Abstract and Introduction
Abstract
There is much debate about the optimal sedation strategy for transoesophageal echocardiography (TEE). Despite previous studies demonstrating the potential benefits of combining opiates and benzodiazepines for conscious sedation, and previous published national surveys and recommendations, sedation practice for TEE in clinical practice varies widely within the UK. All UK centres routinely use midazolam, but only 7% of centres use it in combination with an opiate: 14% of hospitals report no routine use of sedation for TEE. Thereis no British Society of Echocardiography (BSE) recommended TEE sedation protocol within the UK and even where guidelines exist locally, 82% of operators report being unaware of their details. Consequently, a wide range of sedative doses are used and many patients are reported to be over-sedated. We developed a new protocol for conscious sedation using intravenous pethidine and midazolam for TEE and have shown it to be safe and effective when implemented within an existing TEE service
Introduction
It is known that there is significant variation in transoesophageal echocardiography (TEE) practice, particularly with regards to sedation in the UK. Previous studies have demonstrated that choice of sedation used is highly variable and more than half of patients were over-sedated and verbally unresponsive (i.e. under general anaesthesia) during TEE. A recent National Patient Safety Agency (NPSA) statement in the UK has further highlighted the risks of sedation in the elderly; a population that make up a large proportion of patients undergoing TEE. Several speciality-specific guidelines for use of sedation have been published in line with national recommendations, and a need for TEE-specific guidelines has been recommended. Recent published evidence suggests that a combined sedation strategy incorporating midazolam with an ultra-short acting opiate (remifentanil) significantly improves tolerance of TEE, results in faster recovery time after TEE, and reduces resource consumption. However, the use of an infused opiate may be impractical in clinical cardiological practice as it is staff intensive and requires the presence of an anaesthetist. The longer-term safety data for this remifentanil and midazolam combination is also unavailable at present. Prior to developing our new TEE sedation protocol we performed a national survey of TEE sedation practice in the UK and, subsequently, developed a combined intravenous (IV) pethidine and midazolam protocol for routine clinical use. This combination of agents is well established for conscious sedation and has a reasonable safety record internationally. We propose this as a safe and effective TEE sedation protocol and present data from the survey and clinical sedation data on 150 consecutive patients undergoing TEE using this protocol.