Physician-led Conscious Sedation for External Direct Current Cardioversion for Atrial Arrhythmia

Direct current cardioversion for atrial fibrillation (AF) and flutter (A Fl) is commonly done under general anaesthesia, hence adding an extra burden on public hospital resources. Methods: We analysed a total of 136 patients undergoing cardioversion with physician-led conscious sedation with weight-adjusted midazolam and fentanyl infusion between January 2012- January 2015. Patients were excluded if BMI ≥ 40 kg/m2, had severe obstructive sleep apnoea or used recreational drugs. Patients were given reversal agents (Flumazenil/Naloxone) routinely post procedure and were observed for 2 hours before discharge. Patients completed questionnaires to evaluate comfort level (0-10, 0 being best), recollection of events (0 being no recollection), recovery post-procedure (0 being quickest) and time on the waiting list and if they would prefer conscious sedation again (Yes/No). Results: Mean patient age was 67±11 years, 74 men, average BMI 29.7 Kg/M2. Average waiting time was 7.4±5 weeks. Mean midazolam dose was 6.4±2.4mg, fentanyl was 62±20mcg. Reversal agents were used in 131 patients (96%). Sinus rhythm was restored in 131(96%). Average of 1.2±0.6 shocks were delivered, mean energy 187.6±127Joules. There were no complications and all were discharged <2 hours post-cardioversion. Patients reported high comfort levels (0.68±1.7) with minimal recollection (0.91±2.2). Perceived recovery was quick (1.2±2.3) and all patients except one preferred conscious sedation. Conclusions: Physician-led cardioversion for AF/AFl under conscious sedation is safe, associated with high patient comfort, acceptance, short recovery and discharge time. It may also result in less resource utilisation and shorter waiting times.