CC Cardiol Croat Cardiologia Croatica Cardiol. Croat. 1848-543X 1848-5448 Croatian Cardiac Society CC 2026 21_1-2_46-7 10.15836/ccar2026.46 Extended Abstract Interdisciplinary approach to the patient with cardiovascular disease Sedation options in a cardiac catheterization laboratory and coronary care unit: protocol review and clinical experience from General Hospital Slavonski Brod https://orcid.org/0009-0002-9918-7575SilovićJosip1* https://orcid.org/0000-0003-4600-0498MiškovićDomagoj1 https://orcid.org/0009-0006-0014-6642MajdandžićIvan1 https://orcid.org/0000-0002-8727-7357Knežević PravečekMarijana12 https://orcid.org/0000-0001-6188-0708Cvitkušić LukendaKatica12 General Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health Osijek, Osijek, Croatia ADDRESS FOR CORRESPONDENCE: Josip Silović, Opća bolnica Dr. Josip Benčević, Andrije Štampara 42, HR-35000 Slavonski Brod, Croatia. / Phone: +385-91-552-5995 / E-mail: jsilovic93@gmail.com 122025 122025 21 1-2 46 47 19102025 14112025 Croatian Cardiac Society 2025 Croatian Cardiac Society KEYWORDS: coronary care unitsedationpropofoldexmedetomidineremifentanil

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.

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
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.

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