Safety and tolerability of a cardiologist-only approach to sedation for electrical cardioversion in the Emergency Department: The INSTEAD pilot trial

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

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 peri-procedural 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.

Safety and efficacy of a cardiologist-only approach to deep sedation for electrical cardioversion

AIMS

Electrical cardioversion is still the preferred method to restore sinus rhythm in patients with atrial fibrillation. The main disadvantage is that electrical cardioversion requires deep sedation, generally administered by anaesthesiologists, for safety concern. An exclusively cardiologic management of deep sedation should have the advantage to reduce resources and time consumed.

METHODS

All consecutive patients admitted to our division with persistent atrial fibrillation or atrial flutter to undergo elective electrical cardioversion from June 2002 to December 2016 were included. The sedation protocol was managed only by cardiologists and involved the administration of a 5-mg bolus of midazolam, followed by increasing doses of propofol to achieve the desired sedation level. Exclusion criteria were strictly observed. Complications were recorded. A retrospective analysis on a deidentified database has been performed.

RESULTS

A total of 1188 electrical cardioversions were scheduled in our centre. A total of 1195 patients were scheduled in our centre, of whom 1188 met inclusion criteria. Electrical cardioversion was performed in 1073 cases (90.3%). Electrical cardioversion was successful in restoring sinus rhythm in 1030 (96.0%) patients. Immediate recurrence of atrial fibrillation occurred in 89 patients (8.3%). 99/1073 (9.22%) patients underwent trans-oesophagel echocardiography before cardioversion. Deep sedation, according to our protocol, was effective in 100% of cases. Midazolam was administered at a dosage of 5 mg to all patients, while propofol was administered at a dosage ranging from 20 to 80 mg (25.1 ± 11.0 mg SD). No anaesthesia-related complications were observed, neither significant respiratory depression requiring intubation nor anaesthesiologist support.

CONCLUSION

The exclusively cardiological procedure of deep sedation seems to be safe and effective.

Sedation in cardiac arrhythmias management

INTRODUCTION

Procedural sedation is of paramount importance for a plethora of electrophysiological procedures. From electrical cardioversion to electrophysiology studies, device implantations, and catheter ablations, intraprocedural sedation and anesthesia have a pivotal role in allowing procedural success while ensuring patient safety and avoiding discomfort. Areas covered: The present review will discuss the current state-of-the-art in sedation and anesthesia during electrical cardioversion, cardiac implantable electronic device implantation, catheter ablation and electrophysiology studies. Specific information will be provided for each procedure in order to reach the core of this important clinical issue, and specific protocols will be compared. The main pro-arrhythmic and anti-arrhythmic effects of the most commonly used sedatives will also be discussed. Expert commentary: According to much recent evidence, the cardiologist can be the only person responsible for sedation administration in many settings, highlighting few safety issues associated with the absence of a dedicated anesthesiologist thus a concomitant reduction in costs. However, many concerns have been raised in allowing non-anesthesiologists to manage sedatives, as adverse events, while rare, could have catastrophic consequences. The present paper will highlight when a cardiologist-directed sedation is considered safe, how it should be performed, and the pros and cons related to this strategy.