title: Evaluation of the safety and efficacy of deep sedation for electrophysiology procedures administered in the absence of an anesthetist.
abstract: Several procedures performed in the electrophysiology laboratory (EP lab) require surgical manipulation and are lengthy. Patients undergoing such procedures usually receive general anesthesia or deep sedation administered by an anesthesiologist. In 536 consecutive procedures performed in the EP lab, we assessed the safety and efficacy of deep sedation administered under the direction of an electrophysiologist and in the absence of an anesthetist. Patients were monitored with pulse oximetry, noninvasive blood pressure recordings, and continuous ECGs. The level of consciousness and vital signs were evaluated at 5-minute intervals. Deep sedation was induced in 260 patients using midazolam, phenergan, and meperidine, then maintained with intermittent dosing of meperidine at the following mean doses: midazolam 0.031 +/- 0.024 mg/kg; phenergan 0.314 +/- 0.179 mg/kg; and meperidine 0.391 +/- 0.167 mg/kg per hour. In the remaining 276 patients, deep sedation was induced with midazolam and fentanyl and maintained with a continuous infusion of fentanyl at a mean dose of 2.054 +/- 1.43 micrograms/kg per hour. Fourteen patients experienced a transient reduction in oxygen saturation that was readily reversed following administration of naloxone. An additional 11 patients desaturated secondary to partial airway obstruction, which resolved after repositioning the head and neck. Fourteen patients experienced hypotension with fentanyl. All but one returned to baseline blood pressures following an infusion of normal saline. No patient required intubation and no death occurred. Only three patients had recollection of periprocedure events. No patient remembered experiencing pain with the procedure. Hospital stays were not prolonged as a result of the sedation used.
  
  
  CONCLUSIONS
  (1) deep sedation during EP procedures can be administered safely under the guidance of the electrophysiologist without an anesthetist present; (2) the drugs used should be readily reversible in case of respiratory depression; and (3) this approach may reduce the overall cost of the procedures in the EP lab, maintaining adequate patient comfort.
authors.affiliation: VA Medical Center/Duke University, Durham, North Carolina, USA.
authors.forename: M J
authors.initials: MJ
authors.lastname: Geiger
authors.forename: A
authors.initials: A
authors.lastname: Wase
authors.forename: M M
authors.initials: MM
authors.lastname: Kearney
authors.forename: M J
authors.initials: MJ
authors.lastname: Brandon
authors.forename: V
authors.initials: V
authors.lastname: Kent
authors.forename: K H
authors.initials: KH
authors.lastname: Newby
authors.forename: A
authors.initials: A
authors.lastname: Natale
mesh_terms: D000759:Adjuvants, Anesthesia / Q000008:administration & dosage; D000402:Airway Obstruction / Q000150:complications; D000771:Anesthesia, Intravenous / Q000191:economics; D000776:Anesthesiology; D018686:Anesthetics, Intravenous / Q000008:administration & dosage / Q000009:adverse effects; D001794:Blood Pressure / Q000187:drug effects; D003243:Consciousness / Q000187:drug effects; D003363:Cost Control; D004562:Electrocardiography / Q000187:drug effects; D004594:Electrophysiology / Q000191:economics; D005069:Evaluation Studies as Topic; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage / Q000009:adverse effects; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage* / Q000191:economics; D007022:Hypotension / Q000139:chemically induced; D007753:Laboratories / Q000191:economics; D007902:Length of Stay; D008297:Male; D008568:Memory / Q000187:drug effects; D008614:Meperidine / Q000008:administration & dosage; D008874:Midazolam / Q000008:administration & dosage; D008875:Middle Aged; D008991:Monitoring, Physiologic; D009270:Naloxone / Q000627:therapeutic use; D009292:Narcotic Antagonists / Q000627:therapeutic use; D010092:Oximetry; D010100:Oxygen / Q000097:blood; D011398:Promethazine / Q000008:administration & dosage; D012449:Safety
chemical_list: D000759:Adjuvants, Anesthesia; D018686:Anesthetics, Intravenous; D006993:Hypnotics and Sedatives; D009292:Narcotic Antagonists; D009270:Naloxone; D008614:Meperidine; D011398:Promethazine; D008874:Midazolam; D010100:Oxygen; D005283:Fentanyl