Remimazolam for direct current cardioversion

Abstract

Remimazolam is a novel short-acting GABA-A agonist. We introduced remimazolam sedation to an existing nurse-led direct current cardioversion (DCCV) service using midazolam and assessed the impact on time to patient discharge, patient safety, satisfaction, and efficiency-related cost savings. To our knowledge, this is the first such use of remimazolam for DCCV in the UK. We performed a service evaluation of the introduction of remimazolam sedation to a nurse-led DCCV service at a large dedicated cardiac hospital. The project was registered with our clinical effectiveness unit as a non-research evaluation. Patients routinely selected for nurse-led DCCV were included. A remimazolam administration standard operating procedure was developed, and patients received remimazolam sedation when anaesthetic support was available (midazolam sedation on alternate days). Progression from an anaesthetic-led service to an autonomous nurse-led service occurred during the evaluation. We recorded time to DCCV, recovery and discharge, pre- and post-procedure physiology, patient satisfaction, and adverse events, using a case report form, the Iowa sedation questionnaire, and World Society of Intravenous Anaesthesia adverse event reporting tool. A cost analysis was also performed. During the 9-month project period, 48 patients were included (19 midazolam, 29 remimazolam). Baseline characteristics were similar. Median total dose administered was 4 mg in the remimazolam group and 5 mg in midazolam group. Median times from drug administration to DCCV, being alert, and discharge from recovery with remimazolam and midazolam were 2 (interquartile range IQR] 1-4) vs 7 (IQR 4-7), 7 (IQR 5-11) vs 11 (IQR 10-18), and 15 (IQR 11-18) vs 26 (IQR 22-28) min, respectively. Median time from drug administration to hospital discharge was 101 (IQR 84-131) min with remimazolam and 168 (IQR 157-187) min with midazolam, with median of differences 67, 95% confidence interval 51-86 min, and P1 In this evaluation, remimazolam was associated with a reduction in time to onset and offset of sedation for elective DCCV and time to discharge (as compared with midazolam). The small number of adverse events reinforced the need for effective sedation training for nurse-led services. Remimazolam for nurse-led DCCV offers an alternative to midazolam that was associated with reduced time to patient discharge and an opportunity for cost saving while maintaining patient satisfaction and safety.