PSA may be used for any procedure in which a patient’s pain or anxiety may be excessive and may impede successful completion of the procedure. Common cardiology procedures include electrical cardioversion, transesophageal echocardiogram, diagnostic and ablation procedures for cardiac arrhythmias, coronary angiography, transcutaneous valve replacements and repair, and insertion of implantable electronic device [2].

There are no absolute contraindications to PSA. Relative contraindications may include older age, significant medical comorbidities and signs of a difficult airway. In older patients, sedating agents should be given at a lower starting dose, using slower rates of administration and repeated dosing of medications at less frequent intervals. Patients with major comorbid medical conditions are at increased risk for adverse events however there is no evidence that alternative approaches (monitored anesthesia care or general anesthesia) are safer. PSA is relatively contraindicated in patients who are likely to be difficult to ventilate or oxygenate. Patients who have eaten recently are not contraindicated to PSA, however if a procedure is not emergent, the American Society of Anesthesiologists (ASA) recommends that the patient fast for 2 h after drinking clear liquids and 6 h after ingesting solid foods or cow’s milk [1].

Intravenous access should be established. Patients should have constant cardiac and respiratory monitoring, with careful monitoring of blood pressure, heart rate, respiratory rate, oxygen saturation, end-tidal carbon dioxide level and cardiac rhythm. Supplemental oxygen is often recommended to maintain oxygen levels during hypoventilation. In the event of respiratory compromise, equipment for performing endotracheal intubation and managing the airway should be readily available. Resuscitation medications, including medications for advanced life support and reversal agents should be available at bedside [1].

Ideal pharmacologic agents for PSA will have rapid onset and short duration of action, maintain hemodynamic stability and lack major side effects (Table 16.2). Some shorter procedures may be performed with the patient awake or only lightly sedated with concomitant local anesthesia. Agents that depress cardiac function may be problematic during ablation of ventricular tachycardia. Pre-oxygenation should usually accompany sedative administration [1].