1. Propofol at a dose of 1 mg/kg for hemodynamically stable patients and 0.5mg/kg in hemodynamically unstable patients appears to be a safe drug for procedural sedation in DC cardioversion of atrial tachyarrhythmias.
2. Propofol’s use in the cardioversion of ventricular tachyarrhythmias remains unknown.
Evidence Rating Level: 2 (Good)
Study Rundown: Propofol has been used in procedural sedation since the 1980s, though its use in Emergency Medicine did not pick up until the 1990s. Since that time, several studies have provided unclear conclusions on the drug’s optimal dosing as well as safety in hemodynamically stable patients. The drug provides several benefits, including short onset and duration of action, over midazolam – the current gold standard for procedural sedation. This study demonstrated that propofol appears to be a safe drug for procedural sedation in DC cardioversion for atrial tachyarrythmias in hemodynamically stable patients and, at a reduced dose, for hemodynamically unstable patients. The evidence for propofol’s use in ventricular tachyarryhthmias remains limited by small numbers, and warrants further investigation through a large and randomized trial that compares propofol with midazolam head-to-head.
In-Depth [prospective study]: This study enrolled 111 patients requiring emergency direct current cardioversion (DCCV) for new onset atrial or ventricular tachyarrhythmia between 2010 and 2013. Patients were evaluated for hemodynamic compromise (defined by associated shock, myocardial ischemia, syncope or heart failure) and initially treated with antiarrhythmic drugs at the attending physician’s discretion. They then underwent pre-oxygenation, were sedated with propofol (1mg/kg if less than 80 years old, 0.5mg/kg if older than 80 years old), and all complications were recorded and reviewed. One hundred patients presented with atrial tachyarrythmias, of whom 77% were hemodynamically stable. Cardioversion was successful in 98% of these patients and 2% of procedures experienced complications – hypotension which responded to crystalloid bolus, only in the hemodynamically compromised group. Of the 11 patients with ventricular tachyarrythmias, 55% were hemodynamically stable and 27% of procedures experienced complications.
By Elizabeth Kersten and Andrew Bishara
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