Safety and efficacy of a nurse-led deep sedation protocol for invasive pulsed-field ablation of atrial fibrillation

Abstract Introduction and objectives Pulsed-field ablation has emerged as a promising treatment option in invasive electrophysiology procedures. Deeper patient sedation is required for these procedures, but availability of support but anesthesia or other specialists is often limited. Our goal was to assess the safety and efficacy of a nurse-led sedation protocol. Methods This is a single-centre, observational, prospective study of consecutive patients undergoing pulsed field ablation of atrial fibrillation under deep sedation. Continuous infusion of weight-adjusted(< 60 Kg: 20–25 ml/h, 60-80 Kg: 25–35 ml/h, 80-100 Kg: 35–45 ml/h, >100 Kg: 45 - 50 ml/h) Propofol 1% was initiated before patients draping and stopped 5 minutes before catheter removal. Patients with intolerance or contraindication to propofol were excluded. The primary efficacy and safety endpoints were achievement of deep sedation (score of -4 on RASS scale) and need for airway interventions respectively. Results 214 patients (67.1±10.7 years, 39.72% female, 82.4±15.7kg, BMI 28.8±4.8 kg/m2) were recruited in 9 months, including the physicians and nursing staff learning curve on deep sedation protocol. All patients (100%) achieved deep sedation. No patient requiring cardioversion needed additional sedation. Airway management included pillow removal (68.2%), oropharyngeal (Guedel) cannula (50.9%), occasional jaw-thrust maneuver (37.4%), and occasional ventilation with bag valve mask (Ambu®) (3.27%). These were applied according to the predefined protocol (Figure 1). No patients required orotracheal intubation or laryngeal mask. Initial and final infusion rates were 34.1±8.1 ml/h and 38.2±12.2 ml/h respectively. 52.3% of patients required additional 20mg boluses, 59.8% an increase and 36.4% a decrease in infusion rate. Conclusion Nurse-led administration of deep sedation according to a predefined protocol is a safe and effective alternative for invasive electrophysiology procedures, even during the learning curve.Figure 1- Desaturation protocol