7. Anaesthesia for ECT

Etomidate and seizure duration in electroconvulsive therapy (2013). vLammeren A, Dols A, dVen P et al., J of ECT 29; 101-105.

In this retrospective study of 74 patients whose ECT anaesthetic induction agent was etomidate there was no statistically significant correlation between routine dose of etomidate and length of seizure.

 

Effect of propofol versus sodium thiopental in electroconvulsive therapy in major depressive disorder. (2013) Purtuloglu T, Ozdemir B, Erdem M et al. J of ECT; 29:37-40.

This was a randomised double blind control trial if 96 patients undergoing bilateral ECT in Turkey. Both groups improved but there was a significant difference in HAMD scores; the propofol group doing better. There was no correlation with age or body mass index and no association with length of seizure and duration of recovery.

 

Neuropsychological and mood effects of ketamine in electroconvulsive therapy: a randomised controlled trial. (2012). Loo C., Katalinic N., Garfield J et al. J of Affective Disorders; 142:233-240. http://dx.doi.org/10.1016/j.jad.2012.04.032. The addition of ketamine to anaesthetic is reported to have neuroprotective effects possibly by blocking glutamate receptors. However this study of 51 patients failed to show any reduction in cognitive side effects in those receiving ketamine. On the other hand the ketamine group showed slightly improved efficacy in the first week of treatment and at one week follow up.

 

Canadian survey of perianesthetic care for patients receiving electroconvulsive therapy. (2012). Gilron I., Delva N., Graf P et al. J of ECT; 28:219-224r.
This was a nationwide survey of anaesthetic practice. There was a 61% return and results suggested safe practice with the vast majority using oximetry, BP and electrocardiography monitoring as routine. A recommendation to have ready access to dantrolene and capnography for all units was made.

 

Effects of propofol and ketamine combined anesthesia for electroconvulsive therapy in patients with depressive disorder.(2012). Wang x, Chen Y, Zhou X et al., J of ECT; 28:128-132

Forty eight patients receiving ECT for the treatment of a severe depressive episode were divided in to three groups: propofol, ketamine and propofol plus ketamine. The Hamilton Rating Scale for Depression (HRSD) was used to rate severity and outcome. Decreases in HRSD were significantly greater in the ketamine and combined anaesthesia groups. Adverse effects including hypertension and a sense of fear upon wakening were less in the group receiving both ketamine and propofol compared to ketamine alone.

The effect of repeated etomidate anesthesia on adrenocortical function during a course of electroconvulsive therapy.(2011). Wang N, Wang X, Lu J et al. J of ECT 27: 281-285

This investigation compared the effects of propofol and etomidate on cortisol levels, adrenocoticotrophic function and blood pressure following ECT. There were no significant differences.

Electroconvulsive therapy anaesthesia practice patterns; results of a UK postal survey. (2011). Bwalya G, Srinivasin V & Wang M. J of ECT 27;81-85

Fifty-one percent of clinics throughout the UK responded to this 12 item questionnaire about anaesthetic practice. Most units were remotely located and although self report practice was of generally high standard there was variable practice with respect to pre-ECT assessment and monitoring and consultant supervision.

Medical Evaluation of patients undergoing electroconvulsive therapy. (2009). Tess AV, Smetana Gerald W. New England Journal of Medicine, 360, 1437-1444.

The authors describe cardiac risk in anaesthesia for ECT as analogous to a low risk procedure as defined by the American College of Cardiology and the American Heart Association. They give recommendations for pre-ECT workup and management of inter-current illness.

Comparison of propofol and thiopental as anesthetic agents for electroconvulsive therapy. (June 2009), Bauer J et al. J of ECT; 25: 85-90.

In the 62 patients studied propofol significantly decreased seizure duration without affecting clinical outcome. Seizure threshold had been measured and patients whose anaesthesia was induced by propofol required higher doses of electricity. However the groups were not matched for age and differences in other variables like the number of treatments required and cognitive side effects did not reach significance.

Cognitive impairment following electroconvulsive therapy – does the choice of anaesthetic agent make a difference? March 2008. MacPherson R, Loo C. J of ECT, 24:52-56.

This review summarises the history of anaesthetic agents for ECT. It describes their relative properties and proposes that more be done to search for an anaesthetic agent that might help reduce cognitive side effects. The authors suggest that short acting opioids and ketamine might be the place to start.

Effects of general anaesthetic agent in adults receiving electroconvulsive therapy: a systematic review.September 2008. Hooten W, Rasmussen jnr K. J of ECT; 24:208-223

The authors review 41 randomised trials of 14 induction agents either alone or in combination. Observations include an effect on seizure duration and small but significant effects on recovery times. Only a few studies have looked at clinical outcome, suggesting the choice of agent is immaterial provided the dose of electricity has been titrated to the individual.

Anaesthetic management for electroconvulsive therapy.  (2008). Narayan V, Jain M. J Anaesth Clin Pharmacol; 24(3):259-276.

This is a review article that lists the physiological effects of ECT on the brain, cardiovascular and endocrine systems as well as outlining the process of ECT and the choice of anaesthetic agent. Possible complications are outlined and the effects of co-morbidity and concomitant medication discussed.

Propofol and methohexital as anaesthetic agents for electroconvulsive therapy: a randomised, double-blind comparison of electroconvulsive therapy seizure quality, therapeutic efficacy and cognitive performance. Geretsegger et al. December 2007. J of ECT;23:239-243

This was a study of 50 patients randomised to receive either propofol or methohexitone for ECT. Propofol resulted in a significantly lower  increase in blood pressure with a tendency to a shorter seizure duration and also  improved cognitive performance immediately after treatment. There was no difference in seizure quality and no detected difference in outcome with respect to efficacy.

Cardiovascular effects of anaesthesia in ECT: A randomised, double blind comparison of etomidate, propofol and thiopental. Rosa M et al. March 2007. J of ECT; 23:6-8.

 

30 patients were randomised to receive one of the study anaesthetic agents for ECT. The results showed that etomidate, propofol and thiopental were associated with similar cardiovascular effects.

Blood pressure before and after electroconvulsive therapy in hypertensive and nonhypertensive patients. Albin S, Stevens S, Rasmussen K. March 2007. J of ECT 23;9-10.

This was a case note review of 47 patients, 20 with hypertension and 27 without hypertension, selected because they did not have any medication changes in association with their course of ECT. The authors acknowledge that increased BP during treatment is more likely in patients with hypertension. However the average change in BP for both groups after the ECT treatment was finished was a decrease of 3 mmHg systolic and 2mmHg diastolic.

Seizure length and clinical outcome in electroconvulsive therapy using methohexital or thiopental. March 2005. J of ECT;21:16-18.

This was a retrospective review of 837 treatments administered to 97 patients. Of the 78 with clinical outcome ratings, 45 were given thiopental and 37 methohexital. There was no significant difference in length of seizure though the methohexital group showed a trend to longer seizures at treatments 2 and 5. There was no statistical significance in GAF outcome scores.

Promethazine for the treatment of agitation after electroconvulsive therapy. A case series. June 2005. Vishne T, Amiaz R, Grunhaus L. J of ECT 21:118-121.

This is a case series of eight describing the use of promethazine, a sedative antihistamine, as an oral; premed to prevent the emergence of post ECT agitation. No adverse events were reported.

Double-blind placebo controlled study of the effects of etomidate-alfentanil anaesthesia in electroconvulsive therapy. Van den Broek et al. September 2004. J of ECT 20:107-111.

21 patients were enrolled in this prospective study. The authors report that alfentanil used in combination with etomidate significantly reduced heart rate and lowered blood pressure compared to an alfentanil-placebo combination. They conclude that alfentanil could be useful to reduce tachycardia and hypertension during ECT in high-risk patients.

Inhalational induction with sevoflurane for electroconvulsive therapy: a case series. Palmer J, Khalil M & Meagher D. September 2004. Psychiatric Bulletin, 28,326-328.

Anaesthesia was successfully induced in the five patients studied. Seizure duration was between 24-72 seconds. One patient developed mild hypoxia following the seizure and re-orientation times were described as acceptable. The authors conclude that sevoflurane might be a suitable induction agent but clearly the use of inhalational anaesthesia has resource implications for an ECT service.

Propofol reduces cognitive impairment after electroconvulsive therapy. Butterfield N et al. Journal of ECT March 2004, 20(1)3-9.

This randomised, double blind, crossover study of 15 patients concluded that cognitive impairments were reduced with propofol compared to thiopentone anaesthesia. ECT was right unilateral at three times seizure threshold. The cognitive test battery took 30 minutes to complete at 45 minutes post ECT.

Indications for the Use of Propofol in Electroconvulsive Therapy. Bailine S et al. Journal of ECT September 2003, 19(3):129-132.

The authors advocate the use of propofol to induce shorter seizures in young people and to minimise post treatment nausea and vomiting. Their study was a retrospective look at 28 patients whose anaesthetic had been changed from methohexitone to propofol. All patients, except those on maintenance schedules, remitted after an average of eight bilateral treatments.

Induction agents in electroconvulsive therapy: a comparison of methohexitone and propofol. Scott A & Boddy H. Psychiatric Bulletin December 2002; vol 26, no 12, 455-459.

This retrospective comparison over 10 years looked at the effect a change in anaesthetic agent had on the seizure threshold as well as seizure length. Propofol was not associated with a commensurate rise in seizure threshold though, in keeping with other studies, did reduce the seizure length. Since it is the amount of electricity above threshold, rather than the seizure length, that is associated with efficacy (and side-effects), this adds to the evidence that propofol does not compromise the therapeutic outcome of ECT.

Iwasaki K., et al, Mar (2002), Electroconvulsive therapy with thiamylal or propofol during pregnancy. Can J. Anaesth., 49(3):324-5.

Mudur G., (2002, ) Indian group seeks ban on use of electroconvulsive therapy without anaesthesia. Br Med J 2002 Apr 6;324(7341):806

Walder B., et. al., (2001). Propofol [correction of propfol] versus methohexital for electroconvulsive therapy: a meta-analysis. J Neurosurg Anesthesiol 2001 Apr;13(2):93-8.

Ding Z., et al, (2002), Anesthesia for electroconvulsive therapy. [Review] [130 refs] Anesth Analg 2002 May; 94(5):1351-64.

Kadar AG., et. al.,(2002), Anesthesia for electroconvulsive therapy in obese patients. Anesth Analg 2002 Feb;94(2):360-1

Benbow S., Shah P. and Crentsil J. September (2002), Anaesthesia for electroconvulsive therapy: a role for etomidate. Psychiatric Bulletin, 26, 351-353.

Three case studies where etomidate was used in preference to thiopentone for ECT: to counteract brief seizures, to minimise side-effects, in a patient with severe ischaemic heart disease.

Stadtland C. et al.(March 2002), A switch from Propofol to Etomidate During an ECT Course Increases EEG and Motor Seizure Duration. Journal of ECT 18(1):22-25.

This study looked at the results of changing anaesthetic agent following short seizures using propofol as an induction agent. In 11 out of the 12 patients studied the mean seizure length more than doubled when etomidate was used instead. Unfortunately, although the authors state that the longer seizures were associated with recovery, there were no clinical outcome measures reported.

Folk J. W. et al, June (2000), Anaesthesia for electroconvulsive therapy: a review. Journal of ECT, vol 16, no 2, 157-170.

The authors review the selection, preparation and management of ECT patients from an anaesthetic perspective.

Auriacombe et al. (September 2000), Post-ECT agitation and plasma lactate concentrations., J of ECT, 16(3):263-267.

A prospective study, which supports the hypothesis that emergent agitation post ECT may be caused by lactate induced panic secondary to insufficient neuromuscular blockade.

Lee D., Kenny M., Harrop-Griffiths W. (1996), Anaesthesia for electroconvulsive therapy. Anaesthesia, volume 51; 583-584.