Anaesthesia for electroconvulsive therapy

Electroconvulsive therapy is an effective treatment for severe and medication-resistant depression. There have been no reports describing how a volatile anaesthetic affects haemodynamic responses, seizure duration, and recovery characteristics during electroconvulsive therapy. We carried out a repeated-measure crossover study to compare the effects on haemodynamic responses, seizure duration, and recovery characteristics of the following types of anaesthesia in electroconvulsive therapy: propofol alone, sevoflurane alone, and propofol combined with sevoflurane. We recruited 50 patients requiring electroconvulsive therapy for depression. For anaesthesia induction, 1.5 mg/kg propofol (condition P), 5% sevoflurane in oxygen following a vital capacity rapid inhalation induction (condition S), or 1.5 mg/kg propofol followed by 5% sevoflurane in oxygen (condition PS) was administered. Succinylcholine 1.5 mg/kg was then given. Electrical stimulation was administered after fasciculation. Measurements were obtained before anaesthesia induction (baseline), prior to succinylcholine administration, prior to electroconvulsive therapy, and at the peak after electroconvulsive therapy. After electroconvulsive therapy, peak heart rate and peak mean arterial pressure were highest in condition S. Whereas recovery time was longest in condition PS, motor seizure duration was significantly shorter than in either condition P or S. Electroencephalographic seizure duration was significantly shorter in condition PS than in condition P and significantly shorter in condition S than in condition P. Sevoflurane anaesthesia alone is most disadvantageous in terms of haemodynamics. Propofol-sevoflurane anaesthesia is advantageous in terms of haemodynamics, but disadvantageous in terms of seizure duration and recovery time. Propofol alone is most advantageous in terms of seizure duration.

Electroconvulsive therapy (ECT) is a well-established treatment for severe psychiatric disorders, and its role in modern-day psychiatry continues to expand with rising rates of complex mental illnesses. ECT has proven to be an effective treatment for conditions such as treatment-resistant depression, catatonia, bipolar disorder, schizophrenia, and other serious mental health disorders. Individuals who are resistant to or have contraindications against conventional pharmacologic therapies can particularly benefit from ECT. The procedure involves inducing a brief and controlled generalized seizure by passing an electrical stimulus through a patient's cerebral cortex. The safety of ECT was historically an area of concern due to injuries from the involuntary convulsions during the induced seizure. The use of general anesthesia and adjunct muscle-relaxing agents has made ECT considerably safer in the modern day. The goal of anesthesia in ECT is to induce a quick sedation with adequate depth, to prevent pain and injury from convulsions, and to provide a targeted amnesia. However, many anesthetic agents also function as anticonvulsants and consequently can affect the seizure threshold. The benefits of ECT are inextricably linked to the quality and duration of the induced seizure, therefore, careful consideration must be given to the choice of anesthetic. Alongside its effects on seizure threshold, anesthesia can also affect hemodynamic stability, cardiovascular response, and even the recovery course following ECT. Furthermore, special populations such as elderly patients, pregnant individuals, or those with significant comorbidities require an individual-based approach to anesthetic management. Ultimately, the choice of anesthetic plays an integral role in the therapeutic benefit of ECT. Therefore, strategic management of the anesthetic component of the procedure is critical in improving patient outcomes. This narrative review intends to analyze the dynamic role of anesthesia in ECT by synthesizing current clinical evidence on physiologic changes, pharmacodynamics, procedure optimization, and management of comorbidities and complications.

Objectives: Propofol and ketamine have become progressively popular in electroconvulsive therapy (ECT) anesthesia. Ketofol is a combination of ketamine and Propofol, and the current study was designed to evaluate the effect of Ketofol and Propofol on motor seizure duration, hemodynamic profile and recovery times in patients undergoing ECT. Methods: Fifty-four ECT sessions were randomized into Ketofol and Propofol group. Motor seizure duration, hemodynamic profile and recovery times were recorded. Results: Motor seizure duration in Ketofol group (28.55 + 6.54 seconds) was longer than Propofol group (22.22 + 7.94 seconds) which was statistically significant (p =0.002). Both drugs had motor seizure duration within the therapeutic range. At 1 min after the end of seizure heart rate in Propofol group (97.40 + 18.18 bpm) was lower compared to Ketofol group (109.37 + 17.69 bpm) which was statistically significant (p= 0.017). Similarly at 5 min after the end of seizure the heart rate in Propofol group (95.25 + 10.38 bpm) was lower compared to Ketofol group (102.51 ± 13.65) which was statistically significant (p= 0.032). There was no statistically significant difference in recovery times between Ketofol and Propofol group. Conclusion: Although Ketofol 1:1 mixture is associated with a longer motor seizure duration than Propofol in ECT anesthesia, both drugs are equally effective in producing motor seizure duration within the therapeutic range.

Individualized ECT Succinylcholine Dosing in a Morbidly Obese Patient

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). 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. 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. 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.

Electroconvulsive therapy (ECT) remains the most effective treatment for major depressive disorder. Ketamine is an anesthetic gaining attention for its rapid antidepressant effect. Numerous randomized controlled trials have investigated the effect of ketamine anesthesia in ECT on various clinical outcomes. Previous systematic reviews have not found benefit for overall depression response, although some have found evidence of benefit early in the ECT course. Clear quantitative conclusions have not been established regarding other outcomes, particularly while only using data from high-quality studies. We aimed to examine all data from double-blind randomized controlled trials comparing ketamine to other anesthetics via meta-analysis, to make recommendations regarding ECT practice and future research. Data were extracted for depressive symptoms, seizure duration and electrical dose, neuropsychological performance, and adverse effects. Effect sizes were calculated using Hedge's g and odds ratios. Eighteen studies (n = 915) were included in the meta-analysis. Ketamine was not found to enhance improvement of depressive symptoms, either early in ECT course or at end of study. Ketamine had a large effect on increasing seizure duration both overall (Hedge's g = 0.71, P = 0.038) and in the subgroup receiving ketamine in combination with another anesthetic (Hedge's g = 0.78, P < 0.01), and on decreasing electrical dose (Hedge's g = 1.98, P = 0.039). There was no significant effect of ketamine on any individual neuropsychological domain. Ketamine was not associated with increased adverse effects, except for hypertension in patients receiving ketamine monotherapy. Significant heterogeneity was present for many outcomes, and sensitivity analyses suggested a relation to methodological variation in most cases. This study supports the finding that ketamine does not enhance ECT's antidepressant effect, including on early improvement, but provides substantial evidence for enhancing seizure duration and reducing electrical dose. No significant benefit was found on neurocognitive outcomes, but analysis was limited by small sample sizes and high heterogeneity. Ketamine is generally safe in ECT, particularly as a coanesthetic. Our findings provide meta-analytic support to the recommendations in ECT clinical guidelines for use of coadjuvant ketamine in ECT where seizures are suboptimal. Further studies targeting neurocognitive outcomes are encouraged.

Electroconvulsive therapy (ECT) is a well established and effective therapy in treatment-resistant depression. It is performed under general anesthesia, but no consensus exists regarding the optimal anesthetic drugs. A growing interest in optimizing adjunctive medication regimes in ECT anesthesia has emerged in recent years. Moreover different methods of seizure induction have been evaluated. Pretreatment with dexmedetomidine eased the propofol injection pain and reduced the hyperdynamic response to ECT, but prolonged recovery. Remifentanil exhibited no proconvulsive effect and had no effect on seizure quality. Ketamine showed an antidepressive effect but was associated with cardiovascular side effects and an increased recovery time. A bispectral index-guided anesthesia or a time delay between anesthesia and seizure induction resulted in a better seizure quality presumably by avoiding high concentrations of (anticonvulsive) hypnotics. Seizure induction by magnetism seems to be an alternative to ECT, as the former is associated with less cognitive side effects but comparable antidepressive efficacy. The current practice of anesthesia for ECT should not be modified, as the evidence of studies is either too low or the results are inconsistent. Some approaches are promising but require validation in further studies with a higher number of participants.

This study aimed to compare the effects of propofol, thiopental, and etomidate, which are routinely used in anesthesia for electroconvulsive therapy (ECT), on the cardiovascular system, seizure variables, recovery, cognitive functions, and response to treatment. Male patients hospitalized at the Seventh Psychiatry Clinics of the Bakırköy Teaching Hospital for Psychiatry, Neurology, and Neurosurgery who were treated with ECT were investigated prospectively. The effects on cardiovascular system parameters (heart rate, blood pressure, and blood oxygenation), seizure variables (duration and intensity of seizure), and recovery variables were recorded at every session, on prespecified time points, and the findings of the first session were used in this evaluation. In addition, clinical responses to treatment were evaluated with tests of cognitive functions before and after a course of ECT. Adverse effects were recorded. The sociodemographic characteristics of the 3 treatment groups were similar. There were no significant differences among the groups in terms of effects on cardiovascular system variables, seizure variables, and cognitive functions. The clinical response to ECT was good in all groups, without any significant differences. Propofol, etomidate, and thiopental are associated with similar safety and efficacy profiles.

Brief general anaesthesia has added to the safety and comfort of electroconvulsive therapy (ECT). While usually a simple procedure, there are several areas in which ECT differs from other procedures requiring brief anaesthesia. These differences call for even more collaboration between psychiatrist and anaesthetist than is customary. This review details the areas where the anaesthetic management may affect the outcome of ECT for both an individual treatment and a treatment series. These include the patient evaluation, the patient preparation, the sequence and doses of anaesthetic agents, and the recovery period. Because each patient receives a series of treatments, an optimum regimen from both the psychiatric and anaesthetic standpoints can ultimately be achieved.

Blood pressure control with glyceryl trinitrate during electroconvulsive therapy in a patient with cerebral aneurysm

ELECTROCONVULSIVE THERAPY (ECT) IS ONE OF THE most controversial treatments in all of medicine. There are a number of reasons for this. The discovery in the 1930s that inducing a series of generalized seizures, initially with chemicals, later with electric current, could cause the recovery of patients with severe and previously untreatable mental disorders produced a wave of enthusiasm that eventually led to a period of indiscriminate use and misuse in the middle decades of the 20th century. This period of abuse created, perhaps deservedly at that time, a bad reputation for an effective treatment modality. That reputation was enhanced by the immediate adverse effects of bitten tongues and even fractured bones and teeth caused by the induction of generalized seizures, and the painful effects of electroshocks administered without anesthesia when they did not successfully induce a seizure with loss of consciousness. The 1975 movie One Flew Over the Cuckoo’s Nest contributed to an erroneous view of ECT as a punitive, painful, and assaultive procedure used by authorities to control inconvenient creativity. That view has been associated with attempts to regulate, or even eliminate, the use of ECT through legislation in a number of jurisdictions, and public fears and distrust about the use of ECT have persisted. The best response to such concerns on the part of physicians is to be aware of the facts about current use of ECT, including its efficacy and possible adverse effects, so they can respond to questions from patients, families, and the public. The indications, possible adverse effects, and current recommendations for treatment procedures have been summarized in a task force report just published by the American Psychiatric Association Committee on Electroconvulsive Therapy. An effective and safe treatment for severe major depression, ECT has had response rates reported in the range of 80% to 90% as a first-line treatment, and in the range of 50% to 60% for patients who have not responded to 1 or more trials of treatment with antidepressant drugs. Electroconvulsive therapy may also be seriously considered as treatment for patients with acute mania, and for patients with schizophrenia who have not responded to adequate trials of antipsychotic medications. As currently practiced, ECT involves the use of informed consent, ultra-brief general anesthesia and muscle relaxants (thus attenuating motor seizure activity) with appropriate airway management, and use of ECT devices to provide adequate ictal responses. Most patients in the United States receive 3 treatments per week, and a course of ECT for major depression generally consists of 6 to 12 treatments, with the course ended or tapered as soon as maximum response has been reached. This usually occurs more quickly than the 4 to 6 weeks required for an adequate trial of an antidepressant drug. There continues to be some controversy about the use of right unilateral or bilateral electrode placement, with right unilateral ECT causing less cognitive adverse effects, but bilateral ECT often viewed as being more effective. A recent randomized controlled trial showed that right unilateral ECT at high dosage was as effective as bilateral ECT in many patients and caused less impairment on several measures of anterograde and retrograde memory. The issue of cognitive adverse effects from ECT is central to its reputation for harm and requires careful consideration to separate facts from myths. Studies of this issue have been reviewed and summarized by the American Psychiatric Association Committee on Electroconvulsive Therapy. Patients experience a variable but usually brief period of disorientation (postictal confusion) immediately after seizure induction. Electroconvulsive therapy also typically results in retrograde amnesia, greatest immediately after the course of treatment and for events that occurred temporally close to the treatment. The extent of the retrograde amnesia usually decreases substantially with time, but many patients have persistent loss of memory for some events that occurred in the interval starting several months before and extending to several weeks after their ECT course. Anterograde amnesia, characterized by rapid forgetting of learned information, also may occur during and immediately following ECT but resolves within a few weeks. Importantly, there is no objective evidence that ECT has any long-term effect on the capacity to learn and retain new information. Assessment of cognitive effects from ECT is complicated by the cognitive impairments associated with the mental disorders being treated. For example, patients with severe depression may have substantial impairments in cognitive function, and patients with schizophrenia or other psychotic

BackgroundThere is a robust empirical evidence base supporting the acute efficacy of electroconvulsive therapy (ECT) for severe and treatment resistant depression. However, a major limitation, probably contributing to its declining use, is that ECT is associated with impairment in cognition, notably in anterograde and retrograde memory and executive function. Preclinical and preliminary human data suggests that ketamine, used either as the sole anaesthetic agent or in addition to other anaesthetics, may reduce or prevent cognitive impairment following ECT. A putative hypothesis is that ketamine, through antagonising glutamate receptors, protects from excess excitatory neurotransmitter stimulation during ECT. The primary aim of the ketamine-ECT study is to investigate whether adjunctive ketamine can attenuate the cognitive impairment caused by ECT. Its secondary aim is to examine if ketamine increases the speed of clinical improvement with ECT.Methods/DesignThe ketamine ECT study is a multi-site randomised, placebo-controlled, double blind trial. It was originally planned to recruit 160 moderately to severely depressed patients who had been clinically prescribed ECT. This recruitment target was subsequently revised to 100 patients due to recruitment difficulties. Patients will be randomly allocated on a 1:1 basis to receive either adjunctive ketamine or saline in addition to standard anaesthesia for ECT. The primary neuropsychological outcome measure is anterograde verbal memory (Hopkins Verbal Learning Test-Revised delayed recall task) after 4 ECT treatments. Secondary cognitive outcomes include verbal fluency, autobiographical memory, visuospatial memory and digit span. Efficacy is assessed using observer and self-report efficacy measures of depressive symptomatology. The effects of ECT and ketamine on cortical activity during cognitive tasks will be studied in a sub-sample using functional near-infrared spectroscopy (fNIRS).DiscussionThe ketamine-ECT study aims to establish whether or not adjunctive ketamine used together with standard anaesthesia for ECT will significantly reduce the adverse cognitive effects observed after ECT. Potential efficacy benefits of increased speed of symptom improvement and a reduction in the number of ECT treatments required will also be assessed, as will safety and tolerability of adjunctive ketamine. This study will provide important evidence as to whether adjunctive ketamine is routinely indicated for ECT given for depression in routine NHS clinical practice.Trial RegistrationCurrent Controlled Trials: ISRCTN14689382 (assigned 30/07/2012); EudraCT Number: 2011-005476-41

Electroconvulsive therapy (ECT) is the most effective treatment for severe depression and is often the last resort in patients with medically treatment-resistant depression.1 The clinical effect of ECT relies upon the quality of the seizures elicited.2 In a patient not responding to ECT due to poor seizure quality, eliciting an adequate seizure may be the initial challenge. Anesthesia influences seizure quality.3 Etomidate is an ultrashort-acting, non-barbiturate hypnotic intravenous anesthetic agent with minimal cardiovascular effects, making it suitable for ECT. Etomidate lacks the strong anticonvulsant properties of standard ECT anesthetics (i.e., thiopental and propofol4) and leads to higher-quality and longer seizures.5 However, etomidate inhibits 11β-hydroxylase and steroid biosynthesis, including corticosteroids.6 A major concern is the potential for adrenocortical suppression in rapid-sequence induction of anesthesia in critically ill patients. We present a patient who had null seizures at the maximal stimulus dosage until a change in anesthesia to etomidate, and review the literature on the effect of anesthesia on ECT seizure quality. A 61-year-old man with recurrent major depressive disorder was hospitalized due to moderate depression with suicidal ideation (17-item Hamilton Depression Rating Scale [HAM-D] score = 21). Several treatment regimens with combinations of antidepressants failed, and he consented to ECT. ECT was administered thrice weekly (Table 1). The initial three ECT sessions with rising stimulation doses to the maximal 1021 mC with 3.5-mg/kg thiopental as standard anesthesia completely failed to elicit a seizure. Even 0.5-mg alfentanil augmentation and 50 mg chlorprothixene the evening before ECT to lower the seizure threshold had no effect. Anesthesia was changed to 0.2 mg/kg etomidate and elicited high-quality seizures of >60 s with clinical effect (HAM-D score = 16 after seven seizures), which allowed a down-titration of stimulus, potentially reducing the associated cognitive side-effects of ECT. The patient received 11 high-quality and clinically effective ECT treatments as an inpatient. He was discharged shortly after with fewer depressive symptoms (HAM-D score = 9) and was followed up in outpatient care with once-weekly maintenance ECT. The morning before his 25th maintenance ECT, his serum cortisol was 179 nM and the following morning 212 nM, which is higher than the minimum expected morning plasma cortisol concentration of 133 nM. Similarly, 24-h measurement of total urine cortisol production after the 25th ECT was 101 nmol (reference interval 10–124 nmol), indicating no adrenal suppression. At one of the ECT sessions, after etomidate administration, he had limb contractions before a muscle relaxant was administered. The contractions were confused with a seizure and lasted for ~30 s before termination with 5 mg diazepam and ECT was aborted. Follow-up MRI, electroencephalography (EEG), and neurological assessment concluded that the contractions were myoclonus due to late injection of the muscle relaxant. The patient received 26 successful ECT treatments with etomidate and gave written consent to publishing this case report. We present how etomidate enabled high-quality seizures in a patient unresponsive to ECT during standard thiopental anesthesia. Although >35 treatments using etomidate were given, the patient showed no signs of corticoadrenal suppression in terms of lower circulating levels of cortisol. This is in line with evidence that, although three ECT sessions weekly constitutes repeated use of etomidate in a relatively short time interval, serum levels of cortisol and adrenocorticotropin do not reach abnormally low levels during or after a sequence of ECT with etomidate in this patient population.7 Myoclonus is a very common side-effect during induction with etomidate and can be misinterpreted as a seizure. Unlike thiopental and propofol, which have strong anticonvulsant properties; etomidate has a disinhibitory effect on extrapyramidal motor activity responsible for the majority of myoclonus observed. A more specific and potent etomidate analogue was abandoned during phase II studies due to involuntary muscle movements.8 While involuntary muscle movements are undesirable in a non-ECT setting, they may be desirable for ECT as the cortical disinhibitory effect may be what enables etomidate to provide higher-quality seizures. Etomidate leads to higher-quality seizures and longer motor seizures in ECT.5, 9 In the most recent review of anesthesia for ECT, etomidate and ketamine yielded the longest seizures.3 The same review found that etomidate and a 1:1 (racemic)-ketamine and propofol mixture yielded the highest-quality seizures. The only comparison between etomidate and s-ketamine suggests that s-ketamine showed no difference in seizure duration but may provide higher-quality seizures based on higher postictal suppression, EEG coherence, ictal amplitude, and peak heart rate.10 Given the limited study size and adverse side-effects of s-ketamine (i.e., dissociative symptoms, vomiting, and hypertension), etomidate appears favorable. Our case highlights the impact of anesthesia on seizure generation during ECT, and how etomidate, largely abandoned in intensive care settings, may be considered the anesthetic of choice when patients fail to achieve high-quality seizures and clinical effect during ECT. All authors declare that they have no financial interests or any other conflict of interest with other people or organizations that could inappropriately influence this work.

The effects of electroconvulsive therapy are usually estimated from changes in depression scales from studies with relatively small patient samples. Larger patient samples can be achieved from epidemiological registers, which provide information on other social and clinical predictors, results and risks. To examine whether depression severity predicts the use of electroconvulsive therapy, risk of re-hospitalization, suicidal behaviour and mortality following electroconvulsive therapy in patients with major depression. A cohort of 92,895 patients diagnosed with single or recurrent depression between 2005 and 2016 in the Danish National Patient Registry was followed for electroconvulsive therapy and adverse outcomes. Associations between electroconvulsive therapy and outcomes were analysed using Cox regression. A total of 5004 (5.4%) patients were treated with electroconvulsive therapy. Depression severity was the strongest predictor of electroconvulsive therapy. Electroconvulsive therapy was used more frequently above age 70, in those better educated or married, whereas comorbid alcohol abuse or history of prior stroke at study entry were associated with lower rates. Electroconvulsive therapy was associated with lower mortality. The adjusted hazard ratio for the association between electroconvulsive therapy and suicide in patients with mild depression was 6.99 (3.30-14.43), whereas it was 1.10 (0.55-2.20) in those with severe depression and psychotic symptoms. A similar pattern was seen for emergency contacts and attempted suicide. Electroconvulsive therapy was associated with lower all-cause mortality and the relative risk for re-hospitalization and attempted and committed suicide was lowest in patients with the most severe depression. Electroconvulsive therapy is an important treatment, with significant public health benefits, for patients with severe depression.

Background: Depression is a disorder of concern that affects globally and has become the second leading cause of disability-adjusted life years. The disorder is characterized by persistent sad mood, loss of interest in previous pleasurable activities, reduced energy level, suicidal thoughts, and cognitive disturbances. Electroconvulsive therapy (ECT) is a rapid and effective treatment for severe depression. However, there was stigma toward the application of modified ECT (MECT), the major among them is diminished cognitive particularly memory disturbance. Studies claim that memory disturbances are transient and short-lived. Hence, the current study’s aim is to assess the cognitive status of severe depression patients before and after ECT. Materials and Methods: It is a hospital-based longitudinal analytical study conducted in the psychiatry inpatient department. Ninety-two patients fulfilling the criteria for depression as per DSM-5 were taken into the study after inclusion and exclusion criteria and informed consent. The symptoms of depression are assessed using the Hamilton Depression Rating Scale (HAM-D) and cognitive functions are assessed with Addenbrooke’s Cognitive Examination Scale - Revised (ACE-R). The scale is administered before ECT, post-ECT on day 3, 1 month, and 3 months, respectively. Results: The mean age was 34 years. The majority belonged to the age group of 20–30 years (50%) and were educated up to high school (35%). Before ECT, the mean ACE-R score was 79.39. On day 3 after ECT, the mean score was 78.97. One month after ECT, the mean score was 82.82. Three months after ECT, the mean score was 85.15. The ACE-R scores started to increase at 1 month and at 3 months after ECT, which was statistically significant ( P &lt; 0.05). Before ECT, the mean HAM-D score was 24.41. On day 3 after ECT, the mean HAM-D score was 14.84. One month after ECT, the mean HAM D score was 9.06. Three months after ECT, the mean HAM-D score was 4.43. The decline in HAM-D score from baseline to 3 months after ECT (24.41–4.43) was statistically significant ( P &lt; 0.05). Conclusion: The cognitive impairments due to MECT occur only in the immediate phase following MECT. The impairments are transient and short-lived and improvement in cognition occurs over time.