Procedural sedation for direct current cardioversion: a feasibility study between two management strategies in the emergency department

Abstract

Background: A cardiologist-only approach to procedural sedation with midazolam in the setting of elective cardioversion (DCC) for AF has already been proven as safe as sedation with propofol and anaesthesiologist assistance. No data exist regarding the safety of such a strategy during emergency procedures. The aim of this study is to compare the feasibility of sedation with midazolam, administered by a cardiologist, to an anaesthesiologist-assisted protocol with propofol in emergency DCC. Methods: Single centre, prospective, open blinded, randomized study including all consecutive patients admitted to the Emergency Department requiring urgent or emergency DCC. Patients were randomized in a 1:1 fashion to either propofol or midazolam treatment arm. Patients in the midazolam group were managed by the cardiologist only, while patients treated with propofol group underwent DCC with anaesthesiologist assistance. Results: Sixty-nine patients were enrolled and split into two groups. Eighteen patients (26.1%) experienced periprocedural adverse events (bradycardia, severe hypotension and severe hypoxia), which were similar between the two groups and all successfully managed by the cardiologist. No deaths, stroke or need for invasive ventilation were registered. Patients treated with propofol experienced a greater decrease in systolic and diastolic blood pressure when compared with those treated with midazolam. As the procedure was shorter when midazolam was used, the median cost of urgent/emergency DCC with midazolam was estimated to be 129.0 € (1st-3rd quartiles 114.6-151.6) and 195.6 € (1st-3rd quartiles 147.3-726.7) with propofol (p < .001). Conclusions: Procedural sedation with midazolam given by the cardiologist alone was feasible, well-tolerated and cost-effective in emergency DCC.

Comparison of Bolus Dosing of Methohexital and Propofol in Elective Direct Current Cardioversion

“…A majority of studies previously evaluating recovery time in bolus propofol dosing for cardioversions used a dose of 1 to 1.5 mg/kg. 15 , 20 , 22 , 23 , 24 , 25 , 26 The only 2 studies that cited lower bolus dosing gave lower dosing for older age or unstable arrhythmias. Kaye et al used a lower median dose of 0.4 mg/kg in patients aged >80 years, and a median dose of 0.5 mg/kg in all patients who were deemed unstable.…”

“…However, if there is an increased proportion of cardioversions performed with sedation provided by properly trained cardiologists, the decreased need for anesthesiology support translates to a cost savings. 15 , 26 This also provides more availability of anesthesiology staff for cases that require longer sedation.…”

The Practice of Deep Sedation in Electrophysiology and Cardiac Pacing Laboratories: Results of an Italian Survey Promoted by the AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

“…Almost half of the procedures were performed under local sedation, owing to their low risk of complications and low level of pain [6][7][8][9]. DCC requires rapid, deep sedation; this can be achieved by means of a cardiologist-administered benzodiazepine bolus, or by anaesthesiologist-assisted sedation with propofol as both strategies seem equally safe in elective [10] and urgent settings [11]. By contrast, subcutaneous ICD implantation [5,12], AF and VT ablation [13,14] may be long and painful procedures, while lead extraction is prone to complications that could be life-threatening and may require cardiac surgery.…”

“…This is especially observed in high-volume centres and for less complex procedures. Several data from the literature suggest that this strategy is safe when the cardiologist is experienced in sedative/anaesthetic drugs administration and advanced respiratory care [10,11,[18][19][20][21]. In order to overcome the chronic shortage of anaesthesiologists and to standardize sedation/analgesia strategies in interventional arrhythmology procedures, it would be desirable to institute specific training programs aimed to improve the knowledge and expertise of electrophysiologists in sedative/anaesthetic drugs management.…”

Die elektrische Kardioversion – Schritt für Schritt

“…Alternativ kann zur Sedierung auch Midazolam verwendet werden: Die initiale Dosis beträgt hier ca. 3 mg gefolgt von 2 mg alle 2 min, bis die gewünschte Sedierungstiefe erreicht ist [7]. Die Ausrichtung der Elektroden spielt ebenso eine gewisse Bedeutung.…”