Safety of nurse-administered deep sedation for defibrillator implantation in the electrophysiology laboratory

Implantation of implantable cardioverter defibrillators (ICDs) in the electrophysiology (EP) laboratory has been shown to be safe. However, general endotracheal anesthesia and/or administration of sedatives is mostly performed by anesthesiologists. In 53 patients undergoing ICD implantation in the EP laboratory, we prospectively assessed whether deep sedation without endotracheal intubation can be administered by nursing personnel under medical supervision, The mean patient age was 67 +/- 7 years, and the mean ejection fraction was 32 +/- 8%. All ICDs were placed in the abdomen requiring lead tunneling, Patients were monitored with pulse oximetry and noninvasive blood pressure recordings. The level of consciousness and vital signs were evaluated at 5-minute intervals, Deep sedation was induced with phenergan and midazolam and maintained with either meperidine or fentanyl. The mean doses given were as follows: phenergan 0.33 +/- 0.15 mg/kg, midazolam 0.05 +/- 0.03 mg/kg, meperidine 0.46 +/- 0.10 mg/kg per hour, and fentanyl 1.94 +/- 0.71 mu g/kg per hour. None of the patients required intubation during or after the procedure, No death occurred and no patient had any recollection of the procedure. In three patients, O-2 desaturation was easily managed by transient reversion of the effects of meperidine or fentanyl with naloxone, No patient experienced prolonged hospitalization after the implant (mean 2.4 +/- 0.5 days). In conclusion: (1) adequate sedation for ICD implantation and testing can be administered safely by nursing staff in the EP lab; (2) optimum sedation protocols should include drugs easy to reverse in case of excessive respiratory depression; and (3) this may represent a more cost-effective approach to ICD implantation.