title: Conscious sedation with combined hypnotic agents for implantation of implantable cardioverter-defibrillators.
abstract: OBJECTIVE
  The objective of this study was to evaluate the feasibility, safety and efficacy of placing implantable cardioverter-defibrillators (ICDs) in the electrophysiology laboratory using conscious sedation with combined hypnotic agents and deep sedation with etomidate.
  
  
  BACKGROUND
  Implantable cardioverter-defibrillators with transvenous leads permit the use of simplified implantation techniques similar to those used for the insertion of permanent pacemakers. However, implantation of ICDs without general anesthesia has thus far gained limited acceptance.
  
  
  METHODS
  In 162 patients, conscious sedation during ICD placement was achieved with combined intravenous midazolam, morphine and promethazine (Phenergan). Intravenous etomidate was administered to induce deep sedation for defibrillation threshold testing. First-time implantations were in the prepectoral position (n = 142), but some patients with preexisting devices received abdominal implants (n = 20). The results were compared with those of concurrent patients (n = 56) who received prepectoral implants under propofol anesthesia administered by an attending anesthesiologist.
  
  
  RESULTS
  The anesthetic protocol was implemented without major intraoperative complications. During deep sedation with etomidate, episodes of apnea, hypoxia or arterial hypotension requiring therapeutic intervention did not occur. During a mean (+/-SD) follow-up period of 257 +/- 140 days (median 227, range 14 to 482), there were, among the 162 patients, a total of two nonsudden cardiac deaths-one 71 days and the other 157 days after the operation. There were two nonsudden deaths in the concurrent control subjects (n = 56)-one 13 days and the other 110 days after the operation.
  
  
  CONCLUSIONS
  Implantation of ICDs under conscious sedation with combined hypnotic agents and deep sedation with etomidate is a safe and effective procedure with low perioperative morbidity and low long-term complication rates.
authors.affiliation: Texas Arrhythmia Institute, Houston 77030, USA. A.Pacifico@tmh.tmc.edu
authors.forename: A
authors.initials: A
authors.lastname: Pacifico
authors.forename: F R
authors.initials: FR
authors.lastname: Cedillo-Salazar
authors.forename: N
authors.initials: N
authors.lastname: Nasir
authors.forename: T K
authors.initials: TK
authors.lastname: Doyle
authors.forename: P D
authors.initials: PD
authors.lastname: Henry
mesh_terms: D000368:Aged; D018686:Anesthetics, Intravenous; D016292:Procedural Sedation; D017147:Defibrillators, Implantable; D005045:Etomidate; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives; D008297:Male; D008875:Middle Aged; D011398:Promethazine; D015742:Propofol; D011446:Prospective Studies
chemical_list: D018686:Anesthetics, Intravenous; D006993:Hypnotics and Sedatives; D011398:Promethazine; D015742:Propofol; D005045:Etomidate