Monitored Anesthesia Care for Cardiovascular Interventions

Abstract

The interventional cardiology is growing and evolving. Many complex procedures are now performed outside the operating room to manage cardiovascular pathologies which had been traditionally treated with cardiac surgery. Appropriate sedation strategy is crucial for improved patient comfort and successful procedure while ensuring safety. Sedation for cardiovascular intervention is frequently challenging, especially in critically-ill, high-risk patients. This review addresses pre-procedure evaluation and preparation of patients, proper monitoring, commonly used sedatives and analgesics, and considerations for specific procedures. Appropriate depth of sedation and analgesia should be balanced with patient, procedural and institutional factors. Understanding of the pharmacology of sedatives/analgesics, vigilant monitoring, ability and proper preparation for management of potential complications may improve outcomes in patients undergoing sedation for cardiovascular procedures.

Comparative Safety Profiles of Sedatives Commonly Used in Clinical Practice: A 10-Year Nationwide Pharmacovigilance Study in Korea

“…In the current analysis, included cases were ADEs reportedly caused by the following sedative agents commonly used for invasive procedures or management of critically ill patients in Korea [10,13,14]: alfentanil, dexmedetomidine, diazepam, etomidate, fentanyl, ketamine, midazolam, pethidine (meperidine), propofol, remifentanil, sufentanil, and thiopental. The following information was extracted from the KAERS database: (1) patient demographics including age, sex, and comorbidities; (2) medication information including concomitant medications, dates of treatment initiation and cessation, and the causative agent; (3) ADE information including the year of ADE reports and causality assessment between the reported ADE and the offending agent; and (4) seriousness of ADEs [18].…”

“…Therefore, the SCCM recommends alternatives to benzodiazepines as the preferred sedative agent in the PADIS guideline [8]. However, deviations from this guideline have been reported in the actually prescribed sedative therapy, indicating potential misuse of sedatives [10][11][12]. Actually, the most frequently prescribed sedatives in Korea included benzodiazepines (diazepam, midazolam); non-benzodiazepines including propofol, dexmedetomidine, etomidate, ketamine, opioids (e.g., alfentanil, fentanyl, remifentanil), and thiopental; and the combined use of two or more different sedatives [10,13,14].…”

“…However, deviations from this guideline have been reported in the actually prescribed sedative therapy, indicating potential misuse of sedatives [10][11][12]. Actually, the most frequently prescribed sedatives in Korea included benzodiazepines (diazepam, midazolam); non-benzodiazepines including propofol, dexmedetomidine, etomidate, ketamine, opioids (e.g., alfentanil, fentanyl, remifentanil), and thiopental; and the combined use of two or more different sedatives [10,13,14]. However, the safety profile of these sedative agents, including their combined use, is yet to be comparatively evaluated despite the increasing use of sedatives.…”

Comparison of 2 effect-site concentrations of remifentanil with midazolam during percutaneous transluminal balloon angioplasty under monitored anesthesia care

“…[ 15 , 19 ] Therefore, these adverse events should be considered for elderly patients with diabetes or cardiovascular disease such as hemodialysis patients. [ 2 ] Ketamine with profound analgesic, sedative, and amnestic characteristics is a particularly valuable during MAC because it does not cause clinically significant respiratory depression or PONV. [ 15 ] Low dose ketamine (0.25–0.50 mg/kg) with propofol has been used during ambulatory MAC for plastic surgery.…”

“…[ 22 ] However, in geriatric patients, propofol induces cardiovascular depression, with a greater extent compared with other intravascular sedative agents. [ 2 ] In addition, propofol and remifentanil are often administered with two TCI pumps to respectively provide hypnotic and analgesic effects. [ 9 ] Under certain circumstances where multiple TCI systems or syringe pumps are unavailable or are time- and cost-consuming.…”