Acute and Prophylactic Management of Postictal Agitation in Electroconvulsive Therapy

Tolerability and Clinical Outcomes With Anesthesia Dose Reduction During Electroconvulsive Therapy

Importance

Electroconvulsive therapy (ECT) practice during the COVID-19 pandemic necessitated restriction of bag-valve mask (BVM) ventilation to minimize disease transmission through aerosolization. To reduce BVM use, many sites decreased doses of anesthesia agents, but the associations of such dose reduction with clinical and tolerability outcomes are unknown.

Objectives

To investigate the association of COVID-19 pandemic modifications in ECT, including reduction in anesthetic dosage and BVM use, with the rates of clinical complications and clinical outcomes.

Design, Setting, and Participants

This retrospective cohort study included data from patients receiving an index course of ECT for any clinical indication treated with methohexital and succinylcholine between March 16, 2017, and March 15, 2023, at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada. Data analysis occurred from February to December 2024.

Exposure

Participants were split into 2 cohorts: pre-COVID-19 (treated between March 2017 and March 2020) and COVID-19 (treated between June 2020 and March 2023).

Main Outcomes and Measures

The primary outcomes were BVM use and rates of complications (specifically, aspiration, bradycardia, insufficient initial sedation dosage, postictal agitation [PIA], residual weakness, and prolonged seizures). Secondary outcomes were rates of response and cognitive impairment. Multivariable logistic regression was used to assess associations of COVID-19 pandemic modifications with outcomes.

Results

A total of 616 individuals (median [IQR] age, 45.0 [31.0-59.0] years; 342 female [55.5%]) were included in the analysis, with 362 in the pre-COVID-19 group and 254 in the COVID-19 group. Demographic and clinical characteristics were similar. The COVID-19 group received lower median (IQR) methohexital dosages (0.82 [0.72-0.96] mg/kg vs 0.87 [0.78-1.00] mg/kg; P = .007) and succinylcholine (0.33 [0.27-0.39] mg/kg vs 0.53 [0.45-0.59] mg/kg; P < .001) than the pre-COVID-19 group. The COVID-19 group had higher odds of insufficient initial sedation dosage (odds ratio, 2.16, 95% CI, 1.09-4.38) and PIA (odds ratio, 2.81; 95% CI, 1.76-4.56), with no difference for other complications. BVM use was reduced from standard use to 13.8% (35 individuals) during COVID-19. Groups were similar in the rates of response (pre-COVID-19, 246 individuals [68.0%]; COVID-19, 181 individuals [71.3%]; P = .38) and cognitive impairment (pre-COVID-19, 75 individuals [20.7%]; COVID-19, 49 individuals [19.3%]; P = .66).

Conclusions and Relevance

In this retrospective cohort study, reduction of anesthesia agents was associated with reduced BVM use, with similar clinical outcomes and tolerability other than increased rates of insufficient initial sedation dosage and PIA, suggesting that management of PIA with this anesthesia dosing strategy warrants further investigation.

Effectiveness and Safety of Flumazenil Augmentation During Electroconvulsive Therapy

INTRODUCTION

Benzodiazepines are considered to negatively affect seizure quality and duration during electroconvulsive therapy (ECT). Several researchers have advocated the use of flumazenil, a competitive benzodiazepine receptor antagonist, for patients treated with benzodiazepines during ECT. However, clinical evidence regarding flumazenil use in ECT remains sparse. The aim of this study is to investigate the effects of flumazenil on seizure duration and adverse effects.

METHODS

All patients with depressive disorders, treated with flumazenil during a course of ECT in 2019 in a tertiary hospital, were identified through a retrospective chart review. Seizure duration was recorded before and after flumazenil administration. Effectiveness of ECT was assessed using the Inventory of Depressive Symptomatology and the Bush-Francis Catatonia Rating Scale. Postictal agitation was ascertained by identifying patients who received additional sedatives immediately after ECT or who needed physical restraint.

RESULTS

Twenty-six patients were included, receiving a total of 363 treatments, of which 263 were augmented with flumazenil. Flumazenil administration increased electroencephalogram seizure duration on average with 10.5 seconds comparing ECT with or without flumazenil ( P = 0.003). In 21.8% of the cases, no increase in seizure duration was observed. Postictal agitation occurred at least once in 34.6% of the patients receiving flumazenil during their course of ECT.

CONCLUSION

Our results show that flumazenil increases seizure duration, albeit with limited clinical implications. Noteworthy, the prevalence of postictal agitation is high. When confronted with short seizures, clinicians should therefore deploy other available techniques to lower seizure threshold before considering flumazenil.

Pharmacological prevention of postictal agitation after electroconvulsive therapy-A systematic review and meta-analysis

Background

Postictal agitation (PIA) after electroconvulsive therapy (ECT) is a serious clinical problem estimated to occur in 7-36% of patients and recur in 19-54% of patients. PIA has the potential to cause dangerous situations for the patient and staff members aside from the financial impact. To date, it is unclear which pharmacological interventions should be used in the management of PIA. This study aimed to systematically review the (preventative) pharmacological treatment options for PIA after ECT.

Method

A systematic search was done in PubMed, EMBASE, PsycINFO, and Web of Science from inception until 10 November 2022. We included randomized trials with any pharmacological intervention or comparison and a predefined outcome measure on PIA. Studies that solely included patients with neurodegenerative disorders or stroke were excluded. Data quality was assessed with the RoB2 and GRADE. Meta-analysis was performed if possible. This study was registered on PROSPERO under CRD42021262323.

Results

We screened 2,204 articles and included 14 studies. Dexmedetomidine was investigated in 10 studies. Alfentanil, lignocaine, esmolol, midazolam, propofol, ketamine, haloperidol, and diazepam were each studied in only one study. Meta-analysis revealed an OR of 0.45 (0.32-0.63), a moderate effect size, in favor of dexmedetomidine than placebo to prevent PIA with very low heterogeneity (I² = 0%). The certainty of the evidence was moderate. The other interventions studied were all found to have low certainty of evidence.

Conclusion

For clinical practice, we believe that our results indicate that dexmedetomidine should be considered for the prevention of PIA in patients that have previously experienced PIA.