Emergency department procedural sedation for primary electrical cardioversion — a comparison with procedural sedations for other reasons

doi:10.5847/wjem.j.1920-8642.2017.03.001

Abstract

Abstract:

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia treated in the emergency department (ED), with primary electrical cardioversion (PEC) the preferred method of rhythm control. Anecdotally, patients undergoing ED procedural sedation (EDPS) for PEC differ from those requiring EDPS for other procedures: they are at higher risk of adverse events, and require fewer drugs and lower doses. We attempt to verify this using an EDPS registry at a Canadian, tertiary care teaching hospital.

METHODS: This is a retrospective review of patients that underwent EDPS for the period of June 2006 to September 2014. We compared demographics, medication use and intra-procedural adverse events between those receiving EDPS for PEC for AF compared to that for other indications. We report the asssociation between AEs and predictors using logistic regression.

RESULTS: A total of 4 867 patients were included, 714 for PEC for AF and 4 153 for other indications. PEC patients were more likely male (58.5% vs. 47.1%), older (59.5 years vs. 48.1 years), and less likely to be ASA I (46.6% vs. 69.0%). PEC patients received smaller doses of propofol and less likely to receive adjuvant analgesic therapy (11.5% vs. 78.2%). PEC patients were more likely to experience hypotension (27.6% vs. 16.5%) but respiratory AEs (apnea, hypoxia and airway intervention) were not different.

CONCLUSION: EDPS for PEC differs from that conducted for other purposes: patients tend to be less healthy, receive smaller doses of medication and more likely to suffer hypotension without an increase in respiratory AEs. These factors should be considered when performing EDPS.

Key words: Procedural sedation, Atrial fibrillation, Electrical cardioversion

Michael Butler, Patrick Froese, Peter Zed, George Kovacs, Robert MacKinley, Kirk Magee, Mary-Lynn Watson, Samuel G. Campbell. Emergency department procedural sedation for primary electrical cardioversion — a comparison with procedural sedations for other reasons[J]. World Journal of Emergency Medicine, 2017, 8(3): 165-169.

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Demographics	PEC (n=714)	Non-PEC (n=4 153)	P value
Age (mean±SD)	59.5±13.5	48.1±25.9	<0.001
Gender (male), n (%)	418 (58.5)	1 955 (47.1)	<0.001
ASA, n (%)			<0.001
I	333 (46.6)	2 865 (69.0)
II	319 (44.7)	1 052 (25.3)
III	51 (7.1)	161 (3.9)
IV	10 (1.4)	74 (1.8)
V	1 (0.1)	0 (0.0)
Patient opinion, n (%)			<0.001
Very satisfied	124 (17.4)	657 (15.8)
Satisfied	73 (10.2)	676 (16.3)
No recollection/neutral	464 (65.0)	2 448 (58.9)
Unpleasant	3 (0.4)	23 (0.5)
Very unpleasant	5 (0.7)	46 (1.1)
Unrecorded	45 (6.3)	303 (7.3)
Propofol dose (mg)	96.6±49.7	153.6±123.3	<0.001
Fentanyl dose (μg)¹	80.1±33.2	86.6±42.3	0.020
Without fentanyl, n (%)	558 (78.2)	478 (11.5)	<0.001

Adverse events	PEC (n=714)	Non-PEC (n=4 153)	P value
Hypotension¹	197 (27.6)	684 (16.5)	<0.001
Hypoxia	10 (1.4)	90 (2.2)	0.233
Apnea	6 (0.8)	36 (0.9)	>0.99
Airway intervention²	174 (24.4)	903 (21.7)	0.130

Outcomes	Crude OR (95%CI)	Adjusted OR (95%CI)	P value
Hypotension¹	1.93 (1.61-2.32)	2.21 (1.78-2.74)	<0.001
Hypoxia	0.64 (0.33-1.24)	0.60 (0.29-1.22)	0.160
Apnea	0.97 (0.41-2.33)	0.75 (0.29-1.96)	0.563
Airway maneuver²	1.16 (0.96-1.39)	1.32 (1.06-1.64)	0.011

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