What are you using for TEE cardioversion

[KungPOWChicken]

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So are people generally using propofol? How about in patients with reduced EF say in the 20-30. Anyone using simply midazolam or etomidate.

 

[saratoga733]

So are people generally using propofol? How about in patients with reduced EF say in the 20-30. Anyone using simply midazolam or etomidate.

most elderly chf pts:

3-5 cc propofol

make sure you give it time to circulate

rarely need pressors as sympathetic response to shock usually does the trick

a syringe of levophed just in case

 

[OB1🤙]

Yeah, judicious propofol slowly titrated to effect. No need for anything else.

 

[nimbus]

Straight propofol.....slower/lower +-phenylephrine for low ef.

 

[CodeBlu]

So are people generally using propofol? How about in patients with reduced EF say in the 20-30. Anyone using simply midazolam or etomidate.

I have used etomidate for a cardioversion as well. But, it came in a lipid emulsion and looked like propofol when it was drawn up. Just wondering what your thoughts were on etomidate? I got a lengthy lecture from an attending about not using it, and that it was a bad drug etc etc.

edit: Nevermind, just saw the thread on the front page of the forum.

 

[KungPOWChicken]

Straight propofol.....slower/lower +-phenylephrine for low ef.

So in Residency on patients with low ef tee cardioversions we generally used midazolam/etomidate combinations. Since finishing and being in practice I've switched to small doses of propofol, nothing else. Having done many of these I've noticed recoveries have been remarkably quick with zero recall but I was burned. Sick patient ef 25% ICD in a.flutter on alprazolam at home. BP's generally run low. Systolic's in low 100's. 30mg propofol up front. Wait awhile. Tell cardiologist to proceed. systolic 90. Give 100mcg phenylephrine. Ephedrine 25mg. She's grabbing for tee probe 20mg propofol given. She settles down. Pulse ox waveform dies out but she's noticeably breathing. BP 50 systolic becomes bradycardic to 40. Chest Compressions started and epinephrine and atropine given. BP returns. HOLY ****!!! Anyway, I may rethink my position on propofol us in patients with a depressed EF.

 

[saratoga733]

So in Residency on patients with low ef tee cardioversions we generally used midazolam/etomidate combinations. Since finishing and being in practice I've switched to small doses of propofol, nothing else. Having done many of these I've noticed recoveries have been remarkably quick with zero recall but I was burned. Sick patient ef 25% ICD in a.flutter on alprazolam at home. BP's generally run low. Systolic's in low 100's. 30mg propofol up front. Wait awhile. Tell cardiologist to proceed. systolic 90. Give 100mcg phenylephrine. Ephedrine 25mg. She's grabbing for tee probe 20mg propofol given. She settles down. Pulse ox waveform dies out but she's noticeably breathing. BP 50 systolic becomes bradycardic to 40. Chest Compressions started and epinephrine and atropine given. BP returns. HOLY ****!!! Anyway, I may rethink my position on propofol us in patients with a depressed EF.

phenylephrine increases afterload, not great for an already weak heart. next time use something that has some beta agonistic effects. you didn't mention tee in your initial thread. for tee pre-shock, i find good oral anesthetic prep is key for those you want to get away with using as little as possible.

 

[saratoga733]

sorry, kungpow... u did mention TEE

 

[OB1🤙]

What were the PA pressures/RV function like in that pt? You might have gotten caught in the hypotensive RV ischemia death spiral there.

 

[KungPOWChicken]

What were the PA pressures/RV function like in that pt? You might have gotten caught in the hypotensive RV ischemia death spiral there.

I believe that is exactly what happened. She had moderately increased PA pressures on echo. She did respond nicely to epinephrine though.

 

[sevoflurane]

For TEE ablations. I use low dose prop, roc, lta, tube (aka laryngophed). Then I insert the Tee probe and acquire the images EP guy wants. He bills for it tho. Little fent here and there.

For Tee/cardioversions. I use slowly titrated prop. I aim for amnesia NOT GA. They can grimace a little so long as they don't remember. I want them waking up quickly. 3-5ccs in the right patient goes a long way. Repeat as needed 2-5ccs at a time. The TEE probe has a little TEE-ophed built into it. Rarely do I need to crack open the little vials of purple.

 

[dotcb]

I'm an emergency physician - not exactly the original question, but for elective transthoracic cardioversion, I will usually use either 1/2 induction dose etomidate, or propofol, + 50-100 mcg fentanyl. I have had a few non-critical bad reactions to etomidate, which were myoclonus. They looked somewhat like seizures, chased with touch of midazolam. Resolved 1-2 minutes, but those 2 minutes were - awkward... No desats, no bad outcomes. Useful to have a variety of tools in your toolbox.

 

[Planktonmd]

So in Residency on patients with low ef tee cardioversions we generally used midazolam/etomidate combinations. Since finishing and being in practice I've switched to small doses of propofol, nothing else. Having done many of these I've noticed recoveries have been remarkably quick with zero recall but I was burned. Sick patient ef 25% ICD in a.flutter on alprazolam at home. BP's generally run low. Systolic's in low 100's. 30mg propofol up front. Wait awhile. Tell cardiologist to proceed. systolic 90. Give 100mcg phenylephrine. Ephedrine 25mg. She's grabbing for tee probe 20mg propofol given. She settles down. Pulse ox waveform dies out but she's noticeably breathing. BP 50 systolic becomes bradycardic to 40. Chest Compressions started and epinephrine and atropine given. BP returns. HOLY ****!!! Anyway, I may rethink my position on propofol us in patients with a depressed EF.

I have seen a scenario very similar to your's but without the happy end... the CPR was not successful

 

[Planktonmd]

I'm an emergency physician - not exactly the original question, but for elective transthoracic cardioversion, I will usually use either 1/2 induction dose etomidate, or propofol, + 50-100 mcg fentanyl. I have had a few non-critical bad reactions to etomidate, which were myoclonus. They looked somewhat like seizures, chased with touch of midazolam. Resolved 1-2 minutes, but those 2 minutes were - awkward... No desats, no bad outcomes. Useful to have a variety of tools in your toolbox.

You don't need half the induction dose for a cardioversion, all you need is a little amnesia and it's OK if they move a little.

 

[Consigliere]

We use CRNAs for all our cardioversions.

 

[Planktonmd]

We use CNRAs for all our cardioversions.

What's a CNRA?

 

[Consigliere]

What's a CNRA?

Dunno

 

[nimbus]

I'm an emergency physician - not exactly the original question, but for elective transthoracic cardioversion, I will usually use either 1/2 induction dose etomidate, or propofol, + 50-100 mcg fentanyl. I have had a few non-critical bad reactions to etomidate, which were myoclonus. They looked somewhat like seizures, chased with touch of midazolam. Resolved 1-2 minutes, but those 2 minutes were - awkward... No desats, no bad outcomes. Useful to have a variety of tools in your toolbox.

You're using a lot more than you need unless you are cardioverting big 35 year old men. And fentanyl? why?