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Rapid diagnostic and therapeutic developments in interventional cardiology over the past 15 years, especially in electrophysiology, have increased the demand for patient sedation. Relief of anxiety and pain and achievement of patient immobility are the main goals of sedation. Sedation is not only useful for making the procedure acceptable to the patient but also ensures a higher likelihood of procedural success. Successful ablation of persistent atrial fibrillation is related primarily to the skill and the patience of the electrophysiologist, but also to appropriate sedation of the patient maintained for a long time. The target level of sedation is often minimal or moderate (ie, conscious sedation), but, in a number of cases, deep sedation is reached. In this case, an identical level of care is required to that needed for general anaesthesia. The major issue is to provide safe sedation (ie, sedation with a very low risk of life-threatening complications), and in each situation to achieve the fine balance between under-sedation and over-sedation. Owing to differences in both the techniques used and the clinical settings in the published literature, the quantification of risk, to define what is safe, remains difficult. The main debate on safety now centres on who should be in charge of the sedation. Looking at the differences in practice between countries and specialties, the answer is far from simple. Approximately four organisational models are available:
The classical medical model, with the anaesthetist delivering sedation/anaesthesia and the doctor performing the procedure, but which is challenged by the limited availability of anaesthetists.
The doctor/nurse model, with a nurse sedationist under (or not) the direct supervision of the anaesthetist and the doctor performing the procedure.
The operator model, with either one operator in charge of both the sedation and the procedure (developed by gastroenterologists); or two operators, one in charge of the sedation, the other the procedure.
The nurse model, in which nurses are in charge of both procedures (ie, electrical cardioversion) and sedation.
Irrespective of the educational background, the doctor or the nurse who delivers the sedation must have undergone appropriate training, both in the technique and in patient rescue from a sedation-related adverse event.
The limited availability of anaesthetists and the search for more cost-effective care in a period of increasing activity are the main drivers for developing new strategies. While national academic cardiac societies produce recommendations regarding the facilities used and operator competencies,1 they rarely offer guidance on sedation.2 The Heart review on safe sedation in interventional cardiology is written by Stephen S Furniss, a cardiologist and expert in electrophysiology, on behalf of the British Heart Rhythm Society, together with J Robert Sneyd, an anaesthetist and chair of the UK Academy of Medical Royal Colleges.3 This review follows the publication of the Academy of Medical Royal College Report on safe sedation4 and addresses the main issues concerning sedation in interventional cardiology, especially electrophysiology. Fundamental standards of sedation in the electrophysiology cath-lab are clearly described, which follow the Academy recommendations. Appropriate characteristics in sedation during atrial fibrillation ablation, device implantation or extraction, and electrical cardioversion are summarised. The increasing role of the nurse sedationist is developed, as well as emerging trends such as non-anaesthetist administration of propofol. Although not fully detailed, guidance for the practice of sedation in our subspecialty is provided for the UK and is proposed for others. This paper is important not only for interventional cardiologists but also for all parties involved in care organisation, from health authorities to local committees. It strongly suggests collaborative work to define the best strategies according to national or local resources and a need for continuous evaluation of the quality of sedation and safety. The time has come to develop large registries to address unresolved issues and to produce international recommendations on sedation in interventional cardiology. The review by Furniss and Sneyd should contribute greatly to this fast-moving field, leading to an expected standardisation of care and improvement in quality of sedation.
Provenance and peer review Commissioned; internally peer reviewed.