What medications are used for pain and sedation prior to cardioversion (cardioversion, a procedure to restore a normal heart rhythm)?

From the Guidelines

For cardioversion, the most commonly used medications for pain control and sedation are propofol, etomidate, midazolam, and fentanyl, which are typically administered just before the procedure to provide short-term sedation and analgesia.

Medication Options

The choice of medication depends on patient factors, including cardiovascular stability, comorbidities, and previous medication responses.

• Propofol offers rapid onset and quick recovery but may cause hypotension 1.
• Etomidate provides hemodynamic stability but can cause myoclonus.
• Midazolam has anxiolytic properties but a longer recovery time.
• Fentanyl is often combined with sedatives for additional pain control.

Administration and Monitoring

These medications are usually administered in the following doses: propofol (0.5-1 mg/kg IV), etomidate (0.1-0.2 mg/kg IV), midazolam (0.05-0.1 mg/kg IV), and fentanyl (50-100 mcg IV). Monitoring of vital signs, oxygen saturation, and having resuscitation equipment available are essential during administration.

Goal of Sedation

The goal is to achieve adequate sedation for patient comfort while maintaining spontaneous respiration and hemodynamic stability during this brief but uncomfortable procedure. According to the acc/aha/esc 2006 guidelines for the management of patients with atrial fibrillation, cardioversion should be performed with the patient under adequate general anesthesia in a fasting state, with short-acting anesthetic drugs or agents that produce conscious sedation preferred to enable rapid recovery after the procedure 1.

From the FDA Drug Label

Midazolam 5 mg are not usually necessary. If concomitant CNS depressant premedications are used in these patients, they will require at least 50% less midazolam than healthy young unpremedicated patients Narcotic premedication frequently used during clinical trials included fentanyl (1. 5 to 2 mcg/kg intravenous, administered 5 minutes before induction), morphine (dosage individualized, up to 0. 15 mg/kg intramuscular), and meperidine (dosage individualized, up to 1 mg/kg intramuscular). Sedative premedications were hydroxyzine pamoate (100 mg orally) and sodium secobarbital (200 mg orally). The induction dose requirements of propofol injectable emulsion may be reduced in patients with intramuscular or intravenous premedication, particularly with narcotics (e.g., morphine, meperidine, and fentanyl, etc.) and combinations of opioids and sedatives (e.g., benzodiazepines, barbiturates, chloral hydrate, droperidol, etc.) Dexmedetomidine IM administered at 40 mcg/kg prior to induction with ketamine resulted in a significantly higher proportion of cats that were successfully intubated compared to saline

Medications used for pain and sedation prior to cardioversion include:

• Midazolam: a benzodiazepine used for sedation
• Fentanyl: an opioid used for pain and sedation
• Morphine: an opioid used for pain and sedation
• Meperidine: an opioid used for pain and sedation
• Hydroxyzine pamoate: an antihistamine used for sedation
• Sodium secobarbital: a barbiturate used for sedation
• Propofol: a sedative-hypnotic used for induction of anesthesia
• Dexmedetomidine: an alpha-2 adrenergic agonist used for sedation and analgesia 2, 3, 4

From the Research

Medications Used for Pain and Sedation Prior to Cardioversion

• The medications used for pain and sedation prior to cardioversion include:
  • Propofol 5, 6, 7, 8, 9
  • Midazolam 5, 6, 7, 8, 9
  • Fentanyl 5
  • Etomidate 6, 7, 8
  • Methohexital 8
  • Ketamine 5
  • Lidocaine 5
  • Sevoflurane 7
  • Thiopentone 7
  • Diazepam 7
  • Remifentanil 7

Comparison of Medications

• A study comparing propofol, etomidate, and midazolam for cardioversion in the emergency department found that all three medications were effective, but propofol was well tolerated and lacked the myoclonus, prolonged sedation, and resedation noted with the other two medications 6.
• Another study found that low-dose fentanyl, propofol, midazolam, ketamine, and lidocaine combination was more successful in induction of deep sedation compared to regular dose of propofol and fentanyl combination 5.
• A review of 23 studies comparing different medications for electrical cardioversion found that there was no evidence to suggest that current anaesthetic practice for cardioversion should change 7.
• A study comparing propofol, methohexital, and midazolam for sedation during electrical cardioversion found that all three medications were acceptable choices, but propofol and methohexital provided a more rapid anesthetic onset and recovery compared to midazolam 8.
• A feasibility study comparing sedation with midazolam administered by a cardiologist to an anaesthesiologist-assisted protocol with propofol in emergency direct current cardioversion found that sedation with midazolam was feasible, well-tolerated, and cost-effective 9.