Cost effectiveness of administration of intravenous anesthetics for direct-current cardioversion by nonanesthesiologists

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

Background Methohexital and propofol can both be used as sedation for direct current cardioversion (DCCV). However, there are limited data comparing these medications in this setting. We hypothesized that patients receiving methohexital for elective DCCV would be sedated more quickly, recover from sedation faster, and experience less adverse effects. Methods and Results This was a prospective, blinded randomized controlled trial conducted at a single academic medical center. Eligible participants were randomly assigned to receive either methohexital (0.5 mg/kg) or propofol (0.8 mg/kg) as a bolus for elective DCCV. The times from bolus of the medication to achieving a Ramsay Sedation Scale score of 5 to 6, first shock, eyes opening on command, and when the patient could state their age and name were obtained. The need for additional medication dosing, airway intervention, vital signs, and medication side effects were also recorded. Seventy patients who were randomized to receive methohexital (n=37) or propofol (n=33) were included for analysis. The average doses of methohexital and propofol were 0.51 mg/kg and 0.84 mg/kg, respectively. There were no significant differences between methohexital and propofol in the time from end of injection to loss of conscious (1.4±1.8 versus 1.1±0.5 minutes; P=0.33) or the time to first shock (1.7±1.9 versus 1.4±0.5 minutes; P=0.31). Time intervals were significantly lower for methohexital compared with propofol in the time to eyes opening on command (5.1±2.5 versus 7.8±3.7 minutes; P=0.0005) as well as at the time to the ability to answer simple questions of age and name (6.0±2.6 versus 8.6±4.0 minutes; P=0.001). The methohexital group experienced less hypotension (8.1% versus 42.4%; P<0.001) and less hypoxemia (0.0% versus 15.2%; P=0.005), had lower need for jaw thrust/chin lift (16.2% versus 42.4%; P=0.015), and had less pain on injection compared with propofol using the visual analog scale (7.2±9.7 versus 22.4±28.1; P=0.003). Conclusions In this model of fixed bolus dosing, methohexital was associated with faster recovery, more stable hemodynamics, and less hypoxemia after elective DCCV compared with propofol. It can be considered as a preferred agent for sedation for DCCV. Registration URL: https://www.clinicaltrials.gov/ct; Unique identifier: NCT04187196.

Fast cardiologist-administered midazolam for electrical cardioversion of atrial fibrillation

AIM

To evaluate the safety and the feasibility of sedation administered by cardiologists with rapid intravenous bolus of midazolam followed by flumazenil infusion during transthoracic biphasic electrical cardioversion (TEC) for atrial fibrillation (AF).

METHODS

Two hundred and sixty-five consecutive patients (119 females, mean age 67.4 +/- 8.5 years) with either acute (24 patients) or persistent AF (mean arrhythmia duration 3.7 +/- 3.0 months) underwent TEC. Midazolam (0.05 mg/kg) was administered as rapid intravenous bolus by the cardiologist, whereas the anaesthesiologist was simply alerted. At the end of the procedure, intravenous flumazenil 0.25 mg was given, followed by 0.25 mg over 1 h. Patients received continuous electrocardiographic and pulse-oxymetric monitoring.

RESULTS

Adequate sedation was obtained in 262 patients (98.9%), with a mean midazolam dose of 4.4 +/- 0.9 mg. After drug administration, the mean time to patient's sedation and reawakening were 3.1 +/- 1.9 and 6.1 +/- 2.7 min, respectively. The mean reduction in oxygen saturation was 5.4 +/- 3.7%. Sinus rhythm was restored in 254 patients (95.8%). All but 41 patients (15.5%) were completely amnesic. None reported pain. No adverse events were registered. No urgent call for the anaesthesiologist was made.

CONCLUSIONS

Conscious sedation with fast-administered midazolam followed by flumazenil for cardioversion of atrial fibrillation is safe, effective and well tolerated, easing the procedure and shortening its duration.

Outpatient cardioversion of atrial arrhythmias: efficacy, safety, and costs

BACKGROUND

Outpatient direct current (DC) cardioversion is performed routinely, yet scant data support this approach. We studied the efficacy, safety, and costs of outpatient cardioversion.

METHODS

A retrospective analysis of outpatient cardioversions was performed in a 5-year period at an academic medical center in 532 consecutive outpatients with an atrial tachyarrhythmia. The protocol included anticoagulation (international normalized ratio >or=2.0) for >or=4 consecutive weekly draws and then DC cardioversion with the patient under intravenous anesthesia. Arrhythmia symptoms, antiarrhythmic therapy use, and costs were evaluated.

RESULTS

Ninety percent of patients were discharged in sinus rhythm after cardioversion with a median number of shocks of 1 (range, 1-6) for atrial flutter (n = 113), atrial tachycardia (n = 13), and atrial fibrillation (n = 406). Sixty-seven percent of patients were treated with an antiarrhythmic drug. The complication rate was 2.6%, with 11 unplanned admissions. Thromboemboli occurred only in patients whose anticoagulation deviated from protocol and included chronic hemianopsia starting 4 days after cardioversion, transient right-sided weakness, and cerebral vascular accident 3 days after cardioversion, despite negative results on a transesophageal echocardiogram. Two patients had postcardioversion pulmonary edema. Bradycardia developed in 4 patients; transient pacemaker noncapture after the shock occurred in 4 patients. Transient postshock rhythms also included AV nodal Wenckebach and junctional rhythm. One patient had aspiration pneumonia. The mean cost of cardioversion was 464 dollars. Fees for anesthesia ranged from 525 dollars to 650 dollars. The anesthetic costs ranged from 2.84 dollars to 21.47 dollars. The cardiology fee averaged 501 dollars.

CONCLUSION

Outpatient cardioversion is a low risk, effective, and economical procedure.

Direct current cardioversion: indications, techniques, and recent advances

Direct current cardioversion/defibrillation is an important part of the intensivist's armamentarium. Emergent application may be lifesaving. Elective cardioversion should be used cautiously, with attention to patient selection and proper techniques. Repetitive, futile attempts at direct current cardioversion should be avoided. Reducing or eliminating arrhythmia precipitants may be safer and more effective than this more dramatic intervention.

Cost-effective management of acute atrial fibrillation: role of rate control, spontaneous conversion, medical and direct current cardioversion, transesophageal echocardiography, and antiembolic therapy

Management strategies for the acute treatment of atrial fibrillation (AF) include: (1) the use of intravenous drugs for rate control, (2) drug termination, or (3) direct current (DC) cardioversion. Delays in cardioversion can promote atrial remodeling and add thromboembolic risk. Rate control awaiting spontaneous or pharmacologic conversion may be a cost-effective strategy in patients presenting with recent onset of symptoms. Early DC cardioversion can be cost-effective and minimize antiembolic therapy issues in the acute setting. In patients presenting with AF of unknown or >48 hours' duration, rate control and therapeutic warfarin for 3-4 weeks followed by medical or DC cardioversion is standard practice. However, delays in conversion promote atrial remodeling that makes restoration of sinus rhythm more difficult and increases the likelihood of postcardioversion AF recurrence. Transesophageal echocardiography can identify patients at low risk for a cardioversion-related embolic event and allows cardioversion to be performed earlier, thereby minimizing atrial remodeling.

Procedural anesthesia at the bedside

Procedural anesthesia at the bedside offers patients relief from anxiety, discomfort, and pain and may expedite the procedure by increasing patient cooperation. Prospective planning requires knowledge of the condition of the patient and an assessment of the anesthetic requirements of the proposed procedure. The spectrum of anesthetic options includes sedation and analgesia, monitored anesthesia care, to total intravenous anesthesia (see Fig. 1). Identification of the at-risk patient and modifying the anesthetic should reduce complications (see Box 3). The choice of pharmaceuticals varies depending on the level of anticipated anesthesia. Personnel requirements also vary. Although an anesthesiologist is not required to administer medications and monitor the patient for sedation and analgesia or monitored anesthesia care, TIVA requires the services of an anesthesiologist. Costs are influenced by the personnel requirements and length of the procedure, which sets the drug requirements and drug costs. In the end, personal experience combined with knowledge should guide the provider to offer efficacious and cost-effective procedural anesthesia in the ICU.

Cost-effectiveness analysis in anaesthesia

In order to preserve the quality of anaesthetic care under cost containment programmes, the concept of value-based anaesthesia was introduced. To achieve this goal, namely, the provision of the best possible care attainable at a reasonable cost, studies are necessary that compare anaesthetic techniques in terms of both quality and costs, e.g. by means of cost-effectiveness analyses.

A comparison of 50-J versus 100-J shocks for direct-current cardioversion of atrial flutter

BACKGROUND

Direct-current cardioversion remains the gold standard for restoration of sinus rhythm in patients with atrial flutter. Although an initial energy of 50 J is recommended, the optimal energy settings have not been evaluated in a large series of contemporary patients.

METHODS

We compared the outcome of cardioversion with 50 J versus 100 J in 330 consecutive patients with atrial flutter. Initial energy was based on attending physician preference. One hundred sixty patients received 50 J and 170 patients received 100 J.

RESULTS

Patients in both groups did not differ significantly in age, sex, weight, body mass index, duration of the arrhythmia, postoperative status, presence and type of structural heart disease, or use of antiarrhythmic drugs. Patients in the 100-J group had more first shock conversion (85% vs 70%; P =. 001), fewer total shocks (1.2 +/- 0.5 vs 1.4 +/- 0.7; P =.001), and less induction of atrial fibrillation (2% vs 11%; P =.002). There were no significant differences in overall restoration of sinus rhythm, cumulative energy delivered, anesthetic dose, and procedure room time. On multivariate analysis, delivery of 100 J was the strongest predictor of first shock success (odds ratio 2.6, 95% confidence interval 2.13 to 3.16; P <.001).

CONCLUSION

An initial energy of 100 J is more efficient for restoration of sinus rhythm in patients with atrial flutter.

NASPE expert consensus document: use of i.v. (conscious) sedation/analgesia by nonanesthesia personnel in patients undergoing arrhythmia specific diagnostic, therapeutic, and surgical procedures

Use of IV (Conscious) Sedation/Analgesia by Nonanesthesia Personnel in Patients Undergoing Arrhythmia Specific Diagnostic, Therapeutic, and Surgical Procedures. This article is intended to inform practitioners, payers, and other interested parties of the opinion of the North American Society of Pacing and Electrophysiology (NASPE) concerning evolving areas of clinical practice or technologies or both, that are widely available or are new to the practice community. Expert consensus documents are so designated because the evidence base and experience with the technology or clinical practice are not yet sufficiently well developed, or rigorously controlled trials are not yet available that would support a more definitive statement. This article has been endorsed by the American College of Cardiology, October 1997.