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Why not? Even though it's short acting compared to other opioids, it lasts infinitely longer than the stimulus of cardioversion.
I would give it post-procedure IF they were having pain, but that usually isn't needed.
Unsedated Cardioversion
- Thread starter samiam
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Why not? Even though it's short acting compared to other opioids, it lasts infinitely longer than the stimulus of cardioversion.
I would give it post-procedure IF they were having pain, but that usually isn't needed.
This. Opiates without a pain stimulus to treat can quickly become a nuisance in a sick patient without an airway.
I think the case against fentanyl is even stronger in patients with atrial fibrillation. Many of these patients are already on some form of anti arrhythmic and often other drugs which are monopolizing the cytochromes in the liver. Combined with the hypoperfusion of the kidney, which eliminates a good bit of fentanyl unchanged, that duration of action may not be quite as short as you think.
MonkeyArrow
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I will add that the patient given those meds was bagged by the RT for about 5 minutes after the cardioversion. No adverse effects were seen and the patient's saturation remained high throughout. He was awake and talking shortly. Again, n=1.
And that is what we call induction of general anesthesia without an airway in a patient with a full stomach.
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You don't consider needing to be ventilated an adverse effect?
MonkeyArrow
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No, because it was expected. The RT and the ED doc were already there expecting to have to manage the airway. I guess it could be considered an adverse effect. So maybe I should rephrase and say no unexpected results.
TheLocalMedic
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Definitely agree with you.
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I just don't see a need to induce general anesthesia (which is exactly what 20 of etomidate and 100 of fentanyl is) and take on all the risks that come along with it for cardioversion. There's just no reason to get someone so deep that they need respiratory support. I also think that if you are going to do that, then anesthesia should be involved.
Fentanyl by itself is very safe and easy to use. But when you start mixing it with GABA agonists, especially in hemodynamically compromised patients, and especially in those who are on lots of other meds, things can get really.....interesting.
I'm not questioning the judgement of the folks who made the decision to put this guy all the way to sleep - maybe they had a good reason in this case. But as a routine practice, it just isn't necessary, and is probably not the safest practice.
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RedAirplane
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I'm a BLS guy hanging out in the wrong forum... But I'm surprised to learn that you shock things besides VF and pulsless VT. Is there a brief explanation of this I can find somewhere?
DesertMedic66
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We shock VT with pulses and SVT (in patients who are unstable) because their hearts are not able to maintain perfusion in those rhythms. It's like hitting the reset button.
gotbeerz001
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Google "synchronized cardioversion"... Basically a lower dose of a well-timed shock for someone not dead... Yet.
Not sure where you are in GA, but your ER doc needs remedial education on the different levels of sedation. What he did definitely crosses way over the sedation line, which is all that is indicated for cardioversion, and into general anesthesia. I would seriously question the clinical judgement of that physician if he truly thinks this is acceptable practice. I don't know any hospital that grants "general anesthesia" privileges to ER docs.