I read with great interest the article by Trouve-Buisson et al.1 that was recently published in the European Journal of Anaesthesiology describing the anaesthetic management during implantation of cardiovascular implantable electronic devices (CIEDs).
The authors noted that their results presented new evidence in the recent debate about sedation by nonanaesthesiologists and went on to state that as severe complications represented almost one-third of the overall complication rate, direct supervision by a nurse anaesthetist or anaesthesiologist seems to be required. As the debate is in regard to sedation by nonanaesthesiologists not general anaesthetic by nonanaesthesiologists, the statistic presented to support the authors’ argument is misleading.2 It was reported that 26% (n = 63) of the patients who received deep sedation had at least one complication and 4% (n = 10) experienced a severe complication. Therefore, of the 63 deeply sedated patients who had a complication, in only 16% (n = 10) of patients was it severe. In contrast, 71% (n = 15) of general anaesthetic patients had a complication and of these patients, in 11 (73%) the complication was severe. On the basis of the drastically disparate complication rates between patients who received general anaesthesia and those who received deep sedation, it does not seem reasonable for the same conclusion to be drawn for both groups of patients.
Also, considering the authors noted that their study presented new evidence in the recent debate about sedation by nonanaesthesiologists, it is surprising that the complication rate of the patients who received deep sedation with propofol in this study was not considered in relation to a recent similar study, which involved the administration of propofol by nonanaesthesiologists.3 Sayfo et al.3 reported the frequency of adverse events during proceduralist-directed nurse-administered propofol sedation (PDNAPS) during the implantation of cardiac implantable electronic devices. Interestingly, a higher incidence of both mild (38.7%) and severe complications (10%) was reported in this study.1,3 Potentially then, administration of propofol for deep sedation during the implantation of cardiac implantable electronic devices by anaesthesiologists (or nurse anaesthetists) may actually be associated with decreased risk of complications. Therefore, an adequately powered randomised controlled trial would be required to draw strong conclusions for or against the use of PDNAPS during the implantation of cardiac implantable electronic devices. Yet, the authors noted that on the basis of their findings, such a trial may be unethical. It should be noted that recent surveys of sedation practice in the United States of America and also Australia and New Zealand indicated that PDNAPS is actually already being utilised in practice.4,5 Furthermore, gaining access to monitored anaesthesia care for sedation in the cardiac catheterisation laboratory is difficult in many institutions around the world.4,5 Moreover, the need for more effective sedative and analgesic medications for cardiovascular procedures than the typical benzodiazepine and opioids combination that can be safely administered without an anaesthetist present has been recently observed and is also the subject of numerous recent investigations.3,6,7 For these reasons, in contrast to the authors’ opinion that trials comparing nonanaesthesiologist with anaesthesiologist managed sedation may be unethical, the evidence at hand indicates that such trials are indeed required.
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1. Trouve-Buisson T, Arvieux L, Bedague D, et al. Anaesthesiological support in a cardiac electrophysiology laboratory: a single-centre, prospective observational study. Eur J Anaesthesiol
2. Conway AW, Page K, Rolley JX, Worrall-Carter L. Nurse-administered procedural sedation and analgesia in the cardiac catheter laboratory: an integrative review. Int J Nurs Studies
3. Sayfo S, Vakil KP, Alqaqa’a A, et al. A retrospective analysis of proceduralist-directed, nurse-administered propofol sedation for implantable cardioverter-defibrillator procedures. Heart Rhythm
4. Conway A, Rolley JX, Page K, Fulbrook P. Trends in nurse-administered procedural sedation and analgesia across Australian and New Zealand cardiac catheterisation laboratories: results of an electronic survey. Aust Crit Care
5. Gaitan BD, Trentman TL, Fassett SL, et al. Sedation and analgesia in the cardiac electrophysiology laboratory: a national survey of electrophysiologists investigating the who, how, and why? J Cardiothor Vasc Anesth
6. Conway A, Rolley JX, Fulbrook P, Page K. Issues and challenges associated with nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory: a qualitative study. J Clin Nurs
2013; [Epub ahead of print]. .
7. Dupanović M, Lakkireddy D, Emert MP, Krebill R. Utility of dexmedetomidine in sedation for radiofrequency ablation of atrial fibrillation. J Perianesth Nurs