Abstract
BackgroundA 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.MethodsSingle 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.ResultsSixty-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).ConclusionsProcedural sedation with midazolam given by the cardiologist alone was feasible, well-tolerated and cost-effective in emergency DCC.
Highlights
A cardiologist-only approach to procedural sedation with midazolam in the setting of elective cardioversion (DCC) for atrial fibrillation (AF) has already been proven as safe as sedation with propofol and anaesthesiologist assistance
Concerns have been raised on the use of a cardiologist-only, midazolam-based strategy in urgent or emergency Direct current cardioversion (DCC) as haemodynamic instability and lack of time could precipitate the risk of stroke and serious adverse events [9, 14]
Population and inclusion criteria The “Intravenous beNzodiazepine Safety and Tolerability in Emergency Atrial fibrillation Direct-current cardioversion” (INSTEAD) is a single centre, prospective, open blinded, randomized study included consecutive patients admitted to the Emergency Department or the University Hospital “Ospedali Riuniti Umberto I - Lancisi - Salesi” requiring urgent or emergency DCC
Summary
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. 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. The use of sedation during DCC can play a role in reducing the pain-related catecholamine surge preventing the recollection of such an unpleasant experience by the patient [6, 7]. To this day, no specific guidelines or recommendations with regards to the most appropriate drug that should be used for procedural sedation is available and different sedation strategies have been described in literature but no consensus on the most efficient strategy has been reached. Concerns have been raised on the use of a cardiologist-only, midazolam-based strategy in urgent or emergency DCC as haemodynamic instability and lack of time could precipitate the risk of stroke and serious adverse events [9, 14]
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