Effects of nicardipine and labetalol on the acute hemodynamic response to electroconvulsive therapy

Anesthetic care for electroconvulsive therapy

Counselling and medication are often thought of as the only interventions for psychiatric disorders, but electroconvulsive therapy (ECT) has also been applied in clinical practice for over 80 years. ECT refers to the application of an electric stimulus through the patient’s scalp to treat psychiatric disorders such as treatment-resistant depression, catatonia, and schizophrenia. It is a safe, effective, and evidence-based therapy performed under general anesthesia with muscle relaxation. An appropriate level of anesthesia is essential for safe and successful ECT; however, little is known about this because of the limited interest from anesthesiologists. As the incidence of ECT increases, more anesthesiologists will be required to better understand the physiological changes, complications, and pharmacological actions of anesthetics and adjuvant drugs. Therefore, this review focuses on the fundamental physiological changes, management, and pharmacological actions associated with various drugs, such as anesthetics and neuromuscular blocking agents, as well as the comorbidities, indications, contraindications, and complications of using these agents as part of an ECT procedure through a literature review and our own experiences.

The Cardiovascular Side Effects of Electroconvulsive Therapy and Their Management

ABSTRACT

Electroconvulsive therapy (ECT) remains stigmatized in the broader medical community because of misunderstandings about treatment procedures, mortality rates, and cardiovascular complications. Electroconvulsive therapy causes periprocedural hemodynamic variability because of the surges in parasympathetic and sympathetic nervous systems after the administration of the electrical charge. Patients experience an increase in cardiac workload, which is potentially dangerous for patients with preexisting heart disease. Several findings suggest that cardiac complications occur most frequently in patients with underlying cardiovascular disease. We describe the cardiovascular complications that may result from ECT treatment and offer insight on how to mitigate these concerns if they occur. PubMed was queried using terms "electroconvulsive therapy" and "cardiovascular adverse effects." A table is provided with the common cardiovascular side effects of ECT and the most recent evidence-based treatment strategies to manage them. Generally, ECT is a safe procedure in which complications are minor and manageable. Most major complications caused by ECT are related to the cardiovascular system; however, with an appropriate pre-ECT evaluation and a comprehensive multidisciplinary team approach, the cardiovascular complications can be well managed and minimized. Providing proper cardiac clearance can prevent cardiac complications and provide timely care to treatment-resistant populations who are at risk for excessive morbidity and suicide.

Comparison of effect of etomidate with propofol on hemodynamics during modified electroconvulsive therapy

Background and Aims:

Studies comparing the effect of propofol and etomidate on hemodynamic parameters during electroconvulsive therapy (ECT) have shown ambiguous results. Although some studies observed a larger increase in blood pressure and heart rate during the use of etomidate than propofol in ECT, whereas some studies have shown no difference in hemodynamic parameters with the use of etomidate or propofol. Most of the studies done to compare the hemodynamic effects of etomidate and propofol were limited by small sample size or retrospective in nature. Therefore, we conducted a prospective randomized trial to compare the effects of etomidate and propofol on hemodynamics during ECT.

Material and Methods:

A prospective randomized crossover study was conducted on 30 patients with American Society of Anesthesiologist physical status I and II, between age 18 and 65 years, suffering from a mental disorder as per International Classification of Diseases-10 and requiring bilateral ECT as per clinical decision of consultant psychiatrist. They were randomized to receive both the drugs for their successive ECT sessions and were subjected to evaluation after clubbing together the ECT sessions of propofol or etomidate as anesthetic agent.

Results:

Duration of motor seizures was significantly more in patients receiving etomidate, whereas patients receiving propofol had more stable hemodynamics.

Conclusion:

Though propofol maintains stable hemodynamics during MECT, yet clinical applicability of etomidate outstrips it by a reasonable margin due to its better effect on seizure parameters.

Electroconvulsive Therapy in Elderly Patients With Cerebral Aneurysms: A Systematic Review With Clinical Recommendations

INTRODUCTION

Electroconvulsive therapy (ECT) is commonly used in the elderly due to its proven efficacy and safety profile. However, presence of cardiovascular comorbidities such as cerebral aneurysms may complicate the course of treatment. Our knowledge about the possible risk factors and precautionary measures remains limited.

METHODS

We performed a systematic review of published case reports of elderly patients with cerebral aneurysms treated with ECT.

RESULTS

A total of 11 cases were included for the review. One patient died because of subarachnoid hemorrhage (SAH) secondary to ictal hypertensive surge during treatment with ECT.

DISCUSSION

Risk factors such as history of hypertension, age of the patient, extent of the ictal surge in blood pressure, efficacy of prophylactic treatment to control surge in blood pressure and characteristics of cerebral aneurysm each elevated the risk of complication in these cases. We reviewed safety measures based on the evidence from the current literature available.

CONCLUSION

ECT is safe in elderly patients with cerebral aneurysms provided appropriate safety measures are employed. Screening for cerebral aneurysms in high risk patients, effective prevention and management of blood pressure elevation acutely during ECT is the best practice to avoid adverse outcomes.

Changes in cardiac autonomic nervous system activity during a course of electroconvulsive therapy

AIM

Although electroencephalogram (EEG) seizure duration and seizure threshold change during a course of electroconvulsive therapy, the mechanisms by which these factors influence heart rate during subsequent electroconvulsive therapy sessions are currently unclear. In the current study, we investigated changes in heart rate during electroconvulsive therapy.

METHODS

We recorded electroencephalography and electrocardiography during electroconvulsive therapy in 12 patients with major depressive disorder. Baseline heart rate was defined as the mean heart rate in the 30 seconds prior to stimulus onset. The Time_Max peak refers to the maximum heart rate after stimulus onset. Time_1/2 points represent the time points at which the heart rate had decreased to a value midway between the baseline heart rate and the Time_Max peak. We examined the relationships between EEG seizure duration, Time_Max , and Time_1/2 throughout the course of electroconvulsive therapy.

RESULTS

Time_1/2 decreased as the number of electroconvulsive sessions increased. Time_1/2 was positively correlated with EEG seizure duration.

CONCLUSION

The duration in which electroconvulsive therapy-induced sympathetic nervous system activation returned halfway to baseline levels gradually shortened during the course of electroconvulsive therapy.

The Effects of Remifentanil on Hemodynamic Response Attenuation After Electroconvulsive Therapy Under Sevoflurane Anesthesia

PURPOSE

We evaluated the effects of a single loading dose of remifentanil (1 μg/kg) administered as an adjunct to sevoflurane, on the duration of seizure activity, recovery times, and hemodynamic profiles, during electroconvulsive therapy.

METHODS

The patients were randomly allocated to receive sevoflurane-saline (Group SS) or sevoflurane-remifentanil (Group SR). Sevoflurane (8%) was initiated for anesthesia induction in both groups until loss of consciousness was achieved. Remifentanil was then administered to Group SR via a 1-μg/kg intravenous bolus. Patients in Group SS received saline in the same manner. Mean arterial pressure (MAP) and heart rate (HR) were recorded before anesthetic induction (T1), at the loss of consciousness (T2), and at 0, 1, 3, and 10 minutes after the electrical stimuli were completed (T3, T4, T5, and T6, respectively).

RESULTS

Compared with the baseline values, HR increased significantly in Group SS at times T2 and T4 to T6 and decreased significantly in Group SR at time T2. When the groups were compared, we found that HR decreased significantly in Group SR at T2 and T4 to T6. Compared with baseline, MAP increased in Group SS between T3 and T6, and MAP decreased in Group SR at T2 and increased at T3 to T4. Mean arterial pressure decreased to a greater extent in Group SR than in Group SS during the T2 to T6 period. There were no group differences in seizure duration or recovery time.

CONCLUSIONS

The addition of 1-μg/kg remifentanil to anesthetic induction with sevoflurane attenuated the acute hemodynamic response to electroconvulsive therapy under sevoflurane anesthesia without adversely affecting the duration of seizure activity or the recovery profile.

Minimum Effective Doses of Succinylcholine and Rocuronium During Electroconvulsive Therapy: A Prospective, Randomized, Crossover Trial

BACKGROUND

Neuromuscular blockade is required to control excessive muscle contractions during electroconvulsive therapy (ECT). In a crossover, assessor-blinded, prospective randomized study, we studied the minimum effective dose (MED) of succinylcholine and rocuronium for ECT. The MED was the lowest dose to provide a predefined qualitative measure of acceptable control of muscle strength during induced convulsions.

METHODS

Succinylcholine (0.8 mg kg) or rocuronium (0.4 mg kg) was randomly administered in 227 ECT sessions to 45 patients. The dose was incrementally increased or decreased by 10% based on 2 psychiatrists' (blinded to treatment) assessment of "acceptable" or "not acceptable" control of evoked muscle contractions (sufficient versus insufficient or excessive paralysis). The neuromuscular transmission was monitored quantitatively until full recovery.

RESULTS

In our study, the MEDs of succinylcholine and rocuronium to produce acceptable ECT conditions in 50% of patients (MED50ECT) were 0.85 mg kg (95% confidence interval [CI], 0.77-0.94) and 0.41 mg kg (95% CI, 0.36-0.46) and in 90% of patients (MED90ECT) were 1.06 mg kg (95% CI, 1.0-1.27) and 0.57 mg kg (95% CI, 0.5-0.6), respectively. Nadir twitch height for acceptable muscle activity was 0% (0-4) and 4% (0-30; P < 0.001), respectively, and the time to recovery of the neuromuscular transmission was 9.7 ± 3.5 and 19.5 ± 5.7 minutes, respectively.

CONCLUSIONS

A twitch suppression of >90% is needed for control of motor contractions during ECT. The initial ECT dose of succinylcholine should be selected based on each patient's preprocedural condition, ranging between 0.77 and 1.27 mg kg to produce acceptable muscle blockade in 50% to 90% of patients. Rocuronium-neostigmine combination is a safe alternative if appropriately dosed (0.36-0.6 mg kg) and monitored.

Effects of nicardipine on the onset time and intubation conditions of rocuronium-induced neuromuscular blockade

STUDY OBJECTIVE

The objective of this study was to identify the effects of nicardipine on neuromuscular blockade of rocuronium, such as the onset time and intubation conditions, using a nicardipine dose that attenuates cardiovascular responses during endotracheal intubation.

DESIGN

Randomized, double-blinded, placebo-controlled clinical comparison was used as the design of this study

SETTING

The study was conducted at the operating room of a university hospital.

PATIENTS

Participants of this study comprise 78 American Society of Anesthesiologists physical status 1 and 2 patients, aged 18 to 60 years who were undergoing elective surgery under general anesthesia.

INTERVENTIONS

The nicardipine group was given an intravenous bolus of 20 μg/kg nicardipine before tracheal intubation: the control group was given an intravenous bolus of a comparable volume of normal saline before tracheal intubation.

MEASUREMENTS

Using a TOF-Watch SX monitor, the time from the end of the injection of rocuronium to maximum depression of T1 (onset time) was measured. Intubation was performed 1 minute after rocuronium administration, and the status of the intubation conditions was assessed. The mean blood pressure and heart rate were each measured after endotracheal intubation. Rate pressure product values were also calculated.

MAIN RESULTS

Intubation conditions were clinically acceptable in 37 (94.9%) of 39 patients in group N compared with 29 (74.4%) of 39 in group C (P < .05). The onset time of rocuronium was significantly faster in group N than in group C (P < .05). The mean blood pressure was significantly lower in group N than in group C (P < .05). The heart rate was significantly higher in group N than in group C (P < .05). Rate pressure product values showed no significant difference between the two groups (P > .05).

CONCLUSIONS

Pretreatment with 20 μg/kg nicardipine improves intubation conditions, shortens the onset time of rocuronium, and attenuates cardiovascular responses to tracheal intubation.

Beta-blocking agents during electroconvulsive therapy: a review

Electroconvulsive therapy (ECT) is associated with at least transient episodes of hypertension and tachycardia. Beta-blocking agents may be indicated to prevent cardiovascular complications and may shorten seizure duration. This review evaluates studies that used beta-blocking agents during ECT to determine which agent has the most favourable outcomes on cardiovascular variables and seizure duration. A Medline database search was made using the combined keywords 'adrenergic beta-antagonists' and 'electroconvulsive therapy'. The search was restricted to double-blind randomized controlled trials and yielded 29 original studies. With the use of esmolol, significant attenuating effects were found on cardiovascular parameters in the first 5 min after stimulation; its shortening effects on seizure duration may be dose-related. With the use of labetalol, findings on cardiovascular effects were inconsistent during the first minutes after stimulation but were significant after 5 min and thereafter; seizure duration was scarcely studied. Landiolol attenuates heart rate but with inconsistent findings regarding arterial pressure (AP); seizure duration was mostly unaffected. Esmolol appears to be effective in reducing the cardiovascular response, although seizure duration may be affected with higher dosages. Landiolol can be considered a suitable alternative, but effects on AP need further investigation. Labetalol has been studied to a lesser extent and may have prolonged cardiovascular effects. The included studies varied in design, methodology, and the amount of exact data provided in the publications. Further study of beta-blocking agents in ECT is clearly necessary.

The role of electroconvulsive and neuromodulation therapies in the treatment of geriatric depression

Geriatric depression is associated with increased mortality because of suicide and decreases in functional and physical health. Many elders' depression is resistant to psychotherapy and medication and can become chronic. Electroconvulsive therapy (ECT) is increasingly used in the treatment of medication-resistant or life-threatening geriatric depression. Neuromodulation therapies (subconvulsive, focal, or subconvulsive and focal) are alternatives for the management of treatment-resistant depression in the elderly. Therapies that combine both strategies could be safer but may not be as effective as ECT. This review covers the evidence on the safety and efficacy of ECT and the neuromodulation therapies in geriatric depression.

Comparative prophylactic and therapeutic effects of intravenous labetalol 0.4 mg/kg and nicardipine 20 μg/kg on hypertensive responses to endotracheal intubation in patients undergoing elective surgeries with general anesthesia: a prospective, randomized, double-blind study

BACKGROUND

Laryngoscopy and tracheal intubation (LTI) after induction of general anesthesia often cause hypertension and tachycardia. Labetalol and nicardipine have been used to prevent and treat acute cardiovascular responses to LTI.

OBJECTIVE

The goal of this study was to compare the preventive and therapeutic effects of labetalol 0.4 mg/kg IV and nicardipine 20 μg/kg IV on hypertensive responses to LTI during induction of general anesthesia.

METHODS

Patients undergoing general anesthesia were randomly allocated to 4 groups. In part I (prevention), 80 patients were randomized to receive either 0.4 mg/kg of labetalol (n = 40) or 20 μg/kg of nicardipine (n = 40) 4 minutes before LTI. In part II (treatment), patients were randomized to receive 0.4 mg/kg of labetalol (n = 40) or 20 μg/kg of nicardipine (n = 40) after LTI if hypertension occurred. The number of additional study drug doses required by patients with hypertension (parts I and II) and time to return to normotension (part II) were recorded. Mean arterial pressure and heart rate were monitored, and rate-pressure product was calculated. Adverse events were also monitored.

RESULTS

A total of 130 patients (72 patients in part I and 58 patients in part II) were included in the analysis. In parts I and II, the number of patients who required additional doses of the study drug because of persistent hypertension was lower in the nicardipine groups than in the labetalol groups (P < 0.05). Mean arterial pressure was lower and heart rate was significantly higher over time in the nicardipine groups compared with the labetalol groups (P < 0.05) in parts I and II. In part II, time to return to normotension was shorter in the nicardipine treatment group than in the labetalol treatment group (61 [21] vs 130 [46] seconds; P = 0.01). No statistical differences were observed in the incidence of adverse events except for tachycardia in part I (2 cases in the labetalol prevention group vs 18 cases in the nicardipine prevention group; P = 0.01).

CONCLUSIONS

Patients who received nicardipine were less likely to require additional doses for either the prevention or treatment of hypertensive responses to LTI and responded to the study drug more rapidly than patients who received labetalol for the treatment of hypertensive responses to LTI. However, labetalol was associated with a lower incidence of tachycardia and less of an increase in rate-pressure product when used for the prevention of hypertension during LTI.

Prophylactic continuous administration of landiolol, a novel β1 blocker, blunts hyperdynamic responses during electroconvulsive therapy without altering seizure activity

Abstract Objective. In previous reports, it has been shown that many drugs may act against hyperdynamic responses during electro-convulsive therapy (ECT). The aim of this study was to conduct a randomized, placebo-controlled crossover study to investigate the hemodynamic responses and seizure duration during ECT by continuous administration of two doses of landiolol, a novel short-acting β1-adrenergic blocker, including standard and high-dose. Methods. Thirty-two patients undergoing ECT participated in this study. The control treatment was infusion of saline alone. The standard-dose of landiolol, 0.125 mg/kg per min, was infused over a 1-min period as a standard treatment. The high-dose landiolol treatment was 0.25 mg/kg per min, also infused over a 1-min period. After landiolol treatments, patients received landiolol at 0.04 mg/kg per min. Propofol and succinylcholine was then administered, and electrical stimulation was applied. Results. Both peak heart rate and mean arterial pressure after ECT was lowest with high-dose landiolol treatment. Motor and EEG seizure duration did not differ among the treatments. Conclusion. The results of this study show that high-dose landiolol treatment blunts hyperdynamic responses during ECT. Furthermore, landiolol does not reduce the seizure duration.

Myocardial stunning after electroconvulsive therapy in patients with an apparently normal heart

Myocardial stunning refers to contractile dysfunction that persists after an ischemic episode and restoration of coronary blood flow. In this article, 2 cases of myocardial stunning after electroconvulsive therapy in patients with an apparently normal heart are presented. The incidence of this condition is unknown. It is observed that this condition seems to occur in females and in the obese and is generally associated with rapid recovery. This occurrence seems to be brought about by autonomic changes that occur during electroconvulsive therapy. Several drugs have been used to ameliorate the condition, although studies were limited to establish efficacy of regimens.

Effects of landiolol on hemodynamic response and seizure duration during electroconvulsive therapy

PURPOSE

This study was done to evaluate the effect of landiolol, an ultra-short-acting beta-blocker, on the hemodynamic response and the duration of seizure activity during electroconvulsive therapy (ECT).

METHODS

We designed a prospective, randomized, double-blinded, placebo-controlled, crossover study. Fourteen psychiatric patients participated. Landiolol (0.1 mg x kg(-1) or 0.2 mg x kg(-1)) or saline (placebo) was administered IV 1 min before the induction of anesthesia. Unconsciousness was induced with propofol 1.0 mg x kg(-1) IV, and muscle paralysis was produced with succinylcholine 0.6 mg x kg(-1) IV. Subsequently, electrical stimulus was administered to elicit a seizure, and the duration of the motor seizure activity was noted.

RESULTS

The heart rate (HR) and rate-pressure product (RPP) before ECT were significantly decreased in the 0.2 mg x kg(-1) landiolol group compared with these parameters in the placebo and 0.1 mg x kg(-1) landiolol groups. Both the 0.1 mg x kg(-1) and 0.2 mg x kg(-1) doses significantly attenuated the degree of tachycardia and RPP after ECT in comparison with the placebo group. Pretreatment with 0.2 mg x kg(-1) landiolol resulted in a significantly shorter duration of motor seizure than that in the placebo group (21 +/- 13 s vs 27 +/- 12 s).

CONCLUSION

As the landiolol dose of 0.2 mg x kg(-1) caused shorter seizure duration, and because the hemodynamic effects after ECT of the 0.1 mg x kg(-1) and 0.2 mg x kg(-1) doses were similar, it was concluded that a 0.1 mg x kg(-1) landiolol bolus was the appropriate dose pretreatment before ECT.

Intravenous Nicardipine

Nicardipine is a water soluble calcium channel antagonist, with predominantly vasodilatory actions. Intravenous (IV) nicardipine (Cardene IV), which demonstrates a relatively rapid onset/offset of action, is used in situations requiring the rapid control of blood pressure (BP). IV nicardipine was as effective as IV nitroprusside in the short-term reduction of BP in patients with severe or postoperative hypertension. A potential role for IV nicardipine in the intraoperative acute control of BP in patients undergoing various surgical procedures (including cardiovascular, neurovascular and abdominal surgery), and in the deliberate induction of reduced BP in surgical procedures in which haemostasis may be difficult (e.g. surgery involving the hip or spine) was demonstrated in preliminary studies. Preliminary studies also indicated the ability of a bolus dose of IV nicardipine to attenuate the hypertensive response, but not the increase in tachycardia, after laryngoscopy and tracheal intubation in anaesthetised patients. In large, well designed studies, IV nicardipine prevented cerebral vasospasm in patients with recent aneurysmal subarachnoid haemorrhage; however, overall clinical outcomes at 3 months were similar to those in patients who received standard management. Small preliminary studies have investigated the use of IV nicardipine in a variety of other settings, including acute intracerebral haemorrhage, acute ischaemic stroke, pre-eclampsia, acute aortic dissection, premature labour and electroconvulsive therapy.In conclusion, the efficacy of IV nicardipine in the short-term treatment of hypertension in settings for which oral therapy is not feasible or not desirable is well established. The ability to titrate IV nicardipine to the tolerance levels of individual patients makes this agent an attractive option, especially in critically ill patients or those undergoing surgery. Potential exists for further investigation of the use of this agent in clinical settings where a vasodilatory agent with minimal inotropic effects is appropriate.

The use of nicardipine for electroconvulsive therapy: a dose-ranging study

A wide variety of vasoactive drugs have been used to treat the acute hypertensive response to electroconvulsive therapy (ECT). We designed this randomized, double-blind, saline-controlled, crossover study to compare three different doses of nicardipine when administered before the ECT stimulus. Twenty-five patients undergoing a series of 4 ECT treatments received bolus injections of either saline or nicardipine 20, 40, or 80 mug/kg IV in a random sequence during a standardized methohexital (1 mg/kg) and succinylcholine (1 mg/kg) anesthetic technique. The mean arterial blood pressure (MAP) and heart rate values were recorded at specific time intervals, as were the duration of seizure activity and the need for rescue labetalol. Both the 40 and 80 mug/kg doses of nicardipine reduced the percentage increase in MAP above the baseline value compared with the saline group (7% and 7% versus 30%, respectively). Nicardipine 40 and 80 mug/kg were also associated with a significant reduction in the need for labetalol (7 +/- 3 mg and 5 +/- 0 mg versus 22 +/- 10 mg in the saline group). Compared with the 40 mug/kg dose, nicardipine 80 mug/kg was associated with a more rapid heart rate at the time the ECT stimulus was applied. The 80 mug/kg dose was also associated with a reduced MAP value on awakening compared with the baseline value (91 +/- 12 mm Hg versus 102 +/- 8 mm Hg). We conclude that a bolus injection of nicardipine 40 mug/kg IV immediately before the ECT stimulus was optimal for controlling the acute hemodynamic response to ECT treatments.

Landiolol attenuates acute hemodynamic responses but does not reduce seizure duration during maintenance electroconvulsive therapy

Maintenance electroconvulsive therapy (mECT) is an outpatient procedure that requires further consideration in terms of management of ambulatory anesthesia. Although many adjunctive drugs for stabilizing hemodynamic changes during ECT have been reported, side-effects of these drugs may delay recovery and discharge from hospital. The effects of landiolol, a novel ultra-short-acting beta-adrenergic blocker, have been measured on seizure duration, hemodynamic changes, recovery from anesthesia, and cognitive function during mECT under propofol anesthesia. A total of 10 patients with depression in the remission phase, were studied in a randomized, double-blind, placebo-controlled, crossover manner. Administration of 0.1 mg/kg of landiolol immediately before anesthesia significantly blunted the increase in heart rate and blood pressure during convulsions compared with placebo; landiolol was not associated with excessive hypotension or bradycardia. Landiolol did not affect seizure duration, recovery from anesthesia, or cognitive function before or after ECT. These results suggest that landiolol can be used effectively and safely during mECT.

The effect of remifentanil on seizure duration and acute hemodynamic responses to electroconvulsive therapy

We designed this prospective, randomized, double-blinded, placebo-controlled, crossover study to evaluate the effect of different doses of remifentanil on the acute hemodynamic response and duration of seizure activity after a standardized electroconvulsive therapy (ECT) stimulus. Twenty consenting patients with major depressive disorders receiving maintenance ECT participated in this study. Eighty ECT treatments were evaluated. All patients were premedicated with glycopyrrolate 0.2 mg IV, unconsciousness was induced with methohexital 1 mg/kg IV, and muscle paralysis was produced with succinylcholine 1.2 mg/kg IV. Subsequently, patients received 1 of 3 different doses of remifentanil 25, 50, and 100 microg or saline (control) in a random sequence immediately after methohexital at 4 consecutive ECT treatments. Labetalol, in 5-mg IV boluses, was used as a rescue antihypertensive medication. A fixed suprathreshold electrical stimulus was administered to elicit a seizure, and the times from the stimulus to the cessation of the motor and electroencephalographic (EEG) seizure activity were noted. Pre- and post-ECT blood pressure values were significantly decreased in the 100- microg remifentanil group compared with the control group. The durations of motor (38 +/- 9 s to 43 +/- 15 s) and EEG (55 +/- 29 s to 60 +/- 21 s) seizure activity were not significantly different among the four groups. Similarly, recovery times to eye opening, obeying commands, and discharge from the recovery room did not differ among the four study groups. The requirement for labetalol after ECT was nonsignificantly decreased in the remifentanil groups. In conclusion, remifentanil 100 microg IV attenuated the acute hemodynamic response to ECT. Furthermore, remifentanil had no adverse effect on the duration of ECT-induced seizure activity. Finally, adjunctive use of remifentanil did not prolong recovery times or increase post-ECT side effects.

IMPLICATIONS

Remifentanil (100 microg IV) attenuated the acute hemodynamic response after electroconvulsive therapy (ECT) without adversely affecting the length of the ECT-induced seizure activity or prolonging recovery times.

Effective use of electroconvulsive therapy in late-life depression

OBJECTIVE

To review literature pertaining to the efficacy, safety, and tolerability of electroconvulsive therapy (ECT) in treating late-life depression.

METHOD

We undertook a literature review with an emphasis on research studies published in the last 10 years.

RESULTS

There is a positive association between advancing age and ECT efficacy. Age per se does not necessarily increase the risk of cognitive side effects from ECT, but this risk is increased by age-associated neurological conditions such as Alzheimer's dementia and cerebrovascular disease. With appropriate evaluation and monitoring, ECT can be used safely in patients of very advanced age and in those with serious medical conditions. Several technical factors, including dose of electricity relative to a patient's seizure threshold, position of electrodes, frequency of administration, and total number of treatments, have an impact on the efficacy and cognitive side effects of ECT and need to be taken into account when administering ECT. Naturalistic studies have found that 50% of more of patients have a relapse of depression within 6 to 12 months of discontinuing acute ECT.

CONCLUSIONS

In recent years, there has been substantial progress in our understanding of the effect of technical factors on the efficacy and cognitive side effects of ECT. When administered in an optimal manner, ECT is a safe, well-tolerated, and effective treatment in older patients. Relapse of depression after response to ECT remains a significant problem, and there is a need for further research into the prediction and prevention of post-ECT relapse.

Intravenous verapamil blunts hyperdynamic responses during electroconvulsive therapy without altering seizure activity

IMPLICATIONS

A dose of 0.1 mg/kg of verapamil, administered immediately before anesthesia, significantly reduces the increase in peak heart rate and mean arterial blood pressure after electroconvulsive therapy. Furthermore, the administration of verapamil does not reduce the duration of the seizure.

Comparative hemodynamic effects of urapidil and labetalol after electroconvulsive therapy

Urapidil, a postsynaptic alpha 1 -adrenergic antagonist, has been reported to improve intraoperative hemodynamic stability, although it has never been used to prevent the hemodynamic response of electroconvulsive therapy (ECT). This study was designed to evaluate the clinical effectiveness of urapidil, as an alternative to labetalol, in preventing the hemodynamic response of ECT. Twenty-seven patients undergoing a series of six consecutive ECT treatments were studied. Each patient received all three pretreatments twice: no drug, labetalol 0.2 mg/kg, or urapidil 25 mg. Systolic, diastolic, and mean blood pressure and heart rate (HR) were recorded during the awake state, after anesthesia induction, and 1, 2, 5, 10 and 30 minutes after electroencephalographic (EEG) seizure ended. The duration of the EEG convulsion was also recorded. After induction, the HR increased for no drug and urapidil pretreatments, whereas it decreased when labetalol was given. Labetalol and urapidil attenuated the peak increase of blood pressure and returned it to earlier baseline values. There were no differences in the duration of EEG convulsion between the three pretreatments. Urapidil seems to be a good alternative to labetalol for attenuating the hypertensive response to ECT in cases where there is a contraindication to beta-antagonists.

Update on electroconvulsive therapy (ECT) in older adults

Electroconvulsive therapy (ECT) is used increasingly in the older adult population for major depression, particularly when depression is not responsive to medications, when antidepressants are not tolerated due to side effects, or when depression is accompanied by life-threatening complications such as severe weight loss or catatonia where a rapid definitive response is required. ECT is considered a low-risk procedure that can be successfully done in medically ill older adults, but it is associated with a brief period of increased blood pressure and pulse leading to increased myocardial oxygen demand. ECT may cause delirium, particularly in the cognitively impaired older. As successful management of older patients undergoing a course of ECT often involves geriatricians and other medical practitioners, this review provides an update on the indications for ECT, how it is done, the common complications seen after the procedure, and its efficacy. Finally, specific recommendations for management are made.