Safe Sedation in Modern Cardiological Practice

Recommendations for the Use of Propofol in Nurse-Led Cardiological Sedation

Although the use of propofol for sedation in other fields remains controversial, for the above reasons it is appropriate, with restrictions, for use in cardiological sedation. The issue of training and the need for new guidelines have been highlighted elsewhere. The following are recommended.

1. 
   Capnography (monitoring of end-tidal CO2 and ventilation), although not currently routine, is strongly recommended. Training in correct use of capnography monitoring is required. This is a key recommendation also of American and Australasian guidance.
   
2. 
   A dedicated nurse-sedationist is essential. The cardiologist performing the procedure is scrubbed and it is inappropriate for that individual to also deliver the sedation and monitor the patient.
   
3. 
   Cath lab nurse-sedationists performing propofol-based sedation should be ALS trained and be competent at resuscitation, defibrillation and airway protection.
   
4. 
   The nurse team involved in sedation should attend formal sedation training sessions and also annual practical refresher sessions including airway management.
   
5. 
   If propofol is to be used, it should be delivered via a target controlled infusion (TCI) pump. Staff using TCI pumps should receive appropriate training in their use.
   
6. 
   The nurse responsible for sedation in the cath lab environment should be responsible for patient monitoring and drug delivery during the procedure and be answerable to the consultant performing the ablation procedure. They should ideally also be responsible to the hospital sedation team particularly for continuing training, CPD, audit and record keeping.
   
7. 
   Sedation procedures should be fully recorded and audited.
   
8. 
   Although propofol will be considered for long procedures such as complex device implantations or AF ablations, it may also be appropriate in some short procedures such as cardioversion on the basis of prior intolerance or excess dosage of benzodiazepines.
   
9. 
   Patients with markers of possible difficult airway maintenance (eg, Mallampati score ≥3, collar size ≥17", history of obstructive sleep apnoea (OSA)) should be excluded or discussed with anaesthetic colleagues.