By 2020, traditional cardiovascular surgeries will make up a quarter of cardiac interventions worldwide, while interventional procedures such as catheterizations, ablation, and cardioversion therapy will make up the majority.([FOOTNOTE= Joshi B. Cardiovascular Surgical Devices: Technologies and Global Markets. BCC Research. 2016; Report ID: HLC076C. Retrieved April 13, 2017 from View Abstract.],[ANCHOR=],[LINK=https://www.bccresearch.com/market-research/healthcare/cardiovascular-surgical-devices-markets-report-hlc076c.html]) Monitoring sedation for the patients having these procedures will be key to keeping them safe and comfortable.
Over sedation can result in depressed respiration and certain sedation agents, used alone or with others, can increase the incidence of over sedation to 50 percent. Inadequate monitoring can delay the detection of depressed respiration.([FOOTNOTE=Pino RM. The nature of anesthesia and procedural sedation outside of the operating room. Curr Opin Anaesthesiol. 2007;(4):347-51.],[ANCHOR=],[LINK=])
Patients report minimal sedation as adequate during procedures such as diagnostic coronary angiography and percutaneous interventions. Patient comfort appears correlated to procedure type and length. In such cases, deeper sedation may be required.([FOOTNOTE=Beddoes L, Botti M, Duke MM. Patients' experiences of cardiology procedures using minimal conscious sedation. Heart Lung. 2008;37(3):196-204.],[ANCHOR=],[LINK=])
With capnography and pulse oximetry monitoring, clinicians have access to measurements that help them manage patient comfort levels and match sedation levels to procedures.
For high-risk patients with acute aortic valve stenosis, mortality rates with invasive cardiac surgery can be as high as 50%, but medical management on its own has a poor prognosis and balloon valvuloplasty has only moderate, short-lived success.([FOOTNOTE=Bergmann L, Kahlert P, Eggebrecht H, Frey U, Peters J, Kottenberg E. Transfemoral aortic valve implantation under sedation and monitored anaesthetic care – a feasibility study. Anesthesia. 2011;66(11):977-82.],[ANCHOR=],[LINK=])
Clinicians can employ monitored anesthesia care with transcatheter aortic valve replacement (T-AVR) to significantly improve patient outcomes.([FOOTNOTE=Ben-Dor I, Looser PM, Maluenda G, Weddington TC, Kambouris NG, Barbash IM, Hauville C, Okubagzi P, Corso PJ, Satler LF, Pichard AD, Waksman R. Transcatheter aortic valve replacement under monitored anesthesia care versus general anesthesia with intubation. Cardiovasc Revasc Med. 2012;13(4):207-10.],[ANCHOR=],[LINK=])
Arterial spasms can cause significant discomfort for the patient and procedural complications, including access site crossover and even procedural failure.([FOOTNOTE=Deftereos S, Giannopoulos G, Raisakis K, Hahalis G, Kaoukis A, Kossyvakis C, Avramides D, Pappas L, Panagopoulou V, Pyrgakis V, Alexopoulos D, Stefanadis C, Cleman MW. Moderate Procedural Sedation and Opioid Analgesia During Transradial Coronary Interventions to Prevent Spasm: A Prospective Randomized Study. JACC: Cardiovascular Interventions. 2013;6(3):267-73.],[ANCHOR=],[LINK=])
Clinicians can ease patient discomfort and improve procedural outcomes with a combination of sedatives and analgesics.6
Careful sedative selection, along with pulse oximetry and capnography monitoring, can help reduce respiratory depression and help identify it when it occurs.2
Minimal sedation has been proven to work for cardiac ablation procedures, which can be painful. Deep sedation — though it results in longer procedures — doesn’t result in more complications or sedation effects.([FOOTNOTE=Wutzler A, Mueller A, Loehr L, Huemer M, Parwani AS, Attanasio P, Blaschke F, Storm C, Boldt LH, Haverkamp W. Minimal and deep sedation during ablation of ventricular tachycardia. Int J Cardiol. 2014;172(1):161-4.],[ANCHOR=],[LINK=]) Patients have also reported satisfaction with deep sedation.7
T-AVR has resulted in significantly shorter procedure times and shorter ICU and hospital length of stay, while no significant difference was seen in three-month and one-year mortality rates.4,5
In one study, relatively mild doses of a sedative/analgesic drug combination appeared to lower the frequency of arterial spasms, as well as reduce side effects. Patients receiving the treatment reported significantly less discomfort than the control group.6
Anxiety can have harmful effects on compromised cardiovascular function by increasing heart rate and blood pressure. Anxiety may interfere with the patient's ability to cooperate during a procedure.([FOOTNOTE=Gallagher R, Trotter R, Donoghue J. Preprocedural Concerns and Anxiety Assessment in Patients Undergoing Coronary Angiography and Percutaneous Coronary Interventions. Eur J Cardiovasc Nurs. 2010;9(1):38-44.],[ANCHOR=],[LINK=]) Clinicians take patients' anxiety levels into account when determining appropriate sedatives and sedation levels.([FOOTNOTE=Buzatto LL, Zanei SSV. Patients' anxiety before cardiac catheterization. Einstein (Sao Paulo). 2010;8(4):483-487. doi: 10.1590/S1679-45082010RW1517.],[ANCHOR=],[LINK=])
To address sedation challenges, the British Cardiovascular Society recommends capnography as an element of safe sedation practice.([FOOTNOTE=Furniss SS, Sneyd JR. Safe sedation in modern cardiological practice. Heart. 2015;101(19):1526-1530. doi: 10.1136/heartjnl-2015-307656.],[ANCHOR=],[LINK=])
12. Guerra F, Pavoni I, Romandini A, et al. Feasibility of a cardiologist-only approach to sedation for electrical cardioversion of atrial fibrillation: a randomized, open-blinded, prospective study. Int J Cardiol. 2014;176(3):930-4.