Pre-procedure |
- Obtain medical history that includes the indication for CV and review records.
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- Document that NPO status is at least 6 hours prior to procedure.
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- 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.
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- Complete ECG to confirm presence of AF or flutter.
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- 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.
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- Interrogate any CIED before CV.
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- Review case with supervising physician.
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Procedure |
- Apply cardioversion skin pads using anterior-posterior or base-apex placement.
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- Connect the pads to a synchronized biphasic defibrillator.
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- Complete a Time-Out procedure pursuant to hospital policy.
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- Anesthesia team provides deep sedation.
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- 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.
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- 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.
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Post procedure |
- Perform ECG.
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- Interrogation of any CIED post procedure.
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- Document post procedure note including appropriate discharge medications.
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- Continue anticoagulation for a minimum of 4 weeks.
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- Update family or friends accompanying patient.
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- Ensure follow-up is arranged.
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