Can we implant cardioverter defibrillator under minimal sedation?

Pain During "Noncomplex" Electrophysiological Studies and Cardiac Rhythm Device Surgery

BACKGROUND

There are only limited data about peri-interventional pain during cardiac electrophysiological procedures without analgosedation. In this study, peri-interventional pain and recollection of it after the intervention were evaluated.

METHODS

A total of 101 patients (43 electrophysiological/ablation procedures and 58 device surgeries) reported pain on a numerical rating scale (NRS; 0-10) before (pre), during (peri), and after (post) the intervention. Maximum pain (maxNRS) and the average of pain (meanNRS) were used for statistical analysis. Peri-interventional pain was compared with postinterventional data of the recollection of peri-interventional pain (peri-post). Patients were allocated into 2 groups (with 51 and 50 patients, respectively) to evaluate the mode of patient-staff interaction on pain recollection. Depressive, anxiety, and somatic symptom scales (Patient Health Questionnaire-15, Generalized Anxiety Disorder-7, and Patient Health Questionnaire-15) were used to analyze their influence on pain recollection.

RESULTS

In total, 49.6% of patients (n = 50) complained of moderate to severe pain (maxNRS) at least once during the procedure. The comparison between peri and peri-post data revealed the following (median (range)-maxNRS, peri: 3 (0-10) versus peri-post: 4 (0-9) (ns), and meanNRS, peri: 1.4 (0-7) versus peri-post: 2.0 (0-6) (ns). The mode of patient-staff interaction had no influence on pain. No effect was found for psychosocial factor concerning pain and the recollection of pain. The results of the linear regression showed no influence of low-dose midazolam on recollection of pain.

CONCLUSION

Half of the patients reported moderate to severe pain at least once during cardiac electrophysiological procedures without analgosedation. However, on average, patients reported only low pain levels. Postinterventional derived data on discomfort reflect the peri-interventional situation.

Feasibility and safety of using local anaesthesia with conscious sedation during complex cardiac implantable electronic device procedures

We assessed the feasibility and safety of using local anaesthesia with conscious sedation as an alternative to general anaesthesia during complex and noncomplex cardiac implantable device procedures. We enrolled 279 consecutive patients who underwent cardiac device implantation/replacement at our tertiary/quaternary cardiac specialist hospital during a 17-month study period. Continuous combined intravenous conscious sedation with propofol and midazolam plus fentanyl and local anaesthesia were used for all procedures. Among the patients, 113, 59, 43, and 64 patients underwent pacemaker implantation, implantable cardiac defibrillator implantation, cardiac resynchronisation therapy device implantation, and generator exchange, respectively. The procedural success rate was 100%, with no apnoea or hypoxia episodes requiring therapeutic intervention. None of the patients required conversion to general anaesthesia. The mean surgical duration was longer for complex vs. noncomplex procedures (p = 0.003). The minimum mean arterial pressure during complex procedures was slightly lower than that during noncomplex procedures (p = 0.03). The perioperative (<24 h) mortality rate was 0%, and neither complexity group required tracheal intubation. Only two patients (0.7%) required unplanned intensive care unit admission for further surveillance. Our findings suggest that local anaesthesia with conscious sedation is a safe and feasible option for cardiac device implantation procedures, including complex procedures.

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.

Pectoralis blocks for insertion of an implantable cardioverter defibrillator in two patients with Duchenne muscular dystrophy

Patients with Duchenne muscular dystrophy (DMD) often have systemic manifestations with comorbid involvement of the cardiac and respiratory systems that increase the risk of anesthetic and perioperative morbidity. These patients frequently develop progressive myocardial involvement with cardiomyopathy, depressed cardiac function, and arrhythmias. The latter may necessitate the placement of an automatic implantable cardioverter defibrillator (AICD) insertion. As a means of avoiding the need for general anesthesia and its inherent potential of morbidity, regional anesthesia may be used in specific cases. We present two cases of successful AICD insertion in patients with DMD using unilateral pectoralis and intercostal nerve blocks supplemented with intravenous sedation. Relevant anatomy for this regional anesthetic technique is reviewed and benefits of this anesthetic technique compared to general anesthesia are discussed.

Anaesthesiological support in a cardiac electrophysiology laboratory: a single-centre prospective observational study

BACKGROUND

Implantation of cardiovascular implantable electronic devices (CIEDs) has greatly increased during the last decade and anaesthetic management of these patients remains an open question.

OBJECTIVE

This study describes anaesthetic management and risk factors associated with complications occurring during these procedures.

DESIGN

A single-centre prospective observational study.

SETTING

Grenoble University Hospital, France, from May 2010 to October 2010.

PATIENTS

All patients admitted to the cardiac electrophysiology laboratory were included.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Clinical data, anaesthetic and medical characteristics as well as complications (respiratory or cardiovascular) and treatment were recorded by the anaesthetic nurse at the end of each procedure.

RESULTS

Two hundred and sixty-nine patients were included, 229 (85%) with an American Society of Anaesthesiologists (ASA) status of 3 or 4, 103 (38%) with a New York Heart Association (NYHA) functional class of 3 or 4 and 136 (51%) with a left ventricular ejection fraction of less than 40%. Two hundred and forty-seven (92%) of the patients underwent deep sedation and 12 (8%) general anaesthesia. Seventy-eight (29%) patients had at least one complication, among whom 21 (27%) had at least one considered as severe. Fifty (19%) of the patients had a respiratory complication and 46 (17%) a cardiovascular complication; the latter was more frequently severe (41 vs. 12%; P=0.001). Lead extraction [odds ratio (OR) 13.7, 95% confidence interval (CI) 3.5 to 53.3; P<0.001], NYHA status of 4 (OR 11.8, 95% CI 1.8 to 74.8; P<0.001), implantable cardioverter-defibrillator (ICD) testing by T-wave shock (OR 3.9, 95% CI 1.53 to 10.2; P=0.005) and length of procedure (OR 1.01, 95% CI 1.004 to 1.031; P=0.013) were identified as independent risk factors for cardiovascular complications.

CONCLUSION

Patients requiring cardiovascular implantable electronic device (CIED) implantation were fragile with a high complication rate and a high rate of severe complications even with anaesthesiological support. These complications, as well as the need for deep sedation or general anaesthesia, clearly justify the involvement of a qualified anaesthesiologist.

Sedation for electrophysiological procedures

Administration of intravenous sedation (IVS) has become an integral component of procedural cardiac electrophysiology. IVS is employed in diagnostic and ablation procedures for transcutaneous treatment of cardiac arrhythmias, electrical cardioversion of arrhythmias, and the insertion of implantable electronic devices including pacemakers, defibrillators, and loop recorders. Sedation is frequently performed by nursing staff under the supervision of the proceduralist and in the absence of specialist anesthesiologists. The sedation requirements vary depending on the nature of the procedure. A wide range of sedation techniques have been reported with sedation from the near fully conscious to levels approaching that of general anesthesia. This review examines the methods employed and outcomes associated with reported sedation techniques. There is a large experience with the combination of benzodiazepines and narcotics. These drugs have a broad therapeutic range and the advantage of readily available reversal agents. More recently, the use of propofol without serious adverse events has been reported. The results provide a guide regarding the expected outcomes of these approaches. The complication rate and need for emergency assistance is low in reported series where sedation is administered by nonspecialist anesthesiology staff.

Nurse-administered procedural sedation and analgesia in the cardiac catheter laboratory: an integrative review

OBJECTIVES

To identify and appraise the literature concerning nurse-administered procedural sedation and analgesia in the cardiac catheter laboratory.

DESIGN AND DATA SOURCES

An integrative review method was chosen for this study. MEDLINE and CINAHL databases as well as The Cochrane Database of Systematic Reviews and the Joanna Briggs Institute were searched. Nineteen research articles and three clinical guidelines were identified.

RESULTS

The authors of each study reported nurse-administered sedation in the CCL is safe due to the low incidence of complications. However, a higher percentage of deeply sedated patients were reported to experience complications than moderately sedated patients. To confound this issue, one clinical guideline permits deep sedation without an anaesthetist present, while others recommend against it. All clinical guidelines recommend nurses are educated about sedation concepts. Other findings focus on pain and discomfort and the cost-savings of nurse-administered sedation, which are associated with forgoing anaesthetic services.

CONCLUSIONS

Practice is varied due to limitations in the evidence and inconsistent clinical practice guidelines. Therefore, recommendations for research and practice have been made. Research topics include determining how and in which circumstances capnography can be used in the CCL, discerning the economic impact of sedation-related complications and developing a set of objectives for nursing education about sedation. For practice, if deep sedation is administered without an anaesthetist present, it is essential nurses are adequately trained and have access to vital equipment such as capnography to monitor ventilation because deeply sedated patients are more likely to experience complications related to sedation. These initiatives will go some way to ensuring patients receiving nurse-administered procedural sedation and analgesia for a procedure in the cardiac catheter laboratory are cared for using consistent, safe and evidence-based practices.

[Implantation of cardioverter-defibrillators. How much anesthesia is necessary?]

Updated cardiologic guidelines constitute the background for an extended spectrum of indications for the implantation of automatic implantable cardioverter defibrillators (AICDs) and lead to an increasing number of operative implantations of AICDs. Moreover, during implantation of devices for cardiac resynchronization therapy the anesthesiologist is responsible for the most critically ill patients with the longest duration of surgery. As a result anesthesiologists face an increasing number of critically ill patients, whose management contributes to perioperative outcome. Automatic implantable cardioverter defibrillators can be implanted either during general anesthesia, local anesthesia or during a combination of local anesthesia combined with deep conscious sedation accomplished by an anesthesiologist. Besides economic aspects there is an increasing demand for anesthesia with the least cardiovascular side effects and rapid recovery in the often seriously ill patient with preexisting limitations of cardiac and pulmonary functions. Accordingly procedure and anesthesia-associated risks are reviewed and an algorithm for anesthesia management is suggested.