Sedation options in a cardiac catheterization laboratory and coronary care unit: protocol review and clinical experience from General Hospital Slavonski Brod

    Authors

    Keywords

    coronary care unit, sedation, propofol, dexmedetomidine, remifentanil

    DOI

    https://doi.org/10.15836/ccar2026.46

    Full Text

    **Introduction**: Modern cardiac catheterization laboratories and coronary care units (CCU) require sophisticated sedation protocols that balance patient comfort with hemodynamic stability and respiratory safety (1). This review presents sedation options currently implemented at General Hospital Slavonski Brod’s CCU. **Protocols and Methods**: We analyzed seven primary sedation agents used in our institution: propofol and propofol TCI (Target-Controlled Infusion), remifentanil TCI, dexmedetomidine, sufentanil, fentanyl, and midazolam. Each agent’s pharmacokinetics, pharmacodynamics, indications, contraindications, and adverse effects were systematically reviewed based on current literature and institutional experience (**Table 1** and **Table 2****).** Our sedation protocols are tailored to specific procedures: propofol for electrical cardioversion due to rapid onset and recovery (2); midazolam combined with propofol for transcatheter aortic valve implantation procedures; dexmedetomidine for mechanically ventilated patients post-cardiac arrest or myocardial infarction; and dexmedetomidine-based protocols for anxious elderly patients and non-invasive ventilation (NIV) mask tolerance enhancement (3, 4). Each approach considers patient-specific factors including age, comorbidities, and procedural complexity. Propofol demonstrates rapid onset (30-40 seconds) with significant cardiovascular depression but predictable recovery. TCI systems provide superior concentration control and reduced side effects. Remifentanil TCI offers precise analgesia control with ultra-short elimination half-life (3-10 minutes) but requires vigilant respiratory monitoring. Dexmedetomidine provides unique conscious sedation with minimal respiratory depression, making it ideal for prolonged sedation and NIV tolerance (3, 4). Traditional opioids (fentanyl, sufentanil) and midazolam remain valuable for specific indications with established safety profiles. Each agent presents distinct contraindication patterns. Propofol requires caution in cardiac failure and hypovolemia (2). Dexmedetomidine necessitates monitoring for bradycardia and hypotension. Opioids demand respiratory surveillance, while midazolam may cause paradoxical reactions in elderly patients. ### TABLE 1: Contraindications and special warnings. | **Drug** | **Absolute contraindications** | **Relative contraindications** | **Special warnings** | | --- | --- | --- | --- | | Propofol | Allergy to propofol, eggs, soy | Heart failure, hypovolemia | Propofol infusion syndrome, hypertriglyceridemia | | Remifentanil TCI | Allergy to fentanyl analogues | Severe renal/hepatic insufficiency, COPD, mechanical obstruction of the GIT | Muscle rigidity, respiratory depression | | Dexmedetomidine | No absolute contraindications | Bradycardia <50/min, hypotension, heart block | Bradycardia, prolonged action in the elderly | | Sufentanil/ Fentanyl | Allergy to opioid analgesics, acute asthma | CNS depression, increased intracranial pressure | Respiratory depression, addiction | | Midazolam | Allergy to benzodiazepines, acute glaucoma | Dementia, COPD, myasthenia gravis | Delirium in the elderly, anterograde amnesia | [†] TCI – Target-Controlled Infusion; COPD – Chronic Obstructive Pulmonary Disease; CNS – Central Nervous System; GIT – Gastrointestinal Tract ### TABLE 2: Pharmacokinetics and pharmacodynamics. | Drug | **Mechanism of action** | **Onset of action** | **Elimination half-time** | **Cardiovascular effects** | **Respiratory effects** | | --- | --- | --- | --- | --- | --- | | Propofol | GABA receptor agonist | 30-40 seconds | 4-7 hours | Hypotension, ↓CO, bradycardia | Respiratory depression, apnea | | Propofol TCI | GABA receptor agonist | 30-40 seconds | 4-7 hours | Hypotension, ↓CO, bradycardia | Respiratory depression, apnea | | Remifentanil TCI | μ-opioid receptor agonist | 1-3 minutes | 3-10 minutes | Bradycardia, hypotension | Significant respiratory depression | | Dexmedetomidine | α2-adrenoreceptor agonist | 15 minutes (without loading dose) | 2-3 hours | Bradycardia, hypotension, initial hypertension | Minimal respiratory depression | | Sufentanil | μ-opioid receptor agonist | 1-3 minutes | 2.5-3 hours | Bradycardia, mild hypotension | Significant respiratory depression | | Fentanyl | μ-opioid receptor agonist | 1-2 minutes | 3-4 hours | Bradycardia, mild hypotension | Moderate respiratory depression | | Midazolam | GABA-A receptor agonist | 1-3 minutes | 1-4 hours | Minimal | Mild respiratory depression | [†] TCI – Target-Controlled Infusion; ↓CO – Decreased Cardiac Output; GABA – gamma-aminobutyric acid **Conclusions**: Successful sedation in cardiac catheterization laboratories and coronary units require individualized approaches based on pharmacological understanding, procedural requirements, and patient characteristics. Our institutional experience demonstrates that combined protocols utilizing multiple agents can optimize patient outcomes while maintaining safety. Continuous monitoring and staff education remain paramount for safe sedation practice.

    Literature

    1. Bangalore S, Barsness GW, Dangas GD, Kern MJ, Rao SV, Shore-Lesserson L, et al. Evidence-Based Practices in the Cardiac Catheterization Laboratory: A Scientific Statement From the American Heart Association. Circulation. 2021 August 3;144(5):e107–19. https://doi.org/10.1161/CIR.0000000000000996
    2. Desai PM, Kane D, Sarkar MS. Cardioversion: What to choose? Etomidate or propofol. Ann Card Anaesth. 2015 July-September;18(3):306–11. https://doi.org/10.4103/0971-9784.159798
    3. Akhtar MH, Haleem S, Tauheed N, Khan D. Dexmedetomidine as Conduit for Non-Invasive Ventilation (NIV) Compliance in COVID-19 and Chronic Obstructive Pulmonary Disease (COPD) Patients in Intensive Care Unit (ICU) Setting: Case Series. Cureus. 2023 January 19;15(1):e33981. https://doi.org/10.7759/cureus.33981
    4. Altınkaya Çavuş M, Gökbulut Bektaş GS, Turan S. Comparison of clinical safety and efficacy of dexmedetomidine, remifentanil, and propofol in patients who cannot tolerate non-invasive mechanical ventilation: A prospective, randomized, cohort study. Front Med (Lausanne). 2022;9:995799. https://doi.org/10.3389/fmed.2022.995799
    Cardiologia Croatica
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    Sedation options in a cardiac catheterization laboratory and coronary care unit: protocol review and clinical experience from General Hospital Slavonski Brod

    Extended Abstract
    Issue1-2
    Published
    Pages46-47
    PDF via DOIhttps://doi.org/10.15836/ccar2026.46
    coronary care unit
    sedation
    propofol
    dexmedetomidine
    remifentanil

    Authors

    Josip Silović*ORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Domagoj MiškovićORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Ivan MajdandžićORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Marijana Knežević PravečekORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Katica Cvitkušić LukendaORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia

    *Correspondence email: jsilovic93@gmail.com

    Full Text

    Introduction: Modern cardiac catheterization laboratories and coronary care units (CCU) require sophisticated sedation protocols that balance patient comfort with hemodynamic stability and respiratory safety (1). This review presents sedation options currently implemented at General Hospital Slavonski Brod’s CCU.

    Protocols and Methods: We analyzed seven primary sedation agents used in our institution: propofol and propofol TCI (Target-Controlled Infusion), remifentanil TCI, dexmedetomidine, sufentanil, fentanyl, and midazolam. Each agent’s pharmacokinetics, pharmacodynamics, indications, contraindications, and adverse effects were systematically reviewed based on current literature and institutional experience (Table 1 and Table 2). Our sedation protocols are tailored to specific procedures: propofol for electrical cardioversion due to rapid onset and recovery (2); midazolam combined with propofol for transcatheter aortic valve implantation procedures; dexmedetomidine for mechanically ventilated patients post-cardiac arrest or myocardial infarction; and dexmedetomidine-based protocols for anxious elderly patients and non-invasive ventilation (NIV) mask tolerance enhancement (3, 4). Each approach considers patient-specific factors including age, comorbidities, and procedural complexity. Propofol demonstrates rapid onset (30-40 seconds) with significant cardiovascular depression but predictable recovery. TCI systems provide superior concentration control and reduced side effects. Remifentanil TCI offers precise analgesia control with ultra-short elimination half-life (3-10 minutes) but requires vigilant respiratory monitoring. Dexmedetomidine provides unique conscious sedation with minimal respiratory depression, making it ideal for prolonged sedation and NIV tolerance (3, 4). Traditional opioids (fentanyl, sufentanil) and midazolam remain valuable for specific indications with established safety profiles. Each agent presents distinct contraindication patterns. Propofol requires caution in cardiac failure and hypovolemia (2). Dexmedetomidine necessitates monitoring for bradycardia and hypotension. Opioids demand respiratory surveillance, while midazolam may cause paradoxical reactions in elderly patients.

    TABLE 1: Contraindications and special warnings.

    Propofol
    Absolute contraindications
    Allergy to propofol, eggs, soy
    Relative contraindications
    Heart failure, hypovolemia
    Special warnings
    Propofol infusion syndrome, hypertriglyceridemia
    Remifentanil TCI
    Absolute contraindications
    Allergy to fentanyl analogues
    Relative contraindications
    Severe renal/hepatic insufficiency, COPD, mechanical obstruction of the GIT
    Special warnings
    Muscle rigidity, respiratory depression
    Dexmedetomidine
    Absolute contraindications
    No absolute contraindications
    Relative contraindications
    Bradycardia <50/min, hypotension, heart block
    Special warnings
    Bradycardia, prolonged action in the elderly
    Sufentanil/ Fentanyl
    Absolute contraindications
    Allergy to opioid analgesics, acute asthma
    Relative contraindications
    CNS depression, increased intracranial pressure
    Special warnings
    Respiratory depression, addiction
    Midazolam
    Absolute contraindications
    Allergy to benzodiazepines, acute glaucoma
    Relative contraindications
    Dementia, COPD, myasthenia gravis
    Special warnings
    Delirium in the elderly, anterograde amnesia

    TCI – Target-Controlled Infusion; COPD – Chronic Obstructive Pulmonary Disease; CNS – Central Nervous System; GIT – Gastrointestinal Tract

    TABLE 2: Pharmacokinetics and pharmacodynamics.

    Propofol
    Mechanism of action
    GABA receptor agonist
    Onset of action
    30-40 seconds
    Elimination half-time
    4-7 hours
    Cardiovascular effects
    Hypotension, ↓CO, bradycardia
    Respiratory effects
    Respiratory depression, apnea
    Propofol TCI
    Mechanism of action
    GABA receptor agonist
    Onset of action
    30-40 seconds
    Elimination half-time
    4-7 hours
    Cardiovascular effects
    Hypotension, ↓CO, bradycardia
    Respiratory effects
    Respiratory depression, apnea
    Remifentanil TCI
    Mechanism of action
    μ-opioid receptor agonist
    Onset of action
    1-3 minutes
    Elimination half-time
    3-10 minutes
    Cardiovascular effects
    Bradycardia, hypotension
    Respiratory effects
    Significant respiratory depression
    Dexmedetomidine
    Mechanism of action
    α2-adrenoreceptor agonist
    Onset of action
    15 minutes (without loading dose)
    Elimination half-time
    2-3 hours
    Cardiovascular effects
    Bradycardia, hypotension, initial hypertension
    Respiratory effects
    Minimal respiratory depression
    Sufentanil
    Mechanism of action
    μ-opioid receptor agonist
    Onset of action
    1-3 minutes
    Elimination half-time
    2.5-3 hours
    Cardiovascular effects
    Bradycardia, mild hypotension
    Respiratory effects
    Significant respiratory depression
    Fentanyl
    Mechanism of action
    μ-opioid receptor agonist
    Onset of action
    1-2 minutes
    Elimination half-time
    3-4 hours
    Cardiovascular effects
    Bradycardia, mild hypotension
    Respiratory effects
    Moderate respiratory depression
    Midazolam
    Mechanism of action
    GABA-A receptor agonist
    Onset of action
    1-3 minutes
    Elimination half-time
    1-4 hours
    Cardiovascular effects
    Minimal
    Respiratory effects
    Mild respiratory depression

    TCI – Target-Controlled Infusion; ↓CO – Decreased Cardiac Output; GABA – gamma-aminobutyric acid

    Conclusions: Successful sedation in cardiac catheterization laboratories and coronary units require individualized approaches based on pharmacological understanding, procedural requirements, and patient characteristics. Our institutional experience demonstrates that combined protocols utilizing multiple agents can optimize patient outcomes while maintaining safety. Continuous monitoring and staff education remain paramount for safe sedation practice.

    Literature

    1. 1.
      Bangalore S, Barsness GW, Dangas GD, Kern MJ, Rao SV, Shore-Lesserson L, et al. Evidence-Based Practices in the Cardiac Catheterization Laboratory: A Scientific Statement From the American Heart Association. Circulation. 2021 August 3;144(5):e107–19.DOI
    2. 2.
      Desai PM, Kane D, Sarkar MS. Cardioversion: What to choose? Etomidate or propofol. Ann Card Anaesth. 2015 July-September;18(3):306–11.DOI
    3. 3.
      Akhtar MH, Haleem S, Tauheed N, Khan D. Dexmedetomidine as Conduit for Non-Invasive Ventilation (NIV) Compliance in COVID-19 and Chronic Obstructive Pulmonary Disease (COPD) Patients in Intensive Care Unit (ICU) Setting: Case Series. Cureus. 2023 January 19;15(1):e33981.DOI
    4. 4.
      Altınkaya Çavuş M, Gökbulut Bektaş GS, Turan S. Comparison of clinical safety and efficacy of dexmedetomidine, remifentanil, and propofol in patients who cannot tolerate non-invasive mechanical ventilation: A prospective, randomized, cohort study. Front Med (Lausanne). 2022;9:995799.DOI