| Pre-procedure |
- Obtain medical history that includes the indication for CV and review records.
|
- Document that NPO status is at least 6 hours prior to procedure.
|
- Confirm appropriate anticoagulation unless onset of AF is <24 to 48 hours:
- For warfarin, document therapeutic INRs (>2.0) for last 4 weeks.
- For non-warfarin oral anticoagulants, confirm no doses missed for last 4 weeks.
- Document therapeutic INR and/or NOAC dose within 12 hrs.
- Perform TEE if OAC has not been therapeutic for at least 4 weeks prior to procedure or if there is a history of prior atrial thrombus.
|
- Complete ECG to confirm presence of AF or flutter.
|
- Obtain consent: review indications, discuss risks and benefits, including potential skin irritation, stroke, abnormal rhythms, and inform patient of the role of each care team member.
|
- Interrogate any CIED before CV.
|
- Review case with supervising physician.
|
| Procedure |
- Apply cardioversion skin pads using anterior-posterior or base-apex placement.
|
- Connect the pads to a synchronized biphasic defibrillator.
|
- Complete a Time-Out procedure pursuant to hospital policy.
|
- Anesthesia team provides deep sedation.
|
- Select initial shock energy:
- AF – begin at 200 to 360 joules.
- Atrial flutter – begin at 50 to 100 joules.
- Atrial tachycardia – begin at 50 joules.
|
- If sinus rhythm was restored but there is an IRAF:
- Resynchronize defibrillator and repeat CV at same energy.
- If IRAF continues, contact supervising physician.
- Consider ibutilide 1 mg IV over 10 minutes with repeat CV after 10 additional minutes.
|
| Post procedure |
- Perform ECG.
|
- Interrogation of any CIED post procedure.
|
- Document post procedure note including appropriate discharge medications.
|
- Continue anticoagulation for a minimum of 4 weeks.
|
- Update family or friends accompanying patient.
|
- Ensure follow-up is arranged.
|
