Prolonged apnea following modified electroconvulsive therapy with suxamethonium

Prolonged apnea after ECT in organophosphorus poisoning - the need to redefine norms

BACKGROUND

Poisoning and deaths by organo-phosphorous (OP) compounds are one of the major causes of death in developing and poor countries, and a common admission in the emergency ward and the ICU. OP compounds act by irreversibly binding to pseudocholinesterase enzyme and hence prolong the apnea in patients being given suxamethonium. We present a unusual case of OP poisoning (OPP) in which prolonged apnea ensued in a patient of severe depression following MECT (modified electroconvulsive therapy) in which suxamethonium was used as muscle relaxant, in whom we were cautious of the side-effect of prior organophosphorus poisoning. Since the cases of OPP are very high worldwide, a thorough knowledge of the interaction of the action of the drug and the receptors on which it acts takes pride of place. This article highlights the nuances in the field of psychiatry and anaesthesia in diagnosis and management of prolonged apnea after ECT.

CASE PRESENTATION

A 53/F patient consumed OP 38 days prior to MECT. Since existing literature recommend a delay of 4 weeks and a subminimal dose of suxamethonium to prevent prolonged apnea, both these points were taken into consideration. Despite 38 days post exposure to OP, and a dose of succinylcholine of < 0.3 mg/kg, the patient remained apneic for 3 h. Suxamethionum apnea was managed with elective ventilation. After recovery, patient had no residual effect. Subsequently her pseudocholinesterase levels were done which were found to be very low.

CONCLUSION

This case is being presented to emphasize that behaviour of post synaptic receptors cannot be relied upon after OP poisoning and pseudocholinesterase levels needs to be mandatorily checked, irrespective of duration post-exposure. In strong suspects dibucaine number and fluoride number also needs to be estimated.

Prolonged Apnea During Modified Electroconvulsive Therapy in a Patient of Suicidal Attempt by Organophosphorus Poisoning: A Case Report

Organophosphorus (OP) pesticides are commonly used in agricultural fields to control pests in India. However, exposure to it can cause poisoning in humans and animals, or it can be taken intentionally as poison to commit suicide. We present a case of a 35-year-old suicidal man who developed prolonged apnea for almost 4 hours on day 13 of OP poisoning after brief general anesthesia induced by propofol and 1 mg/kg of suxamethonium, during the first session of the third cycle of modified electroconvulsive therapy, despite all due precautions. Such prolonged apnea secondary to complex interactions has been reported very rarely in literature. This case therefore, highlights the importance of careful evaluation and monitoring while giving anesthesia to OP-poisoning patients.

Pharmacogenetics in electroconvulsive therapy and adjunctive medications

Electroconvulsive therapy (ECT) has shown apparent efficacy in treatment of patients with depression and other mental illnesses who do not respond to psychotropic medications or need urgent control of their symptoms. Pharmacogenetics contributes to an individual's sensitivity and response to a variety of drugs. Clinical insights into pharmacogenetics of ECT and adjunctive medications not only improves its safety and efficacy in the indicated patients, but can also lead to the identification of novel treatments in psychiatric disorders through understanding of potential molecular and biological mechanisms involved. In this review, we explore the indications of pharmacogenetics role in safety and efficacy of ECT and present the evidence for its role in patients with psychiatric disorders undergoing ECT.

Position statement and guidelines on unmodified electroconvulsive therapy

BACKGROUND

In modern day psychiatric practice, it is assumed as a matter of fact that when electroconvulsive therapy (ECT) is administered, it will be administered under anesthesia and with succinylcholine (or its equivalent) modification. Yet, as surveys indicate, there is considerable practice of unmodified ECT in developing countries and, to a small extent, in the developed world, as well.

MATERIALS AND METHODS

This document examines historical and recent literature on the geographical practice, physiology, efficacy, and adverse effects of unmodified ECT. Particular attention is paid to musculoskeletal risks.

RESULTS

Although almost all the research is of poor methodological quality, there is a good reason to accept that unmodified ECT is associated with a wide range of adverse consequences, important among which are musculoskeletal complications, pre-ECT anxiety, and post-ECT confusion. However, it appears from recent data that these risks are not as large as historically portrayed. Possibly explanations are suggested, with seizure modification using parenteral benzodiazepines as a special possibility.

CONCLUSIONS

Under exceptional circumstances, if ECT is strongly indicated and seizure modification with succinylcholine is not feasible, unmodified ECT, especially benzodiazepine-modified ECT, may be a viable option. A detailed set of recommendations for such use of unmodified ECT is proposed along with necessary checks and balances. This document has been approved by the Indian Psychatric Society, the Indian Association of Biological Psychiatry, and the Indian Association of Private Psychiatry (which commissioned the preparation of the document).