Glycopyrrolate prevents extreme bradycardia and cerebral deoxygenation during electroconvulsive therapy

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.

The Role of Voltage-Gated Sodium Channel 1.8 in the Effect of Atropine on Heart Rate: Evidence From a Retrospective Clinical Study and Mouse Model

Atropine is commonly used to counter the effects of the parasympathetic neurotransmitter acetylcholine on heart rate in clinical practice, such as in the perioperative period; however, individual differences in the response to atropine are huge. The association between SCN10A/voltage-gated sodium channel 1.8 (Na_V1.8) and cardiac conduction has been demonstrated; however, the exact role of SCN10A/Na_V1.8 in the heart rate response to atropine remains unclear. To identify the role of SCN10A variants that influence the heart rate responses to atropine, we carried out a retrospective study in 1,005 Han Chinese subjects. Our results showed that rs6795970 was associated with the heart rate response to atropine. The heart rate responses to atropine and methoctramine in Na_V1.8 knockout mice were lower, whereas the heart rate response to isoproterenol was like those in wild type mice. Furthermore, we observed that the Na_V1.8 blocker A-803467 alleviated the heart rate response to atropine in wild type mice. The retrospective study revealed a previously unknown role of Na_V1.8 in controlling the heart rate response to atropine, as shown by the animal study, a speculative mechanism that may involve the cardiac muscarinic acetylcholine receptor M2.

Cerebral Oxygen Saturation During Electroconvulsive Therapy: A Secondary Analysis of a Randomized Crossover Trial

BACKGROUND

Electroconvulsive therapy (ECT) causes acute changes in cerebral perfusion and oxygenation. Near-infrared spectroscopy is a novel, noninvasive technique to assess cerebral oxygen saturation (cSO2). We hypothesized that cSO2 increases during ECT and more so with atropine premedication and decreases when systemic desaturation (peripheral oxygen saturation <90%) occurs during ECT.

METHODS

We performed a secondary analysis of a randomized trial of patients undergoing ECT for psychiatric illness during a 6-month period. During the second ECT session, patients were randomly assigned to receive either 0.01 mg/kg IV atropine or no atropine. During the third ECT session, patients were crossed over. Standard anesthetic management was performed. Data with regard to heart rate, blood pressure, peripheral oxygen saturation, and cSO2 were collected at baseline and continuously examined for 5 minutes from delivery of ECT stimulus.

RESULTS

Forty-one patients underwent 82 ECT sessions. ECT resulted in significant increase in cSO2 during both the atropine and the no-atropine sessions (P<0.001 for both) but no between-session difference was observed (mean difference, 1.9±2.0; 95% confidence interval, -2.0, 5.9; P=0.337). The cSO2 values were lower in patients who developed systemic desaturation when compared with the cSO2 values in those who did not (mean difference, 5.0±2.6; 95% confidence interval -0.1, 10.2; P=0.054). However, the mean cSO2 was >60% at any measured time point, even in those with systemic desaturation.

CONCLUSIONS

ECT increased cSO2 irrespective of atropine premedication. cSO2 was lower when systemic desaturation occurred. Future studies should explore the effect of cerebral oxygenation changes during ECT on outcome of psychiatric conditions.

Effect of Premedication with Oral Clonidine on Hemodynamic Response during Electroconvulsive Therapy

Background:

Electroconvulsive therapy (ECT) is the most effective treatment available for the acute treatment of depression in patients who do not respond to medications. It is generally used as a second line treatment for many psychological disorders, mainly major depression and schizophrenia where medication is not effective. ECT is often associated with some complications such as hypertension, tachycardia arrhythmia and even myocardial infarction. Various methods have been used for prevention or control of these cardiovascular side effects.

Aim:

The aim of this study was evaluating the effect of oral clonidine (0.3 mg) with control group to know the effect of oral clonidine on hemodynamic response during ECT.

Methods and Material:

This prospective randomized crossover clinical trial was performed on 25 patients aged 20-50 years, weight 50-70 kg with ASA I and II who were candidates for ECT. Prior to ECT, each patient received oral doses of clonidine (0.3 mg) or a placebo 90 minutes before ECT. Baseline Heart rate, systolic, diastolic and mean arterial pressures were noted just before securing the intravenous cannula. The same parameters were noted after induction, immediately after seizure cessation following delivery of the electric shock and at 1 minute interval for 10 minutes.

Statistical Analysis:

Data was analyzed by ANOVA test (analysis of variance). P < 0.05 was considered statistically significant.

Results:

Attenuation of maximum rise in the heart rate and mean arterial pressure by clonidine (0.3 mg) was evident and statistically significant when compared with control group.

Conclusion:

Oral clonidine (0.3 mg) decreases the acute hypertensive response after electroconvulsive therapy; however, this antihypertensive effect was achieved by decreasing the blood pressure before the electrical stimulus.

Predictors of bradycardia during the stimulation phase of electroconvulsive therapy

OBJECTIVE

Temporary asystole can be detected at various time points during electroconvulsive treatment. We carefully monitored and documented its incidence during stimulation to evaluate currently known and assumed predictors.

METHOD

All treatments over a 20-month period in 2 separate institutions were recorded prospectively. Data from 119 patients comprising 720 treatments were suitable for multiple regression analysis.

RESULTS

Electrode placement was the most influential determinant. Treatment series using right unilateral placement (64 patients and 291 traces) produced a mean (SD) asystole duration of 5.64 (2.88) seconds (range, 1.21-11.20 seconds), compared to a duration of 0.80 (0.21) seconds (range, 0.47-1.71 seconds) in bifrontal series (55 patients, 429 traces). Multiple regression analysis showed no independent effect of body weight, age, β-blocker medication, or preexisting heart block. Stimulus dose and succinylcholine dose had no influence in univariate analyses. Cardiac action in bifrontal treatment series was highly predictable using baseline values. During unilateral stimulation, between-subject differences accounted for 79% of the observed variation.

CONCLUSIONS

The heart rate during stimulation depends mainly on electrode positioning. A yet unidentified, probably constitutional factor is responsible for the broad range of asystole duration brought about by right unilateral electrode placement. Any assessment using interindividual analysis will therefore be biased as long as that factor remains unknown.

Asymmetric alternation of the hemodynamic response at the prefrontal cortex in patients with schizophrenia during electroconvulsive therapy: a near-infrared spectroscopy study

OBJECTIVE

Although electroconvulsive therapy (ECT) is a well-established treatment for psychiatric disorders, its mechanism of action remains unclear. To investigate the cerebral hemodynamic response during ECT, we measured the changes in the regional cerebral blood flow (rCBF) at the bilateral prefrontal cortex (PFC) using near-infrared spectroscopy (NIRS). Method. The participants included eleven patients with schizophrenia and ten patients with mood disorders. The normalized tissue hemoglobin index (nTHI) was used as a sensitive parameter of rCBF by the SRS method and was measured during bilateral ECT using a two-channel NIRS. Results. 1. All patients responded to ECT treatment. 2. The levels of bilateral nTHI indicated a transient decrease during electrical stimulation and immediately were increased at both ictal and post-ictal phases by approximately 20% above baseline. 3. Patients with schizophrenia, but not mood disorders, showed significant asymmetric alteration of nTHI levels (left>right) during both the ictal and post-ictal phases. 4. The asymmetry index of nTHI, which indicates the difference between the left and right sides of the nTHI, was negatively correlated with the period of illness for schizophrenia, although the asymmetry index was not significantly correlated with any other clinical data, such as the effect of ECT treatment. Conclusion. Preliminary data demonstrated that bilateral ECT caused hemodynamic changes in bilateral PFC, and asymmetric alteration was found for schizophrenia, but not for mood disorders. Although further studies are necessary, the asymmetric hemodynamic response by ECT may be associated with the pathophysiology of schizophrenia, especially in the early stages.

Absence of asystole during bifrontal stimulation in electroconvulsive therapy

Cardiac action was monitored during the stimulation period of 120 consecutive electroconvulsive therapies. Electrode placement was right unilateral in 73, bitemporal in 11, and bifrontal in 36 cases. Anticholinergic premedication was routinely given. A reduction in heart rate was seen consistently with unilateral electrode placement and asystole longer than 2 seconds occurred in 63% of cases. In contrast, no asystole occurred with bifrontal electrode placement. Thus, the vagus nerve seems to be less activated during bifrontal stimulation.