Cardioversion

Cardioversion is a procedure where a heart in an abnormal rhythm is shocked to reset its electrical impulses, hopefully to a normal rhythm. It is, in essence, rebooting the heart. In emergency code situations when a patient's blood pressure is critically low due to an abnormal rhythm, it can be life-saving, but we also do cardioversions electively in someone whose heart rhythm gives them symptoms or limits their activity but cannot be converted with medications alone. As shocking the heart is quite painful, anesthesiology is involved for these quick cases.

I do a quick history and examination of the patient and the EKG. The cardiologist sets up the defibrillator and I set up my mask, draw up some drugs, and check the IV. When everyone's ready, I give a quick bolus of propofol. Once the patient is unresponsive, I start mask-ventilating until the shock. After the shock, we examine the EKG and confirm sinus rhythm. The patient wakes up minutes later without any recall of the event.

I occasionally wonder, with such quick procedures, how necessary it is to have anesthesiologists (and in this case, a resident and a cardiac anesthesia attending), but I've realized we're there for when things go wrong. When everything goes smoothly, the cardioversion can probably be done with a cardiologist directing a nurse. But if the patient aspirates, vomits, has respiratory compromise, goes into an unanticipated heart rhythm, or has any other event, I am prepared to put in a breathing tube, support the blood pressure, and initiate advanced cardiopulmonary resuscitation. Furthermore, recent public events like Michael Jackson's death highlight the serious nature of propofol administration, a drug that anesthesiologists are most familiar and comfortable with as we use it every day.