cardioversion 시 pain control, sedative & analgesic agent

 

 

wikipedia

 

 

 

Electrical cardioversion : 심장 박동이 불규칙한 환자에서 normal sinus rhythm으로 회복시키는데 효과적인 시술임

** 이 때, 환자가 시술을 인식하지 못하게 적절한 약제가 필요함

⇛ rapid onset & short duration & less ADR(cardiovascular or respiratory)

 

 

Cardioversion의 적응증

• Emergency DC cardioversion is indicated for any broad or narrow QRS complex tachyarrhythmia that causes haemodynamic decompensation. Usually this represents heart rates in excess of 150 bpm associated with clinical shock, reduced conscious level, angina or heart failure.
• Relatively urgent cardioversion is indicated for supra ventricular tachycardias (SVTs) and monomorphic ventricular tachycardias that have not responded to a trial of i.v. medical therapy.
• Routine cardioversion is still frequently indicated in the management of atrial fibrillation (AF) when a rhythm rather than rate control strategy is employed. Indications for a rhythm strategy include a reversible cause of the AF, heart failure primarily caused by the AF, new onset AF and situations where a rhythm control strategy is considered more suitable based on the clinical judgement of the attending physician. Numbers attributable to this last indication appear to be increasing probably due to the perception of better symptomatic control in active patients and the increasing popularity of interventional procedures such as percutaneous pulmonary vein isolation. Initial success rates of 90% can be expected following cardioversion, but unfortunately relapse is a common problem.

 

Cardioversion의 금기

• Digitalis toxicity and associated tachycardia. This is due to the high risk of provoking refractory ventricular arrhythmias and fibrillation.
• Stable atrial fibrillation of  > 48 h duration without anticoagulation or TOE exclusion of atrial thrombus. This is due to the risk of thromboembolism and stroke.

TOE : transoesophageal echocardiogram(TOE)

 

Energy level

• 기계마다 권장하는 특정 에너지 수치를 권장
• 일반적으로 biphasic shocks은 monophasic defibrillator 에너지의 절반임

AF	초기 120-150 J → 200 J
Atrial Flutter & paroxysmal SVT	70–120 J

 

주의 사항(procedure management)

• ACEI나 ARB를 cardioversion 예정 2일 전 중단 (evidence는 낮지만 진정/진통약제 투여 이후 생길 수 있는 저혈압 위험 때문에)
• Digoxin 투여 중단 (therapeutic range라면 금기는 아님)

 

현재 이용 가능한 진정제

1. Traditional anaesthetic induction agents: propofol, etomidate, and thiopentone.
2. Inhalational anaesthetic agents: sevoflurane and isoflurane.
3. Drugs classified as sedative agents: diazepam and midazolam.

- 위의 약제들간의 일관된 차이는 없기때문에 현재 관행을 변경할 필요가 없다고 결론 지음

- etomidate는 혈역학적으로 불안정한 환자에게 도움이 될 수 있음

성분명	Regimen[1]
Propofol	0.5-1.5 mg/kg iv over 20-30 sec → *0.25-0.5 mg/kg at 1-min intervals Propofol (0.5 mg/kg iv over 15 seconds) + remifentanil (0.75 μg/kg over 90seconds
Etomidate	0.15-0.2 mg/kg iv over 20-30 sec → *0.05 mg/kg at 1-min intervals Etomidate (0.1 mg/kg iv over 15 seconds) + remifentanil (0.75 μg/kg over 90seconds
Thiopental	3 mg/kg iv over 30 sec
Midazolam	0.15-0.2 mg/kg iv over 20-30 sec → *0.05 mg/kg, at 1-min intervals

* supplemental dose(3-5분 뒤 적절한 induction 유도 실패 시)

 

진통제(controversial)

• Cardioversion is an intensely painful and stimulating procedure, but patients rarely experience pain following the procedure. The coadministration of opioids is therefore unnecessary and potentially increases the risk of apnoea and post procedural nausea and vomiting. ⇛ opioid 진통제는 추천되지 않음
• 2015 AHA electrical cardioversion algorithm과 reference[2]의 경우 opioid의 사용을 권고(?)하고 있음 ; 반드시 필요하진 않지만 전문가들은 같이 사용하는 것을 추천함
• opioid 중 morphine은 STEMI 등의 심근경색 시 1st line analgesic agent임

 

https://www.physio-control.com/uploadedFiles/Physio85/Contents/Podcast/e3/2015%20AHA%20Physio%20Adult%20ALS%20poster.pdf

 

 

 

reference :

(1) Lewis, Sharon R., et al. "Anaesthetic and sedative agents used for electrical cardioversion." Cochrane Database of Systematic Reviews 3 (2015).

(2) Knowles, Patrick R., and Chris Press. "Anaesthesia for cardioversion." Bja Education 17.5 (2017): 166-171.