Defining the Dose Range for Esmolol Used in Electroconvulsive Therapy Hemodynamic Attenuation

A comparison of dexmedetomidine with propofol versus esmolol with propofol to attenuate the hemodynamic stress responses after electroconvulsive therapy

BACKGROUND

Modified electroconvulsive therapy (ECT) under anesthesia is an important modality in the treatment of severe, persistent depression; bipolar disorder and schizophrenia; especially in cases resistant to pharmacologic therapy.

AIM

The aim of the present study is to compare the effects of dexmedetomidine and esmolol on patients' hemodynamics, motor seizure duration, and recovery times following ECT.

MATERIALS AND METHODS

Ninety cases aged between 18 and 50 years of the American Society of Anesthesiologists grade I and II; were randomly divided into three groups of 30 each. Group A received normal saline (placebo), Group B received dexmedetomidine 1 μg/kg, and Group C received esmolol 1 mg/kg; followed by induction with propofol 1 mg/kg and muscle relaxation with succinylcholine 0.75 mg/kg. Hemodynamic parameters at baseline, after study drug infusion, after induction, and after ECT application were recorded at different time intervals. The motor seizure duration using arm isolation method and recovery times using postanesthesia discharge scoring system were noted.

RESULTS

The maximum increase in hemodynamic parameters was seen following the ECT current application. Post-ECT rise in mean arterial blood pressure and heart rate in dexmedetomidine group was significantly less as compared to esmolol and control group at 2, 4, 6, and 8 min using unpaired t-test. There was no significant difference in motor seizure activity duration, emergence, and recovery times among the three groups.

CONCLUSIONS

Both dexmedetomidine and esmolol attenuate the hyperdynamic response to ECT without affecting the seizure duration, but dexmedetomidine has a more favorable response in view of stable vitals, smooth emergence and no adverse effect on recovery duration.

Outcome of four pretreatment regimes on hemodynamics during electroconvulsive therapy: A double-blind randomized controlled crossover trial

Context:

Electroconvulsive therapy (ECT) is associated with tachycardia and hypertension.

Aims:

The aim of this study was to compare two doses of dexmedetomidine, esmolol, and lignocaine with respect to hemodynamics, seizure duration, emergence agitation (EA), and recovery profile.

Methodology:

Thirty patients undergoing ECT were assigned to each of the following pretreatment regimes over the course of five ECT sessions in a randomized crossover design: Group D1 (dexmedetomidine 1 μg/kg), Group D0.5 (dexmedetomidine0.5 μg/kg), Group E (esmolol 1 mg/kg), Group L (lignocaine 1 mg/kg), and Group C (saline as placebo) before induction. Heart rate (HR), mean arterial pressure (MAP), seizure duration, EA, and time to discharge were evaluated.

Results:

Groups D1, D0.5, and esmolol had significantly reduced response of HR, MAP compared to lignocaine and control groups at 1, 3, 5 min after ECT (P < 0.05). Motor seizure duration was comparable in all groups except Group L (P = 0.000). Peak HR was significantly decreased in all groups compared to control. Total propofol requirement was reduced in D1 (P = 0.000) and D0.5 (P = 0.001) when compared to control. Time to spontaneous breathing was comparable in all the groups (P > 0.05). Time to eye opening and time to discharge were comparable in all groups (P > 0.05) except Group D1 (P = 0.001). EA score was least in Group D1 (P = 0.000).

Conclusion:

Dexmedetomidine 1 μg/kg, 0.5 μg/kg, and esmolol produced significant amelioration of cardiovascular response to ECT without affecting seizure duration, results being best with dexmedetomidine 1 μg/kg. However, the latter has the shortcoming of delayed recovery.

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.

Continuous transthoracic echocardiography in a 93-year-old patient with hypertrophic cardiomyopathy during electroconvulsive therapy

Electroconvulsive therapy (ECT) is the treatment of choice for patients with a major depression disorder who have failed antidepressant therapy. Patients with hypertrophic cardiomyopathy (HCM) may have dynamic obstruction to left ventricular (LV) outflow. The effects on myocardial function during ECT and pretreatment with antihypertensive agents in patients with HCM and LV outflow tract obstruction gradients are unknown. We report the first use of continuous transthoracic echocardiography during ECT in a patient with HCM. We confirmed an outflow tract obstruction and showed a decrease in LV outflow tract gradients. Continuous transthoracic echocardiography monitoring using Doppler echocardiography during ECT is feasible.

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.

Landiolol and esmolol prevent tachycardia without altering cerebral blood flow

PURPOSE

Several ss-adrenergic-blocking drugs have been used during electroconvulsive therapy (ECT) to stabilize the hemodynamic alterations following electrical stimulation. The effects of two ultra-short acting ss-adrenergic-blocking drugs, esmolol and landiolol, on systemic and cerebral circulation were studied during ECT.

METHODS

In the first study (n = 15), dose-dependent hemodynamic changes were studied when landiolol was administered immediately after induction of anesthesia. In the second study (n = 12), effects of esmolol and landiolol on systemic and cerebral circulation were compared. Patients in Study 1 received three doses of landiolol, and patients in Study 2 received two types of ss-adrenergic-blocking drugs, in a randomized cross-over design in a series of ECT trials.

RESULTS

In the first study, 0.25 to 0.5 mg.kg(-1) landiolol induced a lower heart rate after the electrical stimulation compared to vehicle (P < 0.01). Landiolol did not have significant effects on blood pressure. In the second study, heart rate was stabilized by 1.0 mg.kg(-1) esmolol iv or 0.5 mg.kg(-1) landiolol iv. Increase in mean blood pressure was ameliorated by esmolol (P < 0.01), but not by landiolol. Mean cerebral blood flow velocity in the middle cerebral artery increased at one to two minutes after the electrical stimulation regardless of the use of ss-adrenergic-blocking drugs (P < 0.01). Muscular and electroencephalographic seizure durations were not significantly altered by the ss-adrenergic-blocking drugs.

CONCLUSION

Landiolol suppresses heart rate elevation during ECT without affecting blood pressure. Cerebral blood flow velocity in the middle cerebral artery is not affected by the use of either esmolol or landiolol.

The effects of intravenous lignocaine on haemodynamics and seizure duration during electroconvulsive therapy

Electroconvulsive therapy (ECT) is commonly associated with acute hyperdynamic cardiovascular responses, and we hypothesize that intravenous lignocaine can blunt this response. We have measured the effect of lignocaine 1.5 mg/kg i.v. on heart rate and mean arterial pressure during electroconvulsive therapy. Furthermore, we also assessed seizure duration using both the cuff method and two-lead electroencephalography. We studied 25 patients using a randomized, double-blind, placebo-controlled crossover study design. Patients in the control group were given intravenous saline 0.075 ml/kg, and those in the lignocaine group were given intravenous lignocaine 2% 1.5 mg/kg, and this treatment was conducted one minute before intravenous propofol 1.5 mg/kg to induce unconsciousness. Succinylcholine 1.5 mg/kg was then administered intravenously and electrical stimulation was administered after fasciculation. Measurements were taken at the baseline, prior to succinycholine, prior to electroconvulsive therapy and at the peak response after electroconvulsive therapy. Intravenous lignocaine significantly reduced the increases in heart rate after electroconvulsive therapy, as compared with the placebo. The use of intravenous lignocaine was, however, associated with a remarkably shortened seizure duration. Due to the reduction in seizure duration, routine administration of intravenous lignocaine may not be advisable since it may interfere with the psychotherapeutic efficacy of electroconvulsive therapy. However, intravenous lignocaine medication for electroconvulsive therapy is potentially useful for reducing tachycardia in high-risk patients and reducing the severity of propofol injection pain in comparison with a placebo.

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.

The effects of diltiazem on hemodynamics and seizure duration during electroconvulsive therapy

Electroconvulsive therapy (ECT) is often associated with acute hyperdynamic responses, and we hypothesize that diltiazem can blunt this response. We measured the effect of a 10-mg dose of diltiazem on heart rate and mean arterial pressure during ECT. Furthermore, we assessed seizure duration by using both the cuff method and two-lead electroencephalogram. We studied 18 patients with a randomized, double-blinded, placebo-controlled cross-over study design. Diltiazem significantly reduced heart rate and mean arterial pressure just after medication, and it also significantly reduced the increases in these variables after ECT, as compared with the placebo. The use of diltiazem was, however, associated with a shortened seizure duration, possibly making ECT less effective. Because of the reduction in seizure duration, the routine administration of diltiazem may not be advisable because it can possibly interfere with the psychotherapeutic efficacy of ECT. However, diltiazem medication for ECT is potentially useful for reducing tachycardia and hypertension in high-risk patients.

IMPLICATIONS

Diltiazem can blunt acute hyperdynamic responses after electroconvulsive therapy, but seizure duration is also significantly reduced, possibly making this therapy less effective.

[Myocardial infarction after electroconvulsive therapy]

Myocardial infarction is an uncommon complication of electroconvulsive therapy. Because of this, in spite of the existence in psychiatric literature of some studies about this question, the knowledge in this regard by most cardiologists is scarce. We present a patient with an acute myocardial infarction after the application of a electroconvulsive therapy. In the end, we accomplish review of the literature in relation to incidence, physiology, prevention and indication or not of fibrinolytic drugs in acute myocardial infarction after electroconvulsive therapy.

Comparative effects of oral clonidine and intravenous esmolol in attenuating the hemodynamic response to epinephrine injection

STUDY OBJECTIVE

To evaluate oral clonidine and intravenous esmolol in blunting hemodynamic changes associated with intranasal injection of an epinephrine-containing local anesthetic solution during general anesthesia.

DESIGN

Prospective, randomized, double-blind, placebo-controlled study.

SETTING

University Medical Center.

PATIENTS

61 consenting ASA physical status I and II outpatients undergoing endoscopic sinus and septoplasty surgery with general anesthesia.

INTERVENTIONS

All patients were assigned to receive either a placebo (P) tablet or a similar-appearing tablet containing either clonidine 0.2 mg (C2) or 0.4 mg (C4) orally 1 hour prior to entering the operating room. Prior to the intranasal injection of epinephrine, patients were administered either saline, 0.03 ml.kg-1 followed by an infusion of 0.016 ml.kg-1.min-1, or esmolol (E) 300 micrograms.kg-1 followed by a continuous infusion of 160 micrograms.kg-1.min-1.

MEASUREMENTS AND MAIN RESULTS

Arterial blood pressure and heart rate (HR) values were recorded preoperatively, immediately before induction of anesthesia, and at 1-minute intervals after induction of anesthesia until 15 minutes after injection of an epinephrine-containing solution. Level of sedation was assessed using a linear visual analog scale (VAS) prior to oral premedication, immediately before induction of anesthesia, and 30 minutes after anesthesia. There were no significant differences in sedation scores among the four treatment groups. HR following injection of epinephrine-containing solution was significantly less in the C2, C4, and E groups than the placebo group. Compared to P and E treatment groups, MAP values were significantly lower in the C4 treatment group.

CONCLUSION

In this healthy, young, nonsmoking outpatient population, premedication with oral clonidine, 0.2 to 0.4 mg, was effective in blunting the acute hemodynamic changes associated with injection of an epinephrine-containing local anesthetic solution during endoscopic sinus or septoplasty surgery.

Regional cerebral oxygen saturation during electroconvulsive therapy: monitoring by near-infrared spectrophotometry

Electroconvulsive therapy (ECT) increases neuronal energy consumption and alters systemic hemodynamics. We examined the effects of ECT on regional cerebral oxygen saturation (rSo2) using a near-infrared spectro-photometer. Heart rate (HR), mean arterial blood pressure (MAP), and rSo2 were continuously monitored throughout ECT under general anesthesia in 43 patients. In all subjects, rSo2 changed in a consistent pattern during ECT, initially decreasing (-9.4% +/- 0.9%) just after application of the electrical current and subsequent increasing (8.7% +/- 0.9%) beyond the pre-ECT value. A close correlation was demonstrated between the increase in rSo2 and the mean blood pressure after the electrical shock (r2 = 0.832, P < 0.0001). We conclude that ECT initially may increase cerebral metabolic rate of oxygen more than cerebral blood flow and that rapidly increasing blood pressure transiently may overwhelm cerebral pressure autoregulation.

The effect of esmolol pretreatment on the incidence of regional wall motion abnormalities during electroconvulsive therapy

Electroconvulsive therapy (ECT) is associated with dramatic increases in arterial blood pressure and heart rate (HR) that may precipitate new left ventricular regional wall motion abnormalities (RWMAs) suggestive of myocardial ischemia. The purpose of this study was to investigate the effect of pretreatment with esmolol on the incidence of RWMAs after ECT. Thirteen patients served as their own controls and, in a random fashion, received a standard succinylcholine/methohexital anesthetic for one of two ECT sessions, and an identical anesthetic with esmolol 1 mg/kg for their other ECT session. Systolic (SBP), diastolic (DBP), mean arterial pressures (MAP) and HR were recorded after drug administration and before ECT and at 1-, 2-, 4-, 5-, 10-, and 15-min intervals after ECT. Echocardiograms were obtained at baseline, after drug administration, 1 min after ECT, and at recovery 15 min later. All patients had significant increases in SBP, DBP, and MAP at 1, 2 and 4 min after ECT versus baseline, whereas HR was significantly faster at all times in the control sessions. HR was significantly slower after anesthetic induction until 2 min after ECT in the esmolol versus the control group (P < 0.05). New RWMAs were seen in only 1 of 26 (4%) ECT sessions, despite the presence of baseline RWMAs in 31% of the patients. We conclude that contrary to previously reported data, new RWMAs after ECT are uncommon. Consequently, this study was unable to demonstrate any beneficial effect of pretreatment with esmolol on the incidence of ECT-induced RWMAs.

Comparative effects of esmolol and labetalol to attenuate hyperdynamic states after electroconvulsive therapy

We studied 18 patients (age range, 53-90 yr) with at least one cardiovascular risk factor who were treated with electroconvulsive therapy (ECT) and compared effects of five pretreatments: no drug; esmolol, 1.3 or 4.4 mg/kg; or labetalol, 0.13 or 0.44 mg/kg. Each patient received all five treatments, during a series of five ECT sessions. Pretreatment was administered as a bolus within 10 s of induction or anesthesia. Doses of methohexital and succinylcholine were constant for the series of treatments and the assignment to no drug or to drug and dose was determined by randomized block design. Measurements of systolic and diastolic blood pressure (SBP, DBP) and heart rate (HR) were recorded during the awake state and 1, 3, 5, and 10 min after the seizure. The deviation of ST segments from baseline was measured by an electrocardiogram (ECG) monitor equipped with ST-segment analysis software. The results (mean +/- SEM) show that without pretreatment, there were significant (P < 0.05) peak increases in SBP and HR (55 +/- 5 mm Hg and 37 +/- 6 bpm, respectively), recorded 1 min after the seizure. Comparable reductions (by approximately 50%) in these peak values were achieved after esmolol (1.3 mg/kg) or labetalol (0.13 mg/kg), and cardiovascular responses were nearly eliminated after the same drugs in doses of 4.4 and 0.44 mg/kg, respectively. The deviation of ST-segment values from baseline in any lead was not measurably influenced by either antihypertensive drug. SBP values were lower after labetalol 10 min after the seizure, but not after esmolol. Asystolic time after the seizure was not significantly longer with either drug.(ABSTRACT TRUNCATED AT 250 WORDS)