Purpose

The resources on this website were gathered as an acknowledgement of the nuanced fragility of heart failure patients receiving Implantable Cardioverter-Defibrillators (ICDs) in the Swedish EP Lab. Drawing on feedback from clinical practice combined with a comprehensive literature review, these resources reflect evidence-based best practice in patient assessment, anesthesia planning, intraoperative management, and patient recovery. They are offered as a reference to all anesthesia providers in EP, but aim specifically to support Care Teams, providers new to Swedish, those infrequently staffed in the EP Lab regarding optimal resource utilization and to inform meaningful conversations regarding patient-centered care. 

Methodology

In 2021, a comprehensive search of the literature utilizing Whittemore and Knafl’s (2005) integrative review methodology, was focused on the question: “What anesthesia techniques are currently being used for adult Implantable Cardioverter-Defibrillator (ICD) surgeries in the Electrophysiology (EP) Lab?”. Databases searched included CINAHL, Cochrane Library, Embase, PubMed, and Scopus yielding 2,110 articles then filtered for relevance and publication date of 2016 or after. Ten full-text articles met review inclusion criteria including: Study populations comprised of adult patients with advanced heart failure necessitating transvenous ICD implant, research focus on providing anesthesia for the ICD implant procedure, and quantitative or descriptive procedural outcome measures related to successful perioperative patient management. 

Analysis and synthesis of the review results yielded three central themes: 

1. Light sedation (local anesthetic plus anxiolysis) is a reasonable alternative to deep sedation and GA for ICD implant (Cheruku et al., 2018; Kaya et al., 2018; Mandel 2017; Yildiz et al., 2018).

2. A detailed patient assessment prior to ICD implant informs the appropriate anesthetic approach (Cheruku et al., 2018; Gerstein et al., 2016; Yildiz et al., 2018).

3. Clinical evidence supports the use of regional blocks, specifically PECS blocks as the primary anesthetic for ICD implant (Arasu et al., 2020; Bozyel et al., 2019; Metinyurt, 2021; Pai et al., 2019; Wang et al., 2020). 

Secondary themes include an emphasis on individualized care for patients with co-morbidities (Cheruku et al., 2018; Gerstein et al., 2016; Yildiz et al., 2018) and the cardiorespiratory and hemodynamic instability associated with propofol use (Gerstein et al., 2016; Mandel et al., 2017; Ugata et al., 2019). 

Representing contemporary best practice for sedation, the "2018 American Society of Anesthesiologist Practice Guidelines for Moderate Procedural Sedation and Analgesia" (ASA, 2018) was selected as the foundational document for this website, and adapted with permission for use in the Swedish EP Lab. 

These practice parameters are a digest of the American Society of Anesthesiologists 2018 Practice Guidelines for Moderate Procedural Sedation and Analgesia. The full Guidelines can be found here. 

ONE: PATIENT EVALUATION

1.   Observational studies indicate that some adverse outcomes (e.g., unintended deep sedation,          hypoxemia, and hypotension) may occur in patients with certain pre-existing medical                       conditions when moderate sedation/analgesia is administered. These conditions include:  

                           a.     Extremes of age

   b.     ASA status III or higher

   c.     Respiratory conditions, OSA, respiratory distress syndrome, allergies

   d.     Obesity, history of gastric bypass surgery

   e.     Psychotropic drug use, long-term benzodiazepine use

    f.     Cardiovascular disorders

TWO: PREPROCEDURE PATIENT PREPARATION

1.    In addition to any comorbidity-specific diagnostics, ICD implant patients will have:

    a.     A current Echocardiogram

    b.     ECG in last 12 months

    c.     BMP in last 6 months

    d.     Repeat BMP (minimum K+) DOS if IV contrast will be used for a vascular visualization 

  2.   Consider length of procedure, patient position, and the amount of strain that becoming  

        obstructed or hypercarbic may put on the cardiopulmonary system

  3.   Consult with a medical specialist when appropriate (i.e., EF < 20%). See Specialist Contact List     at bottom of homepage

THREE: MONITORING

   1. Level of Consciousness

a.     Assess level of consciousness including responsiveness to commands or other              bidirectional communication q5 min

   2.    Ventilation and Oxygenation

a. Monitoring pt ventilation and oxygenation via quantitative clinical signs, capnography,         and pulse oximetry 

   3.    Hemodynamic Monitoring

a. Including BP q3-5 min, HR, EKG

4.     Be prepared to rescue pt from sedation deeper than level intended

a.     Manage hypoventilation or airway compromise

b.   Support cardiovascular function in patients who become hypo/hypertensive or tachy/bradycardic

FOUR: SUPPLEMENTAL OXYGEN

1.     Literature findings show supplemental O2 associated with reduced frequency of hypoxemia.

       These organizations strongly agree with the recommendation to use supplemental O2: 

a.     American Society of Anesthesiologists 

b.     American Association of Oral and Maxillofacial Surgeons 

c.     American Society of Dentist Anesthesiologists 

FIVE: EMERGENCY SUPPORT

1.     Pharmacologic antagonists for benzodiazepines & opiates on hand

2.     Individual present who understands pharmacology of sedatives, analgesics, and their   interaction with other meds pt may be taking

3.     Equipment for establishing patent airway

4.     Individual capable of establishing a patent airway

5.     Functional defibrillator or AED

6.     Individual or service (e.g., code team) with ACLS skills immediately available

SIX: SEDATIVES AND ANALGESICS NOT INTENDED FOR GENERAL ANESTHESIA

                        (Benzodiazepines, Dexmedetomidine, Opiates)

1.     Combinations of sedative and analgesic agents may be administered as appropriate for the 

       procedure and the condition of the patient.

 a.     Administer each component individually to achieve the desired effect (e.g., analgesics

    to relieve pain; sedatives to decrease awareness or anxiety)

2.     Dexmedetomidine can be administered as an alternative to benzodiazepine sedatives on a 

        case-by-case basis   

3.     Administer IV sedative/analgesic drugs in small, incremental doses or by infusion, titrating

        to desired endpoints

 a.     Allow sufficient time between doses so peak effect can be assessed before  

         subsequent drug administration

 b.     Consider maintaining IV access for patients receiving non-IV sedation and/or       

         analgesia 

SEVEN: SEDATIVE AND ANALGESIC MEDICATIONS INTENDED FOR GENERAL ANESTHESIA

                        (Propofol, Ketamine, Etomidate)

1.     When moderate procedural sedation is provided with sedative/analgesic medications       intended for general anesthesia, provide care consistent with that required for general   anesthesia  

2.     Assure that practitioners administering sedative/analgesic medications intended for GA can     identify and rescue patients from unintended deep sedation or general anesthesia

EIGHT: REVERSAL AGENTS

1.     Assure specific antagonists are immediately available whenever opioid analgesic or    benzodiazepines are administered for procedural sedation/analgesia

2.     If pts develop hypoxemia, significant hypoventilation, or apnea during sedation/analgesia:

 a.     Encourage or physically stimulate patients to breathe deeply

 b.     Administer supplemental oxygen (if not already in place)

 c.     Provide positive pressure ventilation if spontaneous ventilation is inadequate

3.     Use reversal agents in cases where airway control, spontaneous ventilation, or positive pressure ventilation is inadequate:

 a.     Flumazenil

 b.     Naloxone

NINE: RECOVERY CARE

1.     Observe and monitor patients until they return to near-baseline level of consciousness and           are no longer at risk for cardiorespiratory depression

2.     Monitor oxygenation continuously (pulse oximetry) and ventilation and circulation at        regular intervals until patients are suitable for discharge

TEN: CREATION AND IMPLEMENTATION OF PATIENT SAFETY PROCESSES

1.     Create a quality improvement process based on established national, regional, or institutional reporting protocols (e.g., adverse events, unsatisfactory sedation)

2.     Strengthen patient safety culture through collaborative practices (e.g., team training, simulation drills, development and implementation of checklists)

3.     Create an emergency response plan