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Bock M, O’Connor M, Chouchane A, Schmidt P, Schaarschmidt C, Knoll K, Bahlke F, Englert F, Storz T, Kottmaier M, Trenkwalder T, Reents T, Bourier F, Telishevska M, Lengauer S, Hessling G, Deisenhofer I, Kolb C, Lennerz C. Cardiologist-Directed Sedation Management in Patients Undergoing Transvenous Lead Extraction: A Single-Centre Retrospective Analysis. J Clin Med 2023; 12:4900. [PMID: 37568301 PMCID: PMC10420171 DOI: 10.3390/jcm12154900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/07/2023] [Accepted: 07/18/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND The demand for transvenous lead extraction (TLE) has increased. In line with this, the safety of such procedures has also increased. Traditionally, TLE is performed under resource-intensive general anaesthesia. This study aims to evaluate the safety and outcomes of Cardiologist-lead deep sedation for TLE. METHODS We retrospectively analysed 328 TLE procedures performed under deep sedation from 2016 to 2019. TLE procedures were performed by experienced electrophysiologists. Sedation was administered by a specifically trained cardiologist (bolus midazolam/fentanyl and propofol infusion). Procedural sedation data including blood pressure, medication administration and sedation time were collected. Complications related to sedation and the operative component of the procedure were analysed retrospectively. RESULTS The sedation-associated complication rate during TLE was 22.0%. The most common complication (75% of complications) was hypotension requiring noradrenaline, followed by bradycardia requiring atropine (13% of complications). Additionally, the unplanned presence of an anaesthesiologist was needed in one case (0.3%). Deep sedation was achieved with midazolam (mean dose 42.9 ± 26.5 µg/kg), fentanyl (mean dose 0.4 ± 0.6 µg/kg) and propofol (mean dose 3.5 ± 1.2 mg/kg/h). There was no difference in medication dosage between those with a sedation-associated complication and those without. Sedation-associated complications appeared significantly more in patients with reduced LVEF (p = 0.01), renal impairment (p = 0.01) and a higher American Society of Anaesthesiologists (ASA) class (p = 0.01). CONCLUSION Deep sedation for TLE can be safely performed by a specifically trained cardiologist, with a transition to general anaesthesia required in only 0.3% of cases. We continue to recommend the on-call availability of an anaesthesiologist and cardiac surgeon in case of major complications.
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Affiliation(s)
- Matthias Bock
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
- DZHK (German Centre for Cardiovascular Research, Partner Site Munich, Heart Alliance), 80336 Munich, Germany
| | - Matthew O’Connor
- Auckland City Hospital, Department of Cardiology, Auckland 1023, New Zealand
| | - Amir Chouchane
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Philip Schmidt
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Claudia Schaarschmidt
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Katharina Knoll
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
- DZHK (German Centre for Cardiovascular Research, Partner Site Munich, Heart Alliance), 80336 Munich, Germany
| | - Fabian Bahlke
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Florian Englert
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Theresa Storz
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Marc Kottmaier
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Teresa Trenkwalder
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Tilko Reents
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Felix Bourier
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Marta Telishevska
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Sarah Lengauer
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Gabriele Hessling
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Isabel Deisenhofer
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Christof Kolb
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Carsten Lennerz
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
- DZHK (German Centre for Cardiovascular Research, Partner Site Munich, Heart Alliance), 80336 Munich, Germany
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Beaty EH, Fernando RJ, Jacobs ML, Winter GG, Bulla C, Singleton MJ, Patel NJ, Bradford NS, Bhave PD, Royster RL. Comparison of Bolus Dosing of Methohexital and Propofol in Elective Direct Current Cardioversion. J Am Heart Assoc 2022; 11:e026198. [PMID: 36129031 DOI: 10.1161/jaha.122.026198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Elijah H Beaty
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Rohesh J Fernando
- Department of Anesthesiology Wake Forest School of Medicine Winston-Salem NC
| | | | - Gillian G Winter
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Catalina Bulla
- Hospital Medicine Cleveland Clinic Florida, Indian River Hospital Vero Beach FL
| | | | - Neel J Patel
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Natalie S Bradford
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Prashant D Bhave
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Roger L Royster
- Department of Anesthesiology Wake Forest School of Medicine Winston-Salem NC
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Bauer J, Beauchamp L, Pavich E. Methohexital for procedural sedation of cardioversions in the emergency department. Am J Emerg Med 2022; 58:79-83. [DOI: 10.1016/j.ajem.2022.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 05/19/2022] [Accepted: 05/21/2022] [Indexed: 10/18/2022] Open
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Yu PX, Bo LJ. Evaluation of efficacy and safety of propofol in the treatment of procedural sedation/anesthesia in neonates: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27147. [PMID: 34664839 PMCID: PMC8448078 DOI: 10.1097/md.0000000000027147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In newborns, propofol anesthesia is commonly utilized. Propofol is increasingly being shown to be effective and safe in treating procedural sedation and anesthesia in neonates. This research aims to evaluate the efficacy and safety of propofol in neonates using systematic review and meta-analysis methodologies. METHODS A thorough review and meta-analysis of studies on propofol anesthesia in neonates will be conducted. Conduct comprehensive searches in Web of Science, PubMed, Cochrane Library, EMBASE database, WanFang database, and Chinese biomedical literature database before May 25, 2021, to obtain published and qualified research. Two reviewers will assess the quality of the included papers and extract the data independently. Then, for meta-analysis, we will utilize RevMan 5.3 software. RESULTS This study will pool the data of separate trials to analyze the efficacy and safety of propofol in the treatment of procedural sedation/anesthesia in neonates. CONCLUSION Our findings will give strong data for determining whether propofol is an effective treatment for procedural anesthesia in neonates.
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Affiliation(s)
- Pei-Xia Yu
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Li-Jun Bo
- The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Homma Y, Norii T, Kanazawa T, Hoshino A, Arino S, Takase H, Albright D, Funakoshi H. A mini-review of procedural sedation and analgesia in the emergency department. Acute Med Surg 2020; 7:e574. [PMID: 33042561 PMCID: PMC7538695 DOI: 10.1002/ams2.574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 09/05/2020] [Indexed: 11/25/2022] Open
Abstract
Procedural sedation and analgesia (PSA) is performed for a variety of indications in emergency departments (EDs). Although the practice of PSA in the ED is somewhat unique from other clinical areas, there is currently no guideline for this practice in Japan. Policy statements and guidelines for PSA have been published in Europe and North America. These guidelines suggest first evaluating patients carefully before performing PSA, and then deciding on target sedative level and choice of medications. Patient evaluation requires a combination of continuous visual observation by trained medical staff to assess the depth of sedation and respiration with noninvasive measurements of blood pressure, continuous electrocardiography monitoring, and pulse oximetry. Sedative selection should be based on its characteristics, peak time, effectiveness, and risks. It is important to administer sedatives and analgesics in small, incremental doses while keeping a close eye on the patient’s reaction to avoid adverse events (AEs) until the planned sedation level is reached. Further, additional attention is needed for special populations such as pediatric and elderly patients. PSA is a key element for patient‐centered care in emergency medicine. In this manuscript, we review the available evidence for PSA in the EDs, including guidelines for evaluation, monitoring, pharmacology, AEs, and special populations such as pediatric and elderly patients.
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Affiliation(s)
- Yosuke Homma
- Department of Emergency and Critical Care Medicine Tokyo Bay Urayasu Ichikawa Medical Center Urayasu Chiba Japan
| | - Tatsuya Norii
- Department of Emergency Medicine University of New Mexico Albuquerque New Mexico United States
| | - Takeshi Kanazawa
- Department of Medical Education Kyushu University Graduate School of Medical Sciences Fukuoka Japan
| | - Atsumi Hoshino
- Surgical Intensive Care Unit Nippon Medical School Hospital Tokyo Japan
| | - Satoshi Arino
- Department of Pediatric Emergency and Critical Care Medicine Tokyo Metropolitan Children's Medical Center Tokyo Japan
| | - Hiroshi Takase
- Emergency and Critical Care Department Sendai City Hospital Miyagi Japan
| | - Danielle Albright
- Department of Emergency Medicine University of New Mexico Albuquerque New Mexico United States
| | - Hiraku Funakoshi
- Department of Emergency and Critical Care Medicine Tokyo Bay Urayasu Ichikawa Medical Center Urayasu Chiba Japan
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Bundgaard JS, Jacobsen PK, Grand J, Lindholm MG, Hassager C, Pehrson S, Kjaergaard J, Bundgaard H. Deep sedation as temporary bridge to definitive treatment of ventricular arrhythmia storm. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:657-664. [DOI: 10.1177/2048872620903453] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background:
Electrical storm and incessant ventricular tachycardia (VT) are characterized by the clustering of episodes of VT or ventricular fibrillation (VF) and are associated with a poor prognosis. Autonomic nervous system activity influences VT threshold, and deep sedation may be useful for the treatment of VT emergencies.
Methods:
We reviewed data from conscious patients admitted to our intensive care unit (ICU) due to monomorphic VT, polymorphic VT or VF at our tertiary center between 2010 and 2018.
Results:
A total of 46 conscious patients with recurrent ventricular arrhythmia, refractory to initial treatment, were referred to the ICU. The majority (n = 31) were stabilized on usual care. The remaining treatment-refractory 15 patients (57 years (range 9–74), 80% males, seven with implantable cardioverter-defibrillators) with VT/VF storm (n = 11) or incessant VT (n = 4) due to ischemic heart disease (n = 10), cardiomyopathy (n = 2), primary arrhythmia (n = 2) and one patient post valve surgery, were deeply sedated and intubated. A complete resolution of VT/VF within minutes to hours was achieved in 12 patients (80%), partial resolution in two (13%) and one (7%) patient died due to ventricular free-wall rupture. One patient with recurrent VT episodes needing repeated deep sedation developed necrotic caecum. No other major complications were seen. Thirteen (87%) patients were alive after a mean follow-up of 3.7 years.
Conclusion:
Deep sedation was effective and safe for the temporary management of malignant VT/VF refractory to usual treatment. In emergencies, deep sedation may be widely accessible at both secondary and tertiary centers and a clinically useful bridge to definitive treatment of VT.
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Stronati G, Capucci A, Dello Russo A, Adrario E, Carsetti A, Casella M, Donati A, Guerra F. Procedural sedation for direct current cardioversion: a feasibility study between two management strategies in the emergency department. BMC Cardiovasc Disord 2020; 20:388. [PMID: 32842955 PMCID: PMC7449000 DOI: 10.1186/s12872-020-01664-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/10/2020] [Indexed: 01/09/2023] Open
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 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.
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Affiliation(s)
- Giulia Stronati
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Via Conca 71, Ancona, Italy
| | - Alessandro Capucci
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Via Conca 71, Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Via Conca 71, Ancona, Italy
| | - Erica Adrario
- Anaesthesia and Intensive Care Unit, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Ancona, Italy
| | - Andrea Carsetti
- Anaesthesia and Intensive Care Unit, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Via Conca 71, Ancona, Italy
| | - Abele Donati
- Anaesthesia and Intensive Care Unit, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Ancona, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Via Conca 71, Ancona, Italy.
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Abstract
Direct current cardioversion is a low-risk and standard procedure to restore normal sinus rhythm in patients with tachyarrhythmias. It requires sedation to facilitate the procedure, as it is painful and distressful. The preferred anesthetic drug must be short acting, producing conscious sedation, to enable rapid recovery after the procedure. In this sense, this narrative review focuses on the critical analysis of recent randomized studies and presents about the safety and effectiveness of propofol, comparing it with other established sedatives, mainly etomidate and midazolam. The research was performed on MEDLINE database with Propofol and Cardioversion keywords. In most cases, propofol comes to be the best option, with a quick recovery time and low rates of side effects. Different studies have demonstrated no inferiority when comparing to other drugs and, when these adverse events happened, they were easily and quickly handled. Exceptions in this scenario are those patients, particularly the elderly, with baseline important structural heart disease, in which etomidate with fentanyl has been pointed to lead to better hemodynamic stability.
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Affiliation(s)
- Bruna Galvão de Wafae
- Medical Sciences Faculty, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rose Mary Ferreira da Silva
- Department of Internal Medicine, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Henrique Horta Veloso
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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Electrical cardioversion for supraventricular arrhythmias in octagenarians. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2020; 16:902-904. [PMID: 31911796 PMCID: PMC6938742 DOI: 10.11909/j.issn.1671-5411.2019.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Results from the Adverse Event Sedation Reporting Tool: A Global Anthology of 7952 Records Derived from >160,000 Procedural Sedation Encounters. J Clin Med 2019; 8:jcm8122087. [PMID: 31805686 PMCID: PMC6947169 DOI: 10.3390/jcm8122087] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 12/28/2022] Open
Abstract
Background: The incidence of sedation-related adverse events, inclusive of both adults and children, administered by multiple specialty providers from different countries and venues, using standardized definitions, has never been reported on an international level. We are reporting the outcome data of the adverse event sedation reporting tool as an important step toward a more complete risk assessment of sedation-related morbidity, mortality, and etiology. The analysis of the AE sedation reporting data include descriptive measures to evaluate the characteristics of the provider, the patient, sedations performed, adverse events, interventions, and outcomes. The primary outcome was the rate and nature of adverse events. Between 12/14/2010 and 12/11/2018 there were 7952 sedations, from an estimated total of 164,114 sedations administered, of which 622 were reported as adverse events. The mean age of the entire patient population is 33.0 years (0.02–98.7). The providers represented 39 countries across six continents. Oxygen desaturation (75%–90%) for <60 s is the most prevalent adverse event with a rate of 7.8 per 10,000, followed by airway obstruction at a rate of 5.42 per 10,000. Apnea occurred at a rate of 4.75 per 10,000. Significant predictors of adverse events are ≥ ASA score III (p = 0.0003), procedure time (6:00 pm–12:00 am: p < 0.0001, 12:00–6:00 am: p = 0.0003), and non-hospital location (p < 0.0001). The AE sedation reporting tool has demonstrated that the majority of adverse events in children and adults who receive procedural sedation from multi-specialists internationally required minor interventions and had outcomes of minor risk.
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Painful Recall in Elective Electrical Cardioversion with Propofol and the Need for Additional Analgesia. Cardiol Res Pract 2018; 2018:2363062. [PMID: 30140454 PMCID: PMC6081497 DOI: 10.1155/2018/2363062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 05/03/2018] [Accepted: 06/24/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Electrical cardioversion (ECV) is a short but painful procedure for treating cardiac dysrhythmias. There is a wide variation regarding the medication strategy to facilitate this procedure. Many different sedative techniques for ECV are described. Currently, the optimal medication strategy to prevent pain in ECV has yet to be established. The role for additional analgesic agents to prevent pain during the procedure remains controversial, and evidence is limited. Methods We conducted a prospective multicenter study to determine the incidence of painful recall in ECV with propofol as a sole agent for sedation, in order to assess the indication for additional opioids. In all patients, sedation was induced with propofol titrated till loss of eyelash reflex and nonresponsiveness to stimuli, corresponding to Ramsay Sedation Score level 5-6. ECV was performed with extracardiac biphasic electrical shocks. The primary outcome was painful recall of the procedure, defined as numeric pain rating scale (NRS) ≥ 1. NRS ≥ 4 is considered inadequately treated pain. Secondary outcome parameters were pain at the side of the defipads and muscle pain after ECV. Results A total of 232 patients were enrolled in this study. Six patients were excluded due to missing data or violation of study protocol. Three patients reported recall of the procedure, and one patient (0.4%) reported recall of severe pain during the procedure with NRS 7. Two patients (0.9%) reported recall of mild pain with NRS 1-3. Complete amnesia was observed in 223 patients (98.7%), with NRS 0. The mean of the total dose of propofol was 1.1 mg/kg. Fifteen patients (6.6%) experienced pain at the side of the defipads, and six patients (2.7%) complained of muscle pain after the procedure. Conclusions In this prospective multicenter study, propofol as a sole agent provided good conditions for ECV with a low incidence of recall. Effective sedation and complete amnesia was achieved in 98.7% of the patients, 0.4% of patients reported recall of severe pain during the procedure, and 0.9% of patients experienced mild pain during the ECV.
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Abstract
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.
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Affiliation(s)
- Federico Guerra
- a Cardiology and Arrhythmology Clinic , Marche Polytechnic University, University Hospital "Ospedali Riuniti" , Ancona , Italy
| | | | - Alessandro Capucci
- a Cardiology and Arrhythmology Clinic , Marche Polytechnic University, University Hospital "Ospedali Riuniti" , Ancona , Italy
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Kidd LR, Lyons SC, Lloyd G. Paediatric procedural sedation using ketamine in a UK emergency department: a 7 year review of practice. Br J Anaesth 2016; 116:518-23. [PMID: 26893406 DOI: 10.1093/bja/aev555] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Ketamine is growing in popularity for procedural sedation in the paediatric population, yet safety concerns remain. We performed a retrospective review of practice and outcomes of paediatric ketamine sedation using the World SIVA International Sedation Task Force reporting tool. METHODS A retrospective inspection of the dedicated emergency department electronic sedation database and subsequent note and sedation chart review was performed for all paediatric sedations throughout a 7 yr period from September 2006. All adverse events were stratified. RESULTS During the study period, procedural sedation was provided for a total of 243 children, of whom 215 were sedated with ketamine, most commonly for wound management (n=131). The median patient age was 4 yr (14 months to 15 yr), and 63.7% were male. Of the total, 76.7% were discharged home either directly (n=101) or after brief observation (n=64). One patient required subsequent general anaesthesia after a failed sedation with paradoxical agitation. Of the total, 9.8% of patients had an adverse event, the most severe risk stratification being 'minor risk'. All interventions were 'minimal risk'. There were no 'sentinel risk' outcomes. CONCLUSIONS These data support the ongoing use of ketamine for paediatric procedural sedation in the emergency department by emergency physicians. Relatively high resource requirements mean that ensuring adequate numbers of procedures may prove challenging.
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Affiliation(s)
- L R Kidd
- Department of Anaesthetics, Royal Devon and Exeter NHS Foundation Trust, Exeter EX2 5DW
| | - S C Lyons
- Department of Anaesthetics, Royal Devon and Exeter NHS Foundation Trust, Exeter EX2 5DW
| | - G Lloyd
- Emergency Department, Royal Devon and Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
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16
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Bellolio MF, Gilani WI, Barrionuevo P, Murad MH, Erwin PJ, Anderson JR, Miner JR, Hess EP. Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2016; 23:119-34. [PMID: 26801209 PMCID: PMC4755157 DOI: 10.1111/acem.12875] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/27/2015] [Accepted: 08/27/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This was a systematic review and meta-analysis to evaluate the incidence of adverse events in adults undergoing procedural sedation in the emergency department (ED). METHODS Eight electronic databases were searched, including MEDLINE, EMBASE, EBSCO, CINAHL, CENTRAL, Cochrane Database of Systematic Reviews, Web of Science, and Scopus, from January 2005 through 2015. Randomized controlled trials and observational studies of adults undergoing procedural sedation in the ED that reported a priori selected outcomes and adverse events were included. Meta-analysis was performed using a random-effects model and reported as incidence rates with 95% confidence intervals (CIs). RESULTS The search yielded 2,046 titles for review. Fifty-five articles were eligible, including 9,652 procedural sedations. The most common adverse event was hypoxia, with an incidence of 40.2 per 1,000 sedations (95% CI = 32.5 to 47.9), followed by vomiting with 16.4 per 1,000 sedations (95% CI = 9.7 to 23.0) and hypotension with 15.2 per 1,000 sedations (95% CI = 10.7 to 19.7). Severe adverse events requiring emergent medical intervention were rare, with one case of aspiration in 2,370 sedations (1.2 per 1,000), one case of laryngospasm in 883 sedations (4.2 per 1,000), and two intubations in 3,636 sedations (1.6 per 1,000). The incidence of agitation and vomiting were higher with ketamine (164.1 per 1,000 and 170.0 per 1,000, respectively). Apnea was more frequent with midazolam (51.4 per 1,000), and hypoxia was less frequent in patients who received ketamine/propofol compared to other combinations. The case of laryngospasm was in a patient who received ketamine, and the aspiration and intubations were in patients who received propofol. When propofol and ketamine are combined, the incidences of agitation, apnea, hypoxia, bradycardia, hypotension, and vomiting were lower compared to each medication separately. CONCLUSIONS Serious adverse events during procedural sedation like laryngospasm, aspiration, and intubation are exceedingly rare. Quantitative risk estimates are provided to facilitate shared decision-making, risk communication, and informed consent.
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Affiliation(s)
- M. Fernanda Bellolio
- Department of Emergency MedicineMayo ClinicRochesterMN
- Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
| | | | - Patricia Barrionuevo
- Division of Preventive, Occupational, and Aerospace MedicineMayo ClinicRochesterMN
- Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
| | - M. Hassan Murad
- Division of Preventive, Occupational, and Aerospace MedicineMayo ClinicRochesterMN
- Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
| | | | | | - James R. Miner
- Department of Emergency MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMN
| | - Erik P. Hess
- Department of Emergency MedicineMayo ClinicRochesterMN
- Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
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17
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Wakai A, Blackburn C, McCabe A, Reece E, O'Connor G, Glasheen J, Staunton P, Cronin J, Sampson C, McCoy SC, O'Sullivan R, Cummins F. The use of propofol for procedural sedation in emergency departments. Cochrane Database Syst Rev 2015; 2015:CD007399. [PMID: 26222247 PMCID: PMC6517206 DOI: 10.1002/14651858.cd007399.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is increasing evidence that propofol is efficacious and safe for procedural sedation (PS) in the emergency department (ED) setting. However, propofol has a narrow therapeutic window and lacks of a reversal agent. The aim of this review was to cohere the evidence base regarding the efficacy and safety profile of propofol when used in the ED setting for PS. OBJECTIVES To identify and evaluate all randomized controlled trials (RCTs) comparing propofol with alternative drugs (benzodiazepines, barbiturates, etomidate and ketamine) used in the ED setting for PS. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9), MEDLINE (1950 to September week 2 2013) and EMBASE (1980 to week 2 2013). We searched the Current Controlled Trials metaRegister of Clinical Trials (compiled by Current Science) (September 2013). We checked the reference lists of trials and contacted trial authors. We imposed no language restriction. We re-ran the search in February 2015. We will deal with the one study awaiting classification when we update the review. SELECTION CRITERIA RCTs comparing propofol to alternative drugs (benzodiazepines, barbiturates, etomidate and ketamine) used in the ED setting for PS in participants of all ages. DATA COLLECTION AND ANALYSIS Two authors independently performed data extraction. Two authors performed trial quality assessment. We used mean difference (MD), odds ratio (OR) and 95% confidence intervals (CI) to measure effect sizes. Two authors independently assessed and rated the methodological quality of each trial using The Cochrane Collaboration tool for assessing risk of bias. MAIN RESULTS Ten studies (813 participants) met the inclusion criteria. Two studies only included participants 18 years and younger; six studies only included participants 18 years and older; one study included participants between 16 and 65 years of age and one study included only adults but did not specify the age range. Eight of the included studies had a high risk of bias. The included studies were clinically heterogeneous. We undertook no meta-analysis.The primary outcome measures of this review were: adverse effects (as defined by the study authors) and participant satisfaction (as defined by the study authors). In one study comparing propofol/fentanyl with ketamine/midazolam, delayed adverse reactions (nightmares and behavioural change) were noted in 10% of the ketamine/midazolam group and none in the propofol/fentanyl group. Seven individual studies reported no evidence of a difference in adverse effects between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions. Three individual studies reported no evidence of a difference in pain at the injection site between intravenous propofol and alternative interventions. Four individual studies reported no evidence of a difference in participant satisfaction between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions (ketamine, etomidate, midazolam). All the studies employed propofol without the use of an adjunctive analgesic and all, except one, were small (fewer than 100 participants) studies. The quality of evidence for the adverse effects and participant satisfaction outcomes was very low.Nine included studies (eight comparisons) reported all the secondary outcome measures of the review except mortality. It was not possible to pool the results of the included studies for any of the secondary outcome measures because the comparator interventions were different and the measures were reported in different ways. Seven individual studies reported no evidence of difference in incidence of hypoxia between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions. AUTHORS' CONCLUSIONS No firm conclusions can be drawn concerning the comparative effects of administering intravenous propofol, with or without an adjunctive analgesic agent, with alternative interventions in participants undergoing PS in the ED setting on adverse effects (including pain at the injection site) and participant satisfaction. The review was limited because no two included studies employed the same comparator interventions, and because the number of participants in eight of the included studies were small (fewer than 100 participants).
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Affiliation(s)
- Abel Wakai
- Division of Population Health Sciences (PHS), Royal College of Surgeons in Ireland (RCSI)Emergency Care Research Unit (ECRU)123 St. Stephen's GreenDublin 2Ireland
| | - Carol Blackburn
- Our Lady's Children's Hospital CrumlinDepartment of Emergency MedicineDublinIreland12
| | - Aileen McCabe
- Division of Population Health Sciences (PHS), Royal College of Surgeons in IrelandEmergency Care Research Unit (ECRU)123 St. Stephen's GreenDublin 2Ireland
| | - Emilia Reece
- Princess Alexandra HospitalDepartment of AnaesthesiaQueenslandAustralia
| | - Ger O'Connor
- Mater Misericordiae University HospitalDepartment of Emergency MedicineEccles StreetDublinIreland7
| | - John Glasheen
- Cork University HospitalDepartment of Emergency MedicineCorkIreland
| | - Paul Staunton
- St. James's HospitalDepartment of Emergency MedicineJames's StreetDublinIrelandDublin 8
| | - John Cronin
- National Children's Research Centre, Our Lady's Children's Hospital Crumlin; University College DublinPaediatric Emergency Research Unit (PERU), Department of Emergency MedicineCrumlinDublinIreland12
| | - Christopher Sampson
- University of Missouri‐ColumbiaDepartment of Emergency Medicine M5621 Hospital Drive DC029.1ColumbiaMOUSA65212
| | - Siobhan C McCoy
- Cork University HospitalDepartment of Emergency MedicineCorkIreland
| | - Ronan O'Sullivan
- Cork University HospitalCorkIreland
- Our Lady's Children's Hospital CrumlinNational Children's Research CentreDublinIreland12
| | - Fergal Cummins
- National AmbulanceDepartment of Clinical ServicesLevel 7 tower 3Etihad TowersAbu DhabiAbu DhabiUnited Arab Emirates63788
- Charles Sturt UniversityPort MacquarieNSWAustralia
- University of LimerickGraduate Entry Medical School ILimerickIreland
- REDSPoT Retrieval Emergency Disaster Medicine Research and Development UnitLimerickIreland
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