Cardioversion

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Cardioversion
Anesthesia type

Sedation (MAC)

Airway

Natural Airway

Lines and access

PIV

Monitors

Standard ASA monitors

Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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Electrical cardioversion is a procedure used for the management of cardiac arrhythmias. Cardioversion is the delivery of an electrical shock that is synchronized with the QRS complex[1]. It is used to convert arrhythmias, including atrial fibrillation and flutter, back to sinus rhythm. These procedures typically require a brief period of sedation and amnesia during which the shock is delivered[2][3]. This article will discuss elective cardioversion in the hemodynamically stable patient.

Preoperative management

Patient evaluation

System Considerations
Neurologic Standard evaluation, these patients are at increased risk for stroke and should have close neural monitoring after procedure.
Cardiovascular EKG to assess and confirm arrhythmia prior to procedure is required and post-procedure to assess procedural success. Recent echocardiography can be helpful to assess cardiac function and any valvular disease.
Pulmonary Patient maintains natural airway but may have some suppression due to sedative agents.
Gastrointestinal NPO for at least 6 hours prior to procedure.
Hematologic The anticoagulation status of these patients needs to be assessed. For patients with atrial fibrillation, unless the onset of atrial fibrillation is between 0-48 hours, anticoagulation status must be confirmed[2][3][4]. This includes:
  • On warfarin: INR >2.0 for last 4 weeks
  • On non-warfarin oral anticoagulants: no missed doses for last 4 weeks
  • Perform TEE if either of these is not confirmed and documented OR history of atrial thrombus
Renal A BMP with urea and electrolytes is often obtained to rule out causes of arrhythmia, but is not necessary prior to procedure[1][5][6].
Endocrine Thyroid function tests should be performed prior to cardioversion as thyroid dysfunction can case atrial fibrillation[4][6].
Other The electrical shock of the cardioversion will often cause activation of skeletal muscles causing movement of arms and thorax during the procedure. These patients should have padding placed between the extremities and any hard railings/surfaces[1].

Labs and studies

Coagulation studies with PT and INR are required to confirm anticoagulation. Transesophageal echocardiogram may be required prior to cardioversion for patients with history of atrial thrombus, unknown onset of arrhythmia or arrhythmia onset >48 hours without therapeutic anticoagulation (.e.g. INR <2.0 on warfarin or missed doses of non-warfarin oral anticoagulants in the last 4 weeks)[1][3][4].

Operating room setup

This procedure is not typically performed in the OR, so the anesthesia provider will not often have access to an anesthesia machine. The provider should ensure access to supplemental oxygen via nasal cannula or face mask to administer prior to and during administration of anesthetics[1][4][7].

The anesthesia provider should ensure access to the standard ASA monitors, suction, emergency airway supplies including ETT, blade and bag-mask ventilation, a code cart, supplemental oxygen and IV access[2][4][7].

Patient preparation and premedication

No medications are required before cardioversion, but for patients with high anxiety, small doses of a benzodiazepine like midazolam can be used.

Intraoperative management

Monitoring and access

  • Peripheral IV x 1
  • Standard ASA monitors with 12 lead ECG prior to procedure
  • Transcutaneous pads are placed on the patient for the procedure and may be use for defibrillation and/or pacing if needed after the procedure.

Induction and airway management

Induction

  • Propofol in small doses, 10-50mg increments, titrated until loss of response to verbal commands and loss of eyelash reflex[1][2][4][7].
  • Other agents such as etomidate, midazolam, ketamine, thiopentone and combinations can also be used, but there is currently no evidence for superiority of one drug or combination over the other. Propofol is generally preferred due to its fast onset and offset without prolonged recovery if the procedure should take longer than expected.[4][8]

Airway Management

  • Patients should be fully pre-oxygenated for at least 3 minutes prior to induction[4]. This allows for more time prior to desaturation in the case of any airway issues or apnea[9][10].
  • The patient maintains a natural airway but advanced airway supplies should be present.

Positioning

  • Supine with transcutaneous pads placed on chest for procedure.
  • Any metal piercings, underwire bras, belts, transdermal patches, etc. should be removed prior to procedure.
  • Padding should be placed between arms and legs and any hard surfaces such as bed railings as the shock delivered can cause activation of skeletal muscle.[1]
  • A bite block may be placed but is not necessary.

Maintenance and surgical considerations

Cardioversion is a very brief procedure that usually only lasts for a few seconds. The anesthetic goal is to produce deep sedation with loss of consciousness and amnesia, while avoiding apnea and the need for assistive ventilation[4][11]. This allows the procedure to be performed 1-2 times.

During the actual delivery of electrical shock, the literature recommends removal of any oxygen delivery device, in particular a mask, to minimize fire risk[3][4]. In practice, however, many providers keep a nasal cannula on with low flow oxygen without issue.

Advanced airway equipment should be available including bag-mask ventilation, LMA, laryngoscope and ETT should be available[1][4][7].

Emergence

After the procedure is completed, ventilatory assistance with temporary bag-mask ventilation may be required as the patient emerges from anesthesia, but the need for endotracheal intubation is rare[2][3][4][7][11].

Postoperative management

Disposition

Patients can go home the same day after a short stay in the PACU where they receive a 12-lead EKG. More complex patients with other cardiac disease or new-onset atrial fibrillation may be kept in the hospital overnight on telemetry for monitoring on the cardiac unit[1][3].

Pain management

Non-opioid pain medicine such as acetaminophen or ibuprofen may be used but is not always required.

Potential complications

  • Thromboembolism: These patients are at increased risk for thromboembolism, very often stroke, after sinus rhythm is restored, typically within the first 10 days[12][13][14]. There is also a risk of return to atrial fibrillation within the first month of cardioversion[15][16]. These patients are therefore typically initiated on anticoagulation prior to the procedure and kept on anticoagulation after for at least a month or longer depending on the patients’ CHA₂DS₂-VASc score.
  • Arrhythmias: Arrhythmias are commonly seen after cardioversion. Most often these are transient benign tachyarrhythmias such as SVT or non-sustained VT, but occasionally they can be hemodynamically significant[17][18].
  • EKG changes: Transient EKG changes including ST segment and T wave abnormalities are common after cardioversion[18][19][20][21][22]. These changes are short-lasting and cannot be used as the sole criteria for identifying an acute ischemic event.
  • Myocardial necrosis: Myocardial necrosis, typically small amounts of the epicardium, can occur and be seen as a small increase in CK or troponins after cardioversion. A large increase in CK or troponin or the development of anginal chest pain should raise suspicion for an acute ischemic event.
  • Myocardial dysfunction: Transient myocardial dysfunction can occur, including stunning of the ventricular and/or atrial tissue[23].
  • Pulmonary edema: Pulmonary edema is very rare complication, more often seen in patients with significant valvular disease.
  • Hypotension: Transient hypotension can occur and patients do not usually need treatment.
  • Burns: Cutaneous burns occur in 20-25% of patients, usually due to improper pad placement or technique[24]. This can be managed with steroid creams, topical NSAIDs and sulfur sulfadiazine cream[25][26].

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Knight, BP (2023). "Cardioversion for specific arrhythmias". www.uptodate.com. Retrieved 2023-05-20.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Stoneham, M. D. (1996-06). "Anaesthesia for cardioversion". Anaesthesia. 51 (6): 565–570. doi:10.1111/j.1365-2044.1996.tb12566.x. ISSN 0003-2409. Check date values in: |date= (help)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Sucu, Murat; Davutoglu, Vedat; Ozer, Orhan (2009). "Electrical cardioversion". Annals of Saudi Medicine. 29 (3): 201–206. doi:10.4103/0256-4947.51775. ISSN 0256-4947. PMC 2813644. PMID 19448376.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 Knowles, Patrick R.; Press, Chris (2017-05). "Anaesthesia for cardioversion". BJA Education. 17 (5): 166–171. doi:10.1093/bjaed/mkw055. Check date values in: |date= (help)
  5. ↑ European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery; Camm, A. John; Kirchhof, Paulus; Lip, Gregory Y. H.; Schotten, Ulrich; Savelieva, Irene; Ernst, Sabine; Van Gelder, Isabelle C.; Al-Attar, Nawwar; Hindricks, Gerhard (2010-10). "Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC)". European Heart Journal. 31 (19): 2369–2429. doi:10.1093/eurheartj/ehq278. ISSN 1522-9645. PMID 20802247. Check date values in: |date= (help)
  6. ↑ 6.0 6.1 Krahn, A. D.; Klein, G. J.; Kerr, C. R.; Boone, J.; Sheldon, R.; Green, M.; Talajic, M.; Wang, X.; Connolly, S. (1996-10-28). "How useful is thyroid function testing in patients with recent-onset atrial fibrillation? The Canadian Registry of Atrial Fibrillation Investigators". Archives of Internal Medicine. 156 (19): 2221–2224. ISSN 0003-9926. PMID 8885821.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Azizad, O; Joshi, GP (2023). "Considerations for non-operating room anesthesia (NORA) - UpToDate". www.uptodate.com. Retrieved 2023-05-20.
  8. ↑ Lewis, Sharon R; Nicholson, Amanda; Reed, Stephanie S; Kenth, Johnny J; Alderson, Phil; Smith, Andrew F (2015-03-24). Cochrane Emergency and Critical Care Group (ed.). "Anaesthetic and sedative agents used for electrical cardioversion". Cochrane Database of Systematic Reviews. 2019 (1). doi:10.1002/14651858.CD010824.pub2. PMC 6353050. PMID 25803543.CS1 maint: PMC format (link)
  9. ↑ Bhatia, P. K.; Bhandari, S. C.; Tulsiani, K. L.; Kumar, Y. (1997-02). "End‐tidal oxygraphy and safe duration of apnoea in young adults and elderly patients". Anaesthesia. 52 (2): 175–178. doi:10.1111/j.1365-2044.1997.14-az016.x. ISSN 0003-2409. Check date values in: |date= (help)
  10. ↑ Valentine, Stephen J.; Marjot, Robert; Monk, Christopher R. (1990-11). "Preoxygenation in the Elderly: A Comparison of the Four-Maximal-Breath and Three-Minute Techniques". Anesthesia & Analgesia. 71 (5): 516???519. doi:10.1213/00000539-199011000-00011. ISSN 0003-2999. Check date values in: |date= (help)
  11. ↑ 11.0 11.1 Miller, RD; Pardo, MC (2011). Basics of Anesthesia. Pittsburgh, PA: Elsevier Saunders. pp. 626–627.
  12. ↑ Flaker, Greg; Lopes, Renato D.; Al-Khatib, Sana M.; Hermosillo, Antonio G.; Hohnloser, Stefan H.; Tinga, Brian; Zhu, Jun; Mohan, Puneet; Garcia, David; Bartunek, Jozef; Vinereanu, Dragos (2014-03). "Efficacy and Safety of Apixaban in Patients After Cardioversion for Atrial Fibrillation". Journal of the American College of Cardiology. 63 (11): 1082–1087. doi:10.1016/j.jacc.2013.09.062. Check date values in: |date= (help)
  13. ↑ Berger, Marvin; Schweitzer, Paul (1998-12). "Timing of thromboembolic events after electical cardioversion of atrial fibrillation or flutter: a retrospective analysis". The American Journal of Cardiology. 82 (12): 1545–1547. doi:10.1016/S0002-9149(98)00704-8. Check date values in: |date= (help)
  14. ↑ Nagarakanti, Rangadham; Ezekowitz, Michael D.; Oldgren, Jonas; Yang, Sean; Chernick, Michael; Aikens, Timothy H.; Flaker, Greg; Brugada, Josep; Kamenský, Gabriel; Parekh, Amit; Reilly, Paul A. (2011-01-18). "Dabigatran Versus Warfarin in Patients With Atrial Fibrillation: An Analysis of Patients Undergoing Cardioversion". Circulation. 123 (2): 131–136. doi:10.1161/CIRCULATIONAHA.110.977546. ISSN 0009-7322.
  15. ↑ Page, R L; Wilkinson, W E; Clair, W K; McCarthy, E A; Pritchett, E L (1994-01). "Asymptomatic arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia". Circulation. 89 (1): 224–227. doi:10.1161/01.CIR.89.1.224. ISSN 0009-7322. Check date values in: |date= (help)
  16. ↑ Israel, Carsten W; Grönefeld, Gerian; Ehrlich, Joachim R; Li, Yi-Gang; Hohnloser, Stefan H (2004-01). "Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device". Journal of the American College of Cardiology. 43 (1): 47–52. doi:10.1016/j.jacc.2003.08.027. Check date values in: |date= (help)
  17. ↑ Waldecker, Bernd; Brugada, Pedro; Zehender, Manfred; Stevenson, William; Wellens, Hein J.J. (1986-01). "Dysrhythmias after direct-current cardioversion". The American Journal of Cardiology. 57 (1): 120–123. doi:10.1016/0002-9149(86)90963-X. Check date values in: |date= (help)
  18. ↑ 18.0 18.1 Eysmann, S B; Marchlinski, F E; Buxton, A E; Josephson, M E (1986-01). "Electrocardiographic changes after cardioversion of ventricular arrhythmias". Circulation. 73 (1): 73–81. doi:10.1161/01.CIR.73.1.73. ISSN 0009-7322. Check date values in: |date= (help)
  19. ↑ Kok, Lai-Chow; Mitchell, Mark A; Haines, David E; Mounsey, J.Paul; DiMarco, John P (2000-04). "Transient ST elevation after transthoracic cardioversion in patients with hemodynamically unstable ventricular tachyarrhythmia". The American Journal of Cardiology. 85 (7): 878–881. doi:10.1016/S0002-9149(99)00886-3. Check date values in: |date= (help)
  20. ↑ Zelinger, Allan B; Falk, Rodney H; Hood, William B (1982-06). "Electrical-induced sustained myocardial depolarization as a possible cause for transient ST elevation post-DC elective cardioversion". American Heart Journal. 103 (6): 1073–1074. doi:10.1016/0002-8703(82)90574-9. Check date values in: |date= (help)
  21. ↑ Chun, P K; Davia, J E; Donohue, D J (1981-01). "ST-segment elevation with elective DC cardioversion". Circulation. 63 (1): 220–224. doi:10.1161/01.CIR.63.1.220. ISSN 0009-7322. Check date values in: |date= (help)
  22. ↑ Van Gelder, Isabelle C.; Crijns, Harry J.; Van Der Laarse, Arnoud; Van Gilst, Wiek H.; Lie, Kong I. (1991-01). "Incidence and clinical significance of ST segment elevation after electrical cardioversion of atrial fibrillation and atrial flutter". American Heart Journal. 121 (1): 51–56. doi:10.1016/0002-8703(91)90954-G. Check date values in: |date= (help)
  23. ↑ Kern, Karl B.; Hilwig, Ronald W.; Rhee, Kyoo H.; Berg, Robert A. (1996-07). "Myocardial dysfunction after resuscitation from cardiac arrest: An example of global myocardial stunning". Journal of the American College of Cardiology. 28 (1): 232–240. doi:10.1016/0735-1097(96)00130-1. Check date values in: |date= (help)
  24. ↑ Ambler, Jonathan J.S.; Sado, Daniel M.; Zideman, David A.; Deakin, Charles D. (2004-06). "The incidence and severity of cutaneous burns following external DC cardioversion". Resuscitation. 61 (3): 281–288. doi:10.1016/j.resuscitation.2004.01.017. Check date values in: |date= (help)
  25. ↑ Ambler, Jonathan J.S.; Zideman, David A.; Deakin, Charles D. (2005-05). "The effect of topical non-steroidal anti-inflammatory cream on the incidence and severity of cutaneous burns following external DC cardioversion". Resuscitation. 65 (2): 173–178. doi:10.1016/j.resuscitation.2004.11.013. Check date values in: |date= (help)
  26. ↑ Ambler, Jonathan J.S.; Zideman, David A.; Deakin, Charles D. (2005-05). "The effect of prophylactic topical steroid cream on the incidence and severity of cutaneous burns following external DC cardioversion". Resuscitation. 65 (2): 179–184. doi:10.1016/j.resuscitation.2004.11.014. Check date values in: |date= (help)

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