October 2003 Reader Discussion

Readers, thank you for helping start up the new discussion group strictly for those in the EP community. Enclosed please find the responses. Keep sending us your answers regarding this topic!

Question Under Discussion: What sedation is used in the EP lab for ICDs? If Diprivan is used, who administers it?

We currently use midazolam and diamorphine during ICD implants, which are administered by the nurses on prescription from the physician. We are currently updating our policy in relation to administration of sedation and plan to use fentanyl and midazolam via infusion, with the nurses taking control of the sedation administration. I would be interested to know if anyone else is using these drugs. Middlesbrough, England In our lab, along with local anesthetic we use mostly Versed and Fentanyl titrated to the patient response and comfort. Occasionally, Valium is used. We had toyed with using Diprivan a long time ago; however, it would require an anesthesiologist to be scheduled to come in and administer it. It was felt  that the  extra time to schedule the anesthesiologist and the extra cost to the patient was not desirable. Rockford, Illinois

We use Diprivan in our lab, but it is administered by an anesthesiologist. name withheld

Regarding the question about sedation for ICDs, we use IV benadryl, versed and fentanyl in our lab successfully. A conscious sedation certified RN administers the medication. Hagerstown, Maryland In our cath lab, we utilize fentanyl and midazolam IVP for the conventional ICD placement. A sedation H&P is completed by the physician prior to the procedure, which assesses the patient's ASA class and airway, using Mallampati measurements. For ASA III patients and for a number of biventricular ICD patients, we may use anesthesiology for propofol and ketamine. Marie Fortuno-Shifflett, RN, BSN, Greater Baltimore Medical Center, Baltimore, Maryland

We use Versed for conscious sedation, and Brevital approximately 1 mg/kg when we test the AICD lead. name withheld

At the various hospitals we cover, we have nursing-delivered sedation when we use fentanyl, Versed or both combined.   If we need deeper sedation, we most-commonly use propofol (Diprivan) delivered by the anesthesia personnel (anesthesia residents in the teaching hospital, anesthesist techs at another hospital and anesthesiologists at the other 2). The preferred method is to have anesthesia coverage, but it is frequently impossible due to scheduling conflicts. At some places, anesthesia coverage is MANDATED for cardioversions. Jose Nazari, MD, Cardiac Arrhythmia Consultants, Chicago, Illinois

In our EP lab at Mercy General Hospital in Sacramento, California, the RNs in our department administer conscious sedation which includes versed and fentanyl. More and more we are using Diprivan (Propofol), and we have had no problems. We use larger doses of Propofol when we are testing the ICD devices and giving the doses based on the patients weight 1 cc per kg. I personally have worked at a few other hospitals in the past few years, and the RNs in the labs also gave Propofol for procedures. We like it better than the other narcotics we give. If patients aren t responding to Versed and Fentanyl, we add in Propofol and it is a great combination. We give give 10-20-30 cc at a time until the desired effect. Sacramento, California 

We are using Diprivan.  The nurses do 10 cases with an anesthesiologist and pass a competency test before they can give it on their own. We have used Brevital in the past and still do if we don't have any Diprivan trained staff on for that case. Cheryl Jennerjohn, Lead Nurse, EP Lab, St. Luke's Hospital, Cedar Rapids, Iowa

Our cath lab uses Versed, Demerol & Morphine in various combinations. All meds are given by the RN. Tampa,Florida

In Ohio, Diprovan, considered an anesthetic agent, can only be administed by a CRNA or an anesthesiologist.  name withheld

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New Question:

I am in the process of working through our pacemaker profitability as I have found that we are losing money on most of the procedures we are doing. I have looked at our costs, processes, billing/coding procedures and labor costs, and have found and corrected some issues. I suspect that part of the reason for the loss is that we do pacemakers only and do not have a full EP service line to help offset the less profitable. I was wondering if any other managers have any other ideas to help me out.