A 10-year single-centre experience, how to simplify subcutaneous implantable cardioverter-defibrillator implantation: from general to regional anesthesia

Background General anesthesia (GA) is still a predominant anesthetic approach for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation in some centres. This strategy should be replaced by regional anesthesia (RA) methods. Purpose To report on our experience with transition from GA to RA, point out some modifications to the recognized techniques, to present an alternative, new regional anesthetic technique for SICD implantation- regional infiltrative anesthesia (RIA) developed and validated in our centre. Methods This retrospective single-centre study conducted (2021 -2025) included 172 consecutive patients undergoing S-ICD implant and analysed anesthesia methods in 3 groups: 1.GA(n=30), 2.RA(n=106), 3. RIA(n=36). RA in the form of truncal plane blocks included serratus anterior plane block (SAPB) I/II with transversus thoracic plane block-parasternal block(PB). Modified hydrolocalization was used with anesthetic agents only, without primary saline dissection. A new efficient, single puncture analgesia technique for sternal tunnelling was developed and implemented. The RIA technique combines SAPB and PB without the need for ultrasound guidance. The anesthetic solution for RIA consists of lidocaine (200-400mg), bupivacaine (100-150mg), epinephrine (0,5-1 mg), sodium bicarbonate (12,5ml, 8,4%) in 200-300 ml of saline. Pain perception was assessed using numerical pain rating scale. Statistical analysis was conducted using SAS software ver. 9.4 (SAS Inc. Institute,NC,USA). Results No differences were found between the groups in terms of demographics, age, BMI, aetiology and clinical parameters. All S-ICD implants were successful. Patients reported no intraprocedural pain or discomfort. Post implant analgesic drugs requirements comparing maximal daily dose within 24 hr. were lower in group 3(0.38 [0.25 – 0.63] vs 0.50 [0.50 – 1.50], group 2, p=0.036. The mean post-operative pain score was 2.2 ± 1.6 in group 3 and 3.1 ± 1.3 in group 2(p=0.17). There were no intra-procedural and post-procedural complications during follow-up time: maximal 4 years. The mean HV impedance was 48±9.6 ohms in group 3 and 68±17.2 ohms in group 2 (p<0.001). Procedure time was shorter in group 3 (median [IQR]: 60 [60 – 65] min vs 70 [62 – 92] min (group 2), p=0.003. DFT was performed in 52 % of patients. No local anesthetic systemic toxicity (LAST) syndrome was observed. In 5 patients the NASA (nonanaesthesiologist-administered sedation and anesthesia) protocol was implemented. Conclusions This study demonstrated that the transition from GA to RA is feasible with anesthesia team( anesthesiologists, cardiologists, anesthesia nurses). A novel RIA method had a similar efficacy, excellent pain control, lower mean HV impedance, shorter procedure time in comparison with more conventional SAPB+PB for S-ICD implantation. RIA technique enables conscious anesthesia with minimal bleeding. Notably, there was a limited need (if any) of an anesthesiologist in the OR.