formation

Several risk factors have been identified for hematoma formation under a pacemaker site, including:

• High-dose heparinization 2
• Combined acetylsalicylic acid (ASA)/thienopyridine treatment after coronary stenting 2
• Low operator experience 2
• Peri-operative therapeutic anticoagulation 3
• Use of warfarin 4
• Bridging to low-molecular-weight heparin (LMWH) 4, 6

Management Strategies

Different management strategies have been proposed to reduce the risk of hematoma formation, including:

• Use of a novel compression device 5
• Perioperative continuation of a coumarin 6
• Postoperative bridging with intravenous heparin 6
• Careful consideration of the risk-benefit ratio of therapeutic anticoagulation 3

Complications and Outcomes

The complications and outcomes of a hematoma under a pacemaker site can be significant, including:

• Grade 3 hematoma requiring anticoagulation therapy interruption, re-operation, or prolonged hospital stay 5
• Skin erosions 5
• Patient discomfort 5
• Increased risk of thromboembolic events 6