Procedural sedation with propofol for emergency DC cardioversion

Abstract

Many emergency patients present with cardiac arrhythmias requiring emergency direct current countershock cardioversion (DCCV) as a part of their management. Almost all require sedation to facilitate the procedure. Propofol has been used for procedural sedation in Emergency Medicine since 1995. In 1996, in a review article in Anaesthesia, it was recommended as the drug which most closely approaches the ideal agent for DCCV. However, the existing evidence for the dosage requirements and safety of propofol in emergency DCCV is limited. We report a prospective case series of patients who underwent sedation-facilitated DCCV using propofol in the emergency department with both sedation and DCCV delivered by emergency physicians. The results indicate propofol is a safe drug for procedural sedation to facilitate emergency DCCV in patients with an atrial tachyarrhythmia without any evidence of haemodynamic compromise. A dose of 1 mg/kg appears to be safe in the majority of these patients. Using the adverse event reporting tool produced by the World SIVA International Sedation Task Force there were no moderate or sentinel adverse events in these patients. A reduced dose should be considered in older patients to prevent transient complications. Propofol at a dose of 0.5 mg/kg appears to be a safe drug for procedural sedation to facilitate emergent or urgent DCCV in patients with an atrial tachyarrhythmia with evidence of haemodynamic compromise. There were no sentinel adverse events associated with its use. Evidence to support the use of propofol to facilitate emergency DCCV for ventricular tachycardia is limited.

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

“…Moreover, as described above, while oxygen saturation and heart rate had a similar trend in both study groups, patients who received propofol experienced a more important drop in systolic blood pressure than in those in the midazolam group. This data con rm the effect of propofol as a peripheral vasodilator, therefore causing a greater impact on haemodynamic parameters [18].…”

Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta‐analysis

“…After screening the titles and abstracts and removing duplicates, we identified 465 potentially relevant studies. After full‐text review, 55 articles met inclusion criteria . Interobserver agreement (kappa) for phase II of the review was 0.99 (95% CI = 0.98 to 1.0).…”

“…The incidence was highest with the use of propofol (19.1 per 1,000 sedation, 95% CI = 12 to 26.3) and midazolam/opiate (15.4 per 1,000 sedations, 95% CI = 2.1 to 28.8). Figure shows the forest plot for hypotension …”

“…Forest plot of the proportion of patients experiencing hypotension, by medication. E = etomidate; K = ketamine; KP = ketamine/propofol; M = midazolam; MO = midazolam/opiate; P = propofol …”

Results from the Adverse Event Sedation Reporting Tool: A Global Anthology of 7952 Records Derived from >160,000 Procedural Sedation Encounters

“…The tool was intended to present a taxonomy of sedation outcomes which would be objective and reproducible. By adopting this taxonomy worldwide, particularly valuable in areas with neither organized sedation systems nor prior means of collecting and reporting their own outcomes, all sedation providers now have a means of tracking and sharing their outcomes through the AE sedation reporting tool database [26,29,31,[34][35][36]. This tool is a repository of sedation-related data inputted from all sedation providers worldwide and is a means to report on sedation demographics and outcomes, with the objective of presenting a hierarchical structure to predict the occurrence, risk, and outcome of adverse events ( Figure 1, Table 1, Table 2).…”