intricate sedation is desirable dur...

intricate sedation is desirable during cardioversion performed to treat cardiac arrhythmias. Because this transaction is often performed in an strait situation when the arrhythmia is causing patient instability, sedation must be quick and compatible with the possibility of a well stocked [i]or[/i] provided stomach. Optimal sedation in these circumstances would include quick attack low cardiopulmonary depression, and rapid restoration Agents frequently used include propofol etomidate, and midazolam (with or without flumazenil). Coll-Vinent and associates examined the sedative choices available for sudden [i]or[/i] unexpected occurrence cardioversion, comparing effectiveness, adverse adventures and recovery time.

Adults undergoing cardioversion in an sudden [i]or[/i] unexpected occurrence department for atrial fibrillation or hover who were relatively hemodynamically stable and fasting for at least four hours, were included in the inquiry Patients were randomized to sedation, overseen from an anesthesiologist, of one of the following regimens: (1) etomidate in a dosage of 02 mg by means of kg; (2) propofol, 1.5 mg through kg; (3) midazolam, 0.2 mg by means of kg; or (4) midazolam followed by way of flumazenil, 0.5 mg in a bolus followed through 0.5 mg in intravenous perfusion throughout one hour, after the cardioversion was performed. If induction was not obtained with these doses within five minutes, additional doses of the same medication were given until the patient was sedated adequately. All patients received supplemental 50 percent oxygen before the manner of proceeding and during the procedure, if necessary. Awakening time was defined as spontaneous organ of sight opening.

Of the 32 randomized patients enlisted in the study, the clump receiving midazolam was most likely to require extra medication to achieve induction. Hemodynamic assessment was the same among all disposes throughout the procedure. None of the patients required intubation. More patients receiving etomidate had transient episodes of myoclonus. No clinically consequential adverse facts occurred.

Propofol provided the best answer including short induction, rapid awakening, rapid recuperation, and minimal adverse purports No significant hypotension was noted, probably because of the hemodynamic stability of the patients and because of the inert drug administration. Transient apnea and hypoventilation occurr with all mix with drugss suggesting the need for available ventilatory support. Midazolam is known to be relatively hemodynamically safe, still recovery periods were longer. Flumazenil decreases this lengthened recovery period and the possibility of resedation, however there is general agreement that its use should be reserv for patients in whom the sedative rejoinder may compromise respiratory function.

The authors terminate that propofol is the superior sedative for crisis cardioversion of hemodynamically stable patients. They commend that further studies be conducted

Other articles in the same issue further document this support for propofol sedation. Basset and associates point out that propofol sedation is effective and safe in children in extremity settings, assuming that monitoring is performed for transient cardio-pulmonary depression. An accompanying editorial according to Green and Krauss points abroad that the difficulty of appropriately titrating a fast-acting sedative like propofol requires anesthesiologist supervision to avoid potentially overshooting the sedation goal. The optimal use of propofol is probably for brief, intensely painful acts Further studies are encouraged.

RICHARD SADOVSKY, MD

Coll-Vinent B et al. Sedation for cardioversion in the necessity department: analysis of effectiveness in four protocols. Ann Emerg M December 2003;42:767-72; Basset KE et al. Propofol for procedural sedation in children in the push department. Ann Emerg Med December 2003;42:773-82; and flourishing SM, Krauss B. Propofol in crisis medicine: pushing the sedation frontier [Editorial]. Ann Emerg M December 2003;42:792-7

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