Guide to anaesthetic selection for electroconvulsive therapy

Etomidate Improves the Antidepressant Effect of Electroconvulsive Therapy by Suppressing Hippocampal Neuronal Ferroptosis via Upregulating BDNF/Nrf2

Electroconvulsive therapy (ECT) performed under general anesthesia is an effective treatment for severe depression. Etomidate is an intravenous anesthetic that shows beneficial effects on ECT. However, the potential mechanisms have rarely been reported. In this study, male rats were exposed to chronic unpredictable mild stress for 4 weeks, followed by ECT for 10 days, with or without intervention with ferrostatin-1 (2 mg/kg) or all-trans retinoic acid (ATRA, 5 mg/kg). Rats subjected to etomidate (20 mg/kg) or propofol (120 mg/kg) treatment were administered with designated anesthetic before ECT. Compared to depressive rats without ECT, those who received ECT showed increased numbers of hippocampal neurons, increased expression of negative regulators of ferroptosis including glutathione peroxidase 4, ferritin heavy chain 1, and ferroptosis suppressor protein 1, upregulation of brain-derived neurotrophic factor and nuclear factor erythroid 2-related factor, and downregulation of acyl-CoA synthetase long-chain family member 4, a positive regulator of ferroptosis in the hippocampus. Additionally, compared with propofol, etomidate used in ECT resulted in higher upregulation of BDNF/Nrf2 and inhibited neuronal ferroptosis in hippocampus. These results showed etomidate may enhance the antidepressant effect of ECT by protecting hippocampal neurons against ferroptosis.

Focal points of preanesthesia evaluations for electroconvulsive therapy in patients with depression: a retrospective analysis of clinical characteristics in nonremission

Background

This study explored the patient clinical characteristics that may affect electroconvulsive therapy (ECT) efficacy to enable improved focus during evaluations and preparation for ECT.

Methods

Patients were enrolled for ECT at the Department of Psychiatry and Anesthesiology of the First Affiliated Hospital of Chongqing Medical University from December 2017 to January 2019. The primary outcome in our study was defined as the development of nonremission. A multivariate logistic analysis was performed to identify the risk factors for nonremission.

Results

In total, 874 depressed patients were included in the study. After the ECT treatment, 255 cases (29.2%) exhibited nonremission. A multivariate logistic regression analysis of the variables was performed, and the results showed that atherosclerosis (OR 8.072, 95% CI 2.442 to 16.675; P = 0.001), COPD (OR 2.919, 95% CI 1.240 to 6.871; P = 0.014), diabetes (OR 2.202, 95% CI 1.115 to 4.348; P = 0.023) and smoking (OR 1.519, 95% CI 1.015 to 2.273; P = 0.042) were independent risk factors for nonremission.

Conclusion

In the retrospective analysis, we found that atherosclerosis, diabetes, COPD and smoking may be high-risk factors for nonremission.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01686-6.

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.

Sevoflurane in electroconvulsive therapy: A systematic review and meta-analysis of randomised trials

Sevoflurane is the most commonly used inhaled anaesthetic in electroconvulsive therapy (ECT). The objective of this study was to provide an up-to-date and comprehensive review on how the use of sevoflurane affects seizure adequacy (seizure duration and postictal suppression index [PSI]) and circulatory dynamics in ECT. We performed a meta-analysis of RCTs that investigated seizure adequacy and circulatory dynamics in patients treated with ECT using sevoflurane (sevoflurane group) and intravenous anaesthetics (non-sevoflurane group). A total of 12 RCTs (377 patients and 1339 ECT sessions) were included. Sevoflurane significantly decreased the electroencephalogram (EEG) seizure durations in comparison with intravenous anaesthetics, whereas no significant difference was observed in PSI (EEG: 9 studies, standardized mean difference (SMD) = 0.74, 95% confidence interval (CI) = -1.11 to -0.38, p = 0.0002; PSI: 4 studies, SMD = -0.06, CI -0.13 to 0.25, p = 0.59). The use of sevoflurane in ECT significantly increased heart rate (HR) compared with intravenous anaesthetics (9 studies, SMD = 0.31, CI 012-0.51, p = 0.004). In the pre-planned subgroup analysis, sevoflurane significantly reduced seizure duration compared with other types of anaesthetics, including propofol, barbiturates and ketamine. Furthermore, it was found that the risk of adverse events in ECT with sevoflurane were not significantly different from intravenous anaesthetics (6 studies, risk ratio = 1.33, CI 0.95-1.86, p = 0.09), with agitaion being the most common adverse effects. The results of our study suggest that using sevoflurane for ECT significantly reduces seizure duration, increases maximum HR and brings about no difference in the adverse event risk compared with those using intravenous anaesthetics for ECT. Therefore, there may not be compelling evidence favouring sevoflurane use for ECT, except in cases where intravenous access is difficult.

The Historical Struggles of Modified Electroconvulsive Therapy: How Anesthesia Came to the Rescue

The complicated history of modified electroconvulsive therapy (ECT) started back before anesthesia was incorporated when unmodified electroconvulsive therapy was not considered humane. When anesthesiologists started working with psychiatrists, ECT gradually regained acceptance by decreasing the obstacles inherent to this therapy despite the complexities of the anesthetics. However, the sociopolitical and medicolegal factors negatively impacted the use of modified ECT leading to a period of time when it was banned from use in the United States. Fortunately, as advances in anesthesia and technology continued to develop, anesthesiologists helped ECT regain widespread usage improving the safety profile, cost effectiveness, quicker onset of seizures, and ease of control despite its stained past. This allowed more accessibility, especially for high-risk medical patients, to a relatively safe and effective treatment for psychiatric diseases.

A comparative study of propofol, thiopentone sodium, and ketofol as induction agents for electro convulsive therapy

Background and Aims:

Thiopentone and propofol are most commonly used induction agents for electro convulsive therapy (ECT). Recently, ketofol, an admixture of propofol and ketamine, is being tried in ECT. We aimed to compare propofol, thiopentone, and ketofol as induction agents during ECT regarding their effects on ECT-induced hemodynamic changes, seizure duration and recovery parameters.

Material and Methods:

This prospective randomized double blind study was conducted in 30 patients between 18 and 65 years with ASA status I and II scheduled for ECT. All patients received all study agents for first three sessions of ECT. The observations were compiled as Group K (Inj. Ketofol i.e., Inj. propofol 0.5mg/kg % Inj. ketamine 0.5mg/kg), Group P (Inj. propofol 1mg/kg), and Group T (Inj. thiopentone 3mg/kg). Heart rate (HR) and blood pressure (systolic, diastolic, and mean) was recorded at pre op, 0, 5, 10, and 20 min after ECT. The seizure duration, time to spontaneous eye opening, andobeying verbal commands and agitation score were recorded.

Results:

Statistically significant difference was seen in HR at 10 min after delivery of shock; in systolic BP at 2 min after shock; in diastolic BP after administration of study drug and immediately after shock and in mean arterial pressure at post induction, 0and2 min after shock with group T showing higher values compared to group K and P (p < 0.05). At all other times HR andBP was comparable in all the three groups. Seizure duration was more in group T than Groups P and K although the difference was statistically insignificant. Time to spontaneous eye opening and obey verbal commands was comparable in all groups. Mean agitation score was highest in group T than Groups P& Kwith Group P showing least value (p = 0.003).

Conclusion:

Propofol and ketofol showed superior hemodynamic stability than thiopentone but comparable seizure duration and recovery parameters. Thus, propofol and ketofol can be effectively used as induction agents for ECT although propofol is associated with lesser agitation than ketofol.

Empirical ratio of the combined use of S-ketamine and propofol in electroconvulsive therapy and its impact on seizure quality

Electroconvulsive therapy (ECT) is an effective treatment for depressive disorders. In certain cases, ECT-associated anaesthesia can be improved by the use of ketofol (i.e., S-ketamine + propofol). We aimed to evaluate the empirical mixing ratio of ketofol in these cases for better clinical implementation. We retrospectively investigated n = 52 patients who received 919 ECT sessions with S-ketamine plus propofol as anaesthetic agents. Several anaesthesia and ECT-related parameters including doses of S-ketamine and propofol were analysed. The mean empirically determined S-ketamine/propofol ratio was 1.38 (SD ± 0.57) for 919 individual ECT sessions and 1.52 (SD ± 0.62) for 52 patients, respectively. The mean relative dose was 0.72 (± 0.18) mg/kg S-ketamine and 0.54 (± 0.21) mg/kg propofol. Higher propofol dose was associated with poorer seizure quality. Seizure quality and time in recovery room were significantly influenced by age. Ketofol could be an option to exploit the advantageous qualities of S-ketamine and propofol, if both doses are reduced compared with single use of S-ketamine or propofol. Patients with poor seizure quality may benefit from lower propofol doses, which are applicable by the addition of ketamine. An empirically determined mixing ratio in favour of ketamine turned out to be preferable in a clinical setting. Recovery time was primarily prolonged by higher age rather than by ketamine dose, which had previously often been associated with a prolonged monitoring time in the recovery room. These new findings could improve electroconvulsive therapy and should be replicated in a prospective manner.

Temporoparietal Connectivity Within Default Mode Network Associates With Clinical Improvements in Schizophrenia Following Modified Electroconvulsive Therapy

Although modified electroconvulsive therapy (ECT) has been reported to be effective for the treatment of schizophrenia (SCZ), its action mechanism is unclear. To elucidate the underlying ECT mechanisms of SCZ, this study used a longitudinal cohort including 21 SCZ patients receiving only antipsychotics (DSZ group) and 21 SCZ patients receiving a regular course of ECT combining with antipsychotics (MSZ group) for 4 weeks. All patients underwent magnetic resonance imaging (MRI) scans at baseline (t1) and follow-up (t2) time points. A matched healthy control (HC) group included 23 individuals who were only scanned at baseline. Functional connectivity (FC) within the default mode network (DMN) was evaluated before and after ECT. Significant interaction of the group over time was found in FC between angular gyrus (AG) and middle temporal gyrus (MTG). Post-hoc analysis showed a significantly enhanced FC of left AG(AG.L) and right MTG (MTG.R) in the MSZ group relative to the DSZ group. In addition, the right AG (AG.R) showed significantly enhanced FC between MTG.R and left MTG (MTG.L) after ECT in the MSZ group, but no in the DSZ group. In particular, the FCs change in AG.L-MTG.R and AG.R-MTG.R were positively correlated with the Positive and Negative Syndrome Scale (PANSS) negative score reduction. Furthermore, the FC change in AG.L-MTG.R was also positively correlated with the PANSS general psychopathology score reduction. These findings confirmed a potential relationship between ECT inducing hyperconnectivity within DMN and improvements in symptomatology of SCZ, suggesting that ECT controls mental symptoms by regulating the temporoparietal connectivity within DMN.

Anaesthesia for electroconvulsive therapy - new tricks for old drugs: a systematic review

OBJECTIVE

The objective of this review is to investigate existing literature in order to delineate whether the use of anaesthesia and timing of seizure induction in a new and optimised way may improve the efficacy of electroconvulsive therapy (ECT).

METHODS

PubMed/MEDLINE was searched for existing literature, last search on 24 June 2015. Relevant clinical studies on human subjects involving choice of anaesthetic, ventilation and bispectral index (BIS) monitoring in the ECT setting were considered. The references of relevant studies were likewise considered.

RESULTS

Propofol yields the shortest seizures, etomidate and ketamine the longest. Etomidate and ketamine+propofol 1 : 1 seems to yield the seizures with best quality. Seizure quality is improved when induction of ECT is delayed until the effect of the anaesthetic has waned - possibly monitored with BIS values. Manual hyperventilation with 100% O2 may increase the pO2/pCO2-ratio, which may be correlated with better seizure quality.

CONCLUSION

Etomidate or a 1 : 1 ketamine and propofol combination may be the best method to achieve general anaesthesia in the ECT setting. There is a need for large randomised prospective studies comparing the effect of methohexital, thiopental, propofol, ketamine, propofol+ketamine 1 : 1 and etomidate in the ECT treatment of major depressed patients. These studies should investigate safety and side effects, and most importantly have antidepressant efficacy and cognitive side effects as outcome measures instead of seizure quality.

S -ketamine compared to etomidate during electroconvulsive therapy in major depression

Objective of the study was to compare two commonly used anesthetic drugs, S-ketamine and etomidate, regarding their influence on seizure characteristics, safety aspects, and outcome of electroconvulsive therapy (ECT) in major depression. Treatment data of 60 patients who underwent a total number of 13 ECTs (median) because of the severe or treatment-resistant major depressive disorder (DSM-IV) were analyzed. Etomidate, mean dosage (SD) = 0.25 (0.04) mg/kg, was used for anesthesia in 29 participants; 31 patients received S-ketamine, mean dosage (SD) = 0.96 (0.26) mg/kg. Right unilateral brief pulse ECTs were performed. The number of ECTs was individually adjusted to clinical needs, mean (SD) = 13.0 (4.3). Seizure characteristics, adverse events, and the clinical global impression (CGI) scores were compared between the both groups during ECT series. In the S-ketamine group, a lower initial seizure threshold (p = 0.014), stimulation charge (p < 0.001), higher postictal suppression (p < 0.001), EEG ictal amplitude (p = 0.04), EEG coherence (p < 0.001) and maximum heart rate (p = 0.015) were measured. Etomidate was associated with more frequent abortive seizures (p = 0.02) and restimulations (p = 0.01). The CGI scores, the number of sessions within an ECT series, and the incidence of adverse events did not differ between groups. Due to its lower initial seizure threshold, S-ketamine might hold a potential to become a clinically favorable anesthetic agent during ECT. However, the current findings should be interpreted with caution, and further prospective randomized clinical trials are required. Also, specific adverse effects profile of S-ketamine, especially with regard to the cardiovascular risk, needs to be taken into account.

General Anaesthesia Protocols for Patients Undergoing Electroconvulsive Therapy: Retrospective analysis of 504 sessions over a five-year period at a tertiary care hospital in Oman

OBJECTIVES

This study aimed to review general anaesthesia protocols for patients undergoing electroconvulsive therapy (ECT) at a tertiary care hospital in Oman, particularly with regards to clinical profile, potential drug interactions and patient outcomes.

METHODS

This retrospective study took place at the Sultan Qaboos University Hospital (SQUH), Muscat, Oman. The electronic medical records of patients undergoing ECT at SQUH between January 2010 and December 2014 were reviewed for demographic characteristics and therapy details.

RESULTS

A total of 504 modified ECT sessions were performed on 57 patients during the study period. All of the patients underwent a uniform general anaesthetic regimen consisting of propofol and succinylcholine; however, they received different doses between sessions, as determined by the treating anaesthesiologist. Variations in drug doses between sessions in the same patient could not be attributed to any particular factor. Self-limiting tachycardia and hypertension were periprocedural complications noted among all patients. One patient developed aspiration pneumonitis (1.8%).

CONCLUSION

All patients undergoing ECT received a general anaesthetic regimen including propofol and succinylcholine. However, the interplay of anaesthetic drugs with ECT efficacy could not be established due to a lack of comprehensive data, particularly with respect to seizure duration. In addition, the impact of concurrent antipsychotic therapy on anaesthetic dose and subsequent complications could not be determined.

Dexmedetomidine for the management of postictal agitation after electroconvulsive therapy with S-ketamine anesthesia

OBJECTIVES

Postictal agitation (PIA) represents one of the most common complications during a modified electroconvulsive therapy (ECT) course. Its clinical management can be challenging especially in cases with poor response to benzodiazepines. Dexmedetomidine, a highly selective alpha-2 adrenoceptor agonist acting predominantly in the locus coeruleus, exerts sedative effects without causing relevant respiratory depression. To the best of our knowledge, this is the first study that aimed to assess the impact of dexmedetomidine use with S-ketamine anesthesia on PIA reduction in ECT.

PATIENTS AND METHODS

We retrospectively analyzed 7 patients who underwent 178 ECT sessions with S-ketamine anesthesia between June 2011 and July 2015 at the Central Institute of Mental Health Mannheim. In 101 sessions, the patients received dexmedetomidine in combination with S-ketamine anesthesia. The decision for dexmedetomidine use was based on individual clinical presentation (patients with positive PIA history). A multivariate repeated measurement logistic regression analysis was conducted to investigate the effect of dexmedetomidine use on the occurrence of PIA. We hypothesized that the use of dexmedetomidine reduced the incidence of PIA also in combination with S-ketamine anesthesia.

RESULTS

The prevalence of PIA in ECT sessions with dexmedetomidine administration was lower (mean per patient, 34% vs 62%). In the multivariate logistic regression analysis, the use of dexmedetomidine predicted the non-occurrence of PIA in a highly significant manner (P=0.001, z=-3.83, odds ratio =0.011-0.303).

CONCLUSION

Adjunctive use of dexmedetomidine to S-ketamine anesthesia in ECT seems to be a promising tool for the management of intractable PIA syndrome.

Remifentanil in electroconvulsive therapy: a systematic review and meta-analysis of randomized controlled trials

In electroconvulsive therapy (ECT), remifentanil is often used concurrently with anesthetics. The objective of this study was to provide an up-to-date and comprehensive review on how the addition of remifentanil to anesthetics affects seizure duration and circulatory dynamics in mECT. We performed a meta-analysis of RCTs that investigated seizure duration and circulatory dynamics in patients treated with ECT using anesthetics alone (non-remifentanil group) and with anesthetics plus remifentanil (remifentanil group). A total of 13 RCTs (380 patients and 1024 ECT sessions) were included. The remifentanil group showed a significantly prolonged seizure duration during ECT compared to the non-remifentanil group [motor: 9 studies, SMD = 1.25, 95 % CI (0.21, 2.29), p = 0.02; electroencephalogram: 8 studies, SMD = 0.98, 95 % CI (0.14, 1.82), p = 0.02]. The maximum systolic blood pressure (SBP) was significantly reduced in the remifentanil group compared to the non-remifentanil group [7 studies, SMD = -0.36, 95 % CI (-0.65, 0.07), p = 0.02]. Substantial heterogeneity was observed for meta-analyses for seizure durations, but a pre-planned subgroup analysis revealed that seizure duration was prolonged only when the use of the anesthetic dose was reduced in the remifentanil group. The results of our study suggest that addition of remifentanil to anesthesia in ECT may lead to prolonged seizure duration when it allows the use of reduced anesthetic doses. Further, the addition of remifentanil was associated with reduced maximum SBP.

Adverse Effects of Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is an effective treatment commonly used for depression and other major psychiatric disorders. We discuss potential adverse effects (AEs) associated with ECT and strategies for their prevention and management. Common acute AEs include headache, nausea, myalgia, and confusion; these are self-limiting and are managed symptomatically. Serious but uncommon AEs include cardiovascular, pulmonary, and cerebrovascular events; these may be minimized with screening for risk factors and by physiologic monitoring. Although most cognitive AEs of ECT are short-lasting, troublesome retrograde amnesia may rarely persist. Modifications of and improvements in treatment techniques minimize cognitive and other AEs.

Impact of the anesthetic agents ketamine, etomidate, thiopental, and propofol on seizure parameters and seizure quality in electroconvulsive therapy: a retrospective study

In electroconvulsive therapy (ECT), the use of anesthetics without relevant anticonvulsant properties such as ketamine and etomidate may be favorable for seizure quality. Since there is a relative paucity of studies devoted to this issue, our aim was to compare different anesthetics for ECT regarding their impact on seizure quality and different seizure parameters. We retrospectively compared ketamine (n = 912 anesthesias), etomidate (n = 227 anesthesias), thiopental (n = 2,751 anesthesias), and propofol (n = 42 anesthesias) on their influence on general seizure quality and different seizure parameters by multivariate repeated measurement regression analyses. The use of ketamine and etomidate as anesthetics led to seizures that were overall higher in quality and also longer in motor seizure activity when compared to anesthesia with thiopental and propofol. Ketamine was most favorable concerning central inhibitory potential that was indirectly quantified by concordance and postictal suppression. The worst seizure quality was observed with propofol anesthesia; further, this substance had a negative impact on autonomic activation and seizure duration. Based on the data of this retrospective study, the use of ketamine or etomidate as anesthetic in ECT might be advantageous due to the induction of high-quality seizures.

Delirious mania: detection, diagnosis, and clinical management in the acute setting

Delirious mania is a severe but under-recognized neuropsychiatric syndrome characterized by the rapid onset of delirium, mania, and psychosis, not associated with a prior toxicity, physical illness, or mental disorder. Catatonia is often a prominent feature of the syndrome. While initially believed to be rare, recent reports suggest that delirious mania may constitute up to 15% of all acute mania cases. When delirious mania is unrecognized or improperly treated, it can progress rapidly in severity and can become life-threatening. This article reviews the pathophysiology, diagnosis, and treatment of delirious mania and includes a detailed case report. Delirious mania is robustly responsive to high-dose lorazepam or electroconvulsive therapy (ECT); thus, early recognition and definitive treatment can be life-saving.

Neurocognitive effects after brief pulse and ultrabrief pulse unilateral electroconvulsive therapy for major depression: a review

BACKGROUND

Neurocognitive functioning is well known to be affected after ECT. However quantified data about the severity of the cognitive impairment after ultrabrief pulse and brief pulse ECT are limited, which makes it hard to judge its clinical relevance.

METHODS

To review all prospective studies using right unilateral (ultra) brief pulse index electroconvulsive therapy published up until February 2011 which used at least one instrument for cognitive assessment before and after ECT. The severity and persistence of neurocognitive side effects immediately (one to seven days post ECT), between one and six months and after six months post ECT were assessed by calculating effect sizes using Cohen's d.

RESULTS

Ten studies fulfilled the inclusion criteria and provided detailed information to compute effect sizes. The results indicate loss of autobiographical memory and impairment of verbal fluency, anterograde verbal and non-verbal memory immediately after brief pulse RUL ECT. To a lesser extent impairment of working memory and reduced speed of processing is found. Autobiographical memory is the only domain still being impaired between one and six months post ECT, but improved in this period. Verbal fluency normalized to baseline performance between one and six months post ECT whereas anterograde verbal and non-verbal memory normalized or even improved. Speed of processing improved within six months after ECT. Long-term data on these cognitive domains were not available. Based on two of the ten included studies the results suggest that ultrabrief pulse RUL ECT causes less decline in autobiographical and anterograde memory after ECT than brief pulse RUL ECT.

LIMITATIONS

This review may be limited because of the small number of included studies and due to unreliable effect sizes. Furthermore, few data were available for non-memory domains and cognitive functioning after six months.

CONCLUSIONS

Loss of autobiographical memory is still present between one and six months after unilateral brief pulse ECT. Ultrabrief pulse RUL ECT shows less decline in autobiographical memory. Other neurocognitive impairments after brief pulse RUL ECT seem to be transient.

Ketofol (Mixture of Ketamine and Propofol) Administration in Electroconvulsive Therapy

The aim of this study was to evaluate the effect of a ketamine:propofol combination (‘ketofol’) for electroconvulsive therapy on seizure activity, haemodynamic response and recovery parameters, and to compare with these with the effects of propofol alone. Twenty-four patients underwent a total of 144 electro-convulsive therapy sessions, allocated in this prospective, double-blind, crossover study. Patients were randomly assigned to receive 1 mg/kg ketofol (0.5 mg/kg propofol plus 0.5 mg/kg ketamine) or 1 mg/kg propofol 1% for anaesthesia induction. Seizure duration and quality, haemodynamic data, recovery parameters and side-effects were recorded and analysed between groups. Both motor and electroencephalography seizure durations in the ketofol group (29±17 and 41±17 seconds, respectively) were similar to that in the propofol group (28±13 and 38±16 seconds, respectively). Postictal suppression index was higher in the ketofol group (89.63±7.88) than in the propofol group (79.74±14.6) (P P <0.05). There were no untoward psychological reactions following ketofol. Although no superiority to propofol in terms of seizure duration, haemodynamic or recovery parameters was found, the ketofol mixture selected in our study provided better seizure quality than propofol. We conclude that ketofol can be an alternative strategy to enhance the seizure quality and clinical efficiency of electroconvulsive therapy.

Neuromuscular blocking agents for electroconvulsive therapy: a systematic review

Electroconvulsive therapy (ECT) is the transcutaneous application of small electrical stimuli to the brain to induce generalised seizures for the treatment of selected psychiatric disorders. The clinical indications for ECT as an effective therapeutic modality have been considerably expanded since its introduction. Anaesthesia and neuromuscular blocking agents (NMBAs) are required to ensure patients' safety during ECT. The optimal dose of muscle relaxant for ECT reduces muscle contractions without inducing complete paralysis. Slight residual motor convulsive activity is helpful in ascertaining that a seizure has occurred, while total paralysis prolongs the procedure unnecessarily. Suxamethonium is commonly used, but nondepolarising NMBAs are indicated in patients with certain comorbidities. In this review, we summarise current concepts of NMBA management for ECT.

Atrioventricular dissociation after electroconvulsive therapy

Electroconvulsive therapy (ECT) is increasingly used as a treatment for psychiatric disorders. Cardiac effects are the principal cause of medical complications in these patients. We report a case of atrioventricular (AV) dissociation that occurred after ECT that was treated with pacemaker implantation. The mechanisms contributing to the onset of AV dissociation in this patient, and the management and rationale for device therapy, in light of the most recent guidelines, are reviewed.

Butyrylcholinesterase gene mutations in patients with prolonged apnea after succinylcholine for electroconvulsive therapy

BACKGROUND

patients undergoing electroconvulsive therapy (ECT) often receive succinylcholine as part of the anesthetic procedure. The duration of action may be prolonged in patients with genetic variants of the butyrylcholinesterase enzyme (BChE), the most common being the K- and the A-variants. The aim of the study was to assess the clinical significance of genetic variants in butyrylcholinesterase gene (BCHE) in patients with a suspected prolonged duration of action of succinylcholine after ECT.

METHODS

a total of 13 patients were referred to the Danish Cholinesterase Research Unit after ECT during 38 months. We determined the BChE activity and the BCHE genotype using molecular genetic methods, the duration of apnea, time to sufficient spontaneous ventilation and whether neuromuscular monitoring was used. The duration of apnea was compared with published data on normal subjects.

RESULTS

in 11 patients, mutations were found in the BCHE gene, the K-variant being the most frequent. The duration of apnea was 5-15 min compared with 3-5.3 min from the literature. Severe distress was noted in the recovery phase in two patients. Neuromuscular monitoring was used in two patients.

CONCLUSION

eleven of 13 patients with a prolonged duration of action of succinylcholine had mutations in BCHE, indicating that this is the possible reason for a prolonged period of apnea. We recommend objective neuromuscular monitoring during the first ECT.

Assessment of QT interval and QT dispersion during electroconvulsive therapy using computerized measurements

BACKGROUND

Electroconvulsive therapy (ECT) used in the treatment of severe psychiatric disorders induces stimulation of the autonomic nervous system with initial parasympathetic outflow immediately followed by a sympathetic response. These responses induce an initial bradycardia, arrhythmias, and hypertension. QT dispersion (QTD), defined as maximal QT interval minus minimal QT interval on 12 leads of the surface electrocardiogram, reflects regional heterogeneity of ventricular repolarization. The effects of electrical stimulus due to ECT on QT interval and QTD are of considerable interest.

OBJECTIVE

: This study was designed to investigate the effects of electrical stimulation caused by ECT on RR interval, QT interval, the rate-corrected QT (QTc) interval, QTD, and the rate-corrected QTD (QTcD) under general anesthesia using computerized measurements.

METHODS

Thirty psychiatric patients scheduled for ECT were studied under propofol anesthesia. A 12-lead electrocardiogram was monitored to measure parameters. Muscle paralysis was achieved by administering succinylcholine 1 mg/kg intravenously, and the efficacy of ECT was determined by the tourniquet technique.

RESULTS

The RR interval and QT interval decreased significantly immediately after electrical stimulus, and returned to the baseline level 1 minute after electrical stimulus. In 25 out of 30 patients, the baseline value of QTc interval was higher than the normal limits, and the QTc interval decreased significantly for 2 minutes after electrical stimulus. In 27 out of 30 patients, the baseline values of QTD and QTcD were higher than the normal limits, and the QTD and QTcD increased significantly from immediately after electrical stimulus to 5 minutes after electrical stimulus.

CONCLUSIONS

The QTc interval, QTD, and QTcD, which were associated with increased risks of ventricular arrhythmias, increased significantly before anesthetic induction in patients with major depression. Electrical stimulus during ECT induced further increases of the QTD and QTcD.

Comparison between the Effects of Propofol and Etomidate on Motor and Electroencephalogram Seizure Duration during Electroconvulsive Therapy

An ideal anaesthetic for electroconvulsive therapy (ECT) should have rapid onset and offset with no effect on seizure duration, and provide cardiovascular stability during the procedure. Propofol is commonly used, even though it has been shown to shorten seizure duration which might affect the efficacy of ECT. Etomidate has been advocated as an alternative. This prospective, randomised, single-blind, crossover study was conducted to compare the effects of etomidate (Etomidate-®Lipuro, B. Braun Ltd, Melsungen, Germany) and propofol (Diprivan®, AstraZeneca, UK) on seizure duration as well as haemodynamic parameters in patients undergoing ECT. Twenty patients aged between 18 and 70 years were recruited. Group I received etomidate 0.3 mg/kg for the first course of ECT (Group IA) and propofol 1.5 mg/kg for the second ECT (Group IB), while Group II received propofol for the first ECT (Group IIA) and etomidate for the second ECT (Group IIB). There was a washout period of two to three days in between procedures. Parameters recorded included motor seizure duration, electroencephalogram seizure duration, blood pressure and heart rate. Analysis demonstrated neither period effect nor treatment period interaction. Etomidate was associated with a significantly longer motor and electroencephalogram seizure duration compared with propofol (P <0.01). Neither drug demonstrated consistent effects in suppressing the rise in heart rate or blood pressure during ECT. Myoclonus and pain on injection were the most common adverse effects in etomidate group and propofol group respectively. Etomidate is a useful anaesthetic agent for ECT and should be considered in patients with inadequate seizure duration with propofol.

Methohexitone, propofol and etomidate in electroconvulsive therapy for depression: a naturalistic comparison study

BACKGROUND

Methohexitone has been the most widely used anaesthetic for electroconvulsive therapy (ECT). However, recent scarcity and erratic availability has led to use of other anaesthetics with differing effects upon ECT. We compared treatment parameters and response to ECT in patients anaesthetised with different anaesthetics in a routine clinical setting.

METHODS

This was a naturalistic retrospective casenote analysis of 81 consecutive courses of ECT (total 659 treatments) for major depression.

RESULTS

Three anaesthetics were compared: methohexitone (n=34), propofol (n=13) and etomidate (n=34). Mean seizure duration was lowest (p<0.0001) for propofol. However, mean stimulus charge was highest in the propofol group (p<0.0001) who required a greater increase in stimulus charge during the course of treatment and also experienced a greater proportion of failed seizures (</=15 s on EEG). Despite differing effects upon treatment parameters, choice of anaesthetic did not appear to significantly affect therapeutic response to ECT. Use of propofol may be associated with longer treatment course that could result in extra cost.

LIMITATIONS

This was a retrospective casenote study, in which patients were not randomised to anaesthetic and standardised outcome measures were not used. The small sample size in the propofol group may have reduced the power of the study to demonstrate other differences between propofol and the other anaesthetic groups. A formal economic analysis was not performed.

CONCLUSION

Individual anaesthetics differentially influence seizure duration and stimulus charge but final response to ECT appears not to be adversely affected.

Dexmedetomidine blunts acute hyperdynamic responses to electroconvulsive therapy without altering seizure duration

BACKGROUND

This study was designed to evaluate the effect of dexmedetomidine on the acute hyperdynamic response, duration of seizure activity and recovery times in patients undergoing electroconvulsive therapy (ECT).

METHODS

Fourteen patients underwent a total of 84 ECT sessions as a crossover design. Patients were randomly allocated to receive either dexmedetomidine (1 mug/kg IV over a period of 10 min) or saline (control). Anaesthesia was induced with propofol 1 mg/kg, and then succinylcholine 0.5 mg/kg IV was administered. Arterial blood pressure and heart rate (HR) were recorded during the study period.

RESULTS

HR in the dexmedetomidine group was lower than that in the control group at 5 and 10 min after the start of study drug infusion, and at 1, 3 and 10 min after the seizure ended (P<0.05). Peak HR was lower in the dexmedetomidine group compared with that in the control group (P<0.05). The mean arterial pressure (MAP) values in the dexmedetomidine group were lower at 0, 1, 3 and 10 min after the seizure ended compared with the control group (P<0.05). Both motor and electroencephalography (EEG) seizure duration in the control group (35.65 +/- 14.89 and 49.07 +/- 9.94 s, respectively) were similar to that in the dexmedetomidine group (33.30 +/- 12.01 and 45.15 +/- 17.79 s, respectively) (P>0.05). Time to spontaneous breathing, eye opening and obeying commands were not different between the groups.

CONCLUSION

A dexmedetomidine dose of 1 mug/kg IV administered over 10 min before the induction of anaesthesia with propofol may be useful in preventing the acute hyperdynamic responses to ECT without altering the duration of seizure activity and recovery time.

Incessant non-sustained ventricular tachycardia after stimulus of electroconvulsive therapy with atropine premedication?

Electroconvulsive therapy (ECT) is an effective and safe treatment for a variety of neuropsychiatric disorders. Premedication with atropine has been recommended in order to avoid bradycardia and transient asystole induced by ECT. In contrast, some other arrhythmias can happen such as atrial flutter and fibrillation. But ventricular tachycardia is rare. Reported herein is a case of incessant non-sustained ventricular tachycardia, possibly triggered by atropine premedication.

Anästhesiologische Aspekte bei Elektrokrampftherapie

Electroconvulsive therapy (ECT) is used in the therapy of severe psychiatric disorders. The treatment, in which a generalized epileptic seizure is provoked by electrical stimulation of the brain, is performed under anaesthesia and muscle relaxation. Considering careful previous clinical examination and anaesthesiological and internal contraindications, ECT is a safe form of treatment. The following review is intended to familiarize with ECT and to provide advice for the anaesthesiological management.