Journal List > Anesth Pain Med > v.17(2) > 1516078264

Joung, Park, Jeong, and Yang: Anesthetic care for electroconvulsive therapy

Abstract

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.

INTRODUCTION

Electroconvulsive therapy (ECT), also known as electroshock therapy, is a unique treatment in patients with major depression, affective disorders, catatonia, schizophrenia, and other psychotic disorders for which pharmacological treatments do not produce adequate responses [1,2]. Historically, ECT was first described in 1938 by Italian doctors Ugo Cereletti and Luigi Bini and was performed without anesthesia for almost 30 years, being referred to as “Unmodified ECT” [3,4]. With the subsequent development of more advanced medications and their increased use in clinical applications, general anesthesia with an intravenous agent and neuromuscular blocking agent is now performed as an important part of the ECT protocol to improve patient safety, enhance treatment effects, and minimize complications.
Recently, ECT has been reported to produce symptom relief effects in 70–90% of cases, which is a superior outcome to the use of antidepressants and has a recurrence rate of approximately 20% [5]. Moreover, the United States Food and Drug Administration’s recent redesignation of ECT devices as Class II (from Class III) for certain indications may impact the application of this therapy, as this facilitates the continued availability of ECT devices worldwide and helps decrease the stigma associated with this procedure by acknowledging its safety and effectiveness [6]. Thus, the use of ECT is expected to increase.
The worldwide frequency of ECT interventions is approximately 4.9 (0.4–81.2) out of 10,000 people. In Asian countries, particularly China, Taiwan, and India, there has been a significant increase in the number of reported cases [79]. In Korea, some hospitals use ECT in both outpatient and inpatient settings; however, data on the overall clinical applications of this technique are currently lacking [10]. The incidence of ECT is increasing, and anesthesia is an essential component of its safe and successful use. Thus, more anesthesiologists will need to become familiar with the characteristics of this procedure. Our present review focuses on the clinical applications of ECT, anesthetic management during this procedure, pharmacological action of various drugs used in ECT, including anesthetics and neuromuscular blocking agents, possible complications, and postprocedural considerations. Evidence from a literature review and our own experiences are discussed.

CLINICAL APPLICATIONS

Procedural aspects of ECT

ECT involves the transmission of an electric current through the brain, causing generalized tonic-clonic seizures. During this procedure, the position of the electrode and the physical properties of the electrical stimulation affect the seizure threshold, which is related to the therapeutic effect and cognitive impairment. Three electrode positions (bitemporal, bifrontal, and right unilateral) are commonly adopted. Among these, the bitemporal position is the most widely used. In addition to the electrode positioning and physical properties of electrical stimulation, various factors can also affect the seizure threshold (Table 1).
The antidepressant effects of ECT are related to seizure duration, as measured using electroencephalography (EEG), electromyography, or muscle movement. Seizure duration assessment by muscle movement during general anesthesia is performed by placing a tourniquet on the arm or leg and blocking the blood flow to exclude the effect of muscle relaxants. The seizure duration on an EEG is approximately 5 s longer than the muscle movement [10]. The appropriate motor seizure duration was 25–50 s.
In the acute phase, the number of ECT treatments is not defined but must be performed until the symptoms are relieved or stabilized. Most patients who undergo ECT receive 6–12 treatments per course. However, patients with depression may require fewer patients, while patients with schizophrenia may require more treatment per course [11]. ECT is usually performed two or three times a week, but in certain urgent cases, such as patients with catatonia, daily courses may be used until symptoms improve [12,13]. In rare instances, ECT may need to be interrupted or discontinued due to tolerability issues, such as adverse cognitive effects, fear of anesthesia, headaches, or nausea.
Maintenance ECT (M-ECT) has been used for ongoing procedures to prevent the recurrence of a new episode of depression and can last for years, possibly indefinitely. In most cases, M-ECT has a schedule of 3–8 weeks, but some patients may require longer periods of weekly treatment [14].

Indications for ECT

Most guidelines recommend ECT as the first-line treatment for severe depressive episodes, such as the presence of psychotic features, catatonia, high suicide risk, and/or food or fluid refusal. A history of previous positive response and patient preference are also important considerations [1517]. ECT is recommended as a second-line treatment for patients with severe major depressive episodes that are unresponsive to psychotherapeutic and/or pharmacological interventions. ECT is not recommended for personality disorders, drug abuse, or psychoneuroses. In children, the most common psychiatric indications are refractory depression, bipolar disorder, schizophrenia, catatonia, autism, and refractory status epilepticus [18].
According to the 2001 consensus statement of the American Psychiatric Association (APA), there are no absolute contraindications for ECT [19]. However, some conditions such as uncontrolled hypertension, coronary artery disease, congestive heart failure, aortic stenosis, implanted cardiac devices, atrial fibrillation, obstructive lung disease, asthma, and increased intracranial pressure with or without mass lesions pose a relatively high risk and may result in death during ECT [20,21]. The details of the indications for ECT are summarized in Table 2 [22,23].

Preoperative evaluations

The preoperative evaluation of ECT was comparable to that used in other general surgeries. Medical histories relevant to these assessments and important for a successful ECT include psychiatric history; drug history, including the type, dose, response, compliance, and side effects of any psychiatric drugs; and physical and laboratory examination results such as electrocardiography, chest radiography, serum creatine, and electrolytes [24]. Airway evaluations are also necessary because some conditions, such as difficulties with mask ventilation, a higher risk of pulmonary aspiration, and prolonged ventilation, may require unplanned intubation. In most cases, patients take their usual medications until the morning of the procedure, except for theophylline, herbal medications, or oral diabetes drugs [21].
Although ECT is a low-risk procedure, certain hemodynamic abnormalities may increase the risk of complications in patients with cardiovascular disease. Abrupt hemodynamic changes during ECT typically spontaneously recover a few minutes after a seizure. However, these changes can cause serious complications in patients with cardiovascular disease, and careful monitoring and preparation, including cardiopulmonary resuscitation, are needed in these patients [21,25].
As in adult patients, appropriate preoperative evaluations should be performed prior to ECT in pediatric patients. If a child has comorbidities, additional examinations and an increased planning time for anesthesia are required. In children with central nervous system malignancies, hydrocephalus, or cardiopulmonary diseases, the anesthesiologist should prepare for the interaction of anesthetics and any immediate negative effects of the procedure [18].
Pregnancy testing should be performed in all women of reproductive age. Although pregnancy is not a contraindication for ECT, fetal exposure to anesthetics must be minimized [26].

Physiologic changes during ECT

The physiology of the patient changes dramatically during the ECT. Between the electrical stimulation and the onset of seizure, conditions such as hypotension, bradycardia, and asystole can occur because the parasympathetic nervous system becomes dominant during this period. Tachycardia and hypertension occur during seizures because of rebound sympathetic activity [21,23,27]. In this period, the rate-pressure product (heart rate × blood pressure) increases 2–4 times with a 30–40% increase in systolic blood pressure, a > 20% increase in heart rate, and an increase in the index of myocardial oxygen consumption [28,29]. After seizures, the heart rate and blood pressure normalize within a few minutes, and any serious cardiovascular and complications that arise usually occur during this period [30]. Acute hemodynamic changes during ECT can cause pulmonary edema, ventricular tachycardia, myocardial infarction, and, in rare instances, cardiac shock [3133].
Cerebral blood flow, intracranial pressure, cerebral metabolic rate, and cerebral oxygen consumption increase during seizures because of transient cerebral ischemia and cerebral hemorrhage [34,35]. Acute neurological and cardiovascular changes, fractures, dislocations, and muscle pain also occur due to generalized convulsions [36,37]. Intraocular pressure also increases during convulsions but normalizes after seizures in most cases [38].

GENERAL ANESTHESIA FOR ECT

Prior to ECT, patients should fast from solid food for more than 8 h. Clear liquids are permissible during this time to enable oral medications such as antihypertensive drugs to be taken up to 2 h before the procedure. To prevent post-ECT myalgia, patients can be pre-medicated with enteric-coated aspirin, acetaminophen, or intravenous ketorolac. Ventilation during ECT is assisted by a face mask with a standard simple bag-valve-mask system. Tracheal intubation is not recommended, except in very specific situations (e.g., late pregnancy or emergency treatments in which the patient has a full stomach), because ECT is typically performed frequently (two or three times a week for 3–4 weeks), and each procedure lasts only a few minutes. In obese patients with sleep apnea syndrome, an oral airway can be helpful in maintaining ventilation during the procedure.
Non-invasive blood pressure, pulse oximetry, electrocardiography, and capnography are recommended during an ECT procedure. A tourniquet technique or electromyographic monitoring should be employed to quantify the duration of the motor seizure activity. The tourniquet technique is used to isolate the distal circulation using a pressure of 160–200 mmHg before administering the muscle relaxant. Although sufficient muscle relaxation is necessary during ECT, forceful jaw clenching is still inevitable with this intervention because of the direct stimulation of the masticatory muscles, particularly the temporalis and masseter muscles, by electrical current. Hence, a bite block should be carefully placed before the application of the electrical stimulus to protect the patient’s teeth and minimize the risk of lacerating the tongue. Standard noninvasive hemodynamic variables and oxygen saturation should be monitored for 15–30 min after ECT [39]. Emergence agitation after ECT is usually treated by administering a small dose of midazolam or dexmedetomidine [40,41].

GENERAL ANESTHESIA DURING ECT FOR SPECIFIC PATIENT GROUPS

Children and adolescents

Although ECT is known to be safe in adults, it is not commonly used in children and adolescents because of the risk of damage to the nervous system at the early stages. However, the indications for ECT in the pediatric population have increased steadily over the past 20 years [18], the most common of which are refractory depression, bipolar disorder, schizophrenia, catatonia, autism, and pediatric refractory status epilepticus. Unique factors related to pediatric ECT include the potential need for a preoperative anxiolytic with dexmedetomidine, likely to be the most appropriate agent in this regard, as oral benzodiazepines are relatively contraindicated. Methohexital remains the gold standard anesthetic for pediatric ECT, although ketamine, propofol, and sevoflurane are becoming increasingly viable options [18,42,43].

Pregnant cases

ECT has been reported to be an effective and safe treatment for pregnancy-induced depression, unipolar depression, bipolar disorder, schizophrenia, and other psychiatric illnesses [44,45]. However, ECT can cause maternal complications such as aspiration and premature labor, as well as fetal complications such as spontaneous abortion and fetal death. Therefore, a multidisciplinary team approach is required to manage this treatment in pregnant cases [44,46].
When it is difficult to maintain the patient's airway, or if fasting is insufficient, laryngeal mask airway or cricoid compression and endotracheal intubation can be helpful [47]. In addition, if there is a history of premature labor or uterine contractions following ECT, tocolytics can be used as prophylaxis. In addition, the use of inhaled anesthetics (e.g., sevoflurane) may reduce the risk of uterine contractions after ECT in late pregnancy [48]. Emergency cesarean section may be required in rare instances; therefore, treating clinicians should always be prepared for the possibility of premature delivery in relevant cases to ensure the child’s safety.

COVID-19 era

ECT units have faced certain challenges during the COVID-19 pandemic. These issues include screening, personal protective equipment, airway management, and maintenance of recovery rooms and facilities to prevent the spread and transmission of COVID-19 [49,50]. However, the most challenging of these issues is airway management. ECT requires close supervision by an anesthesiologist and the patient's oral and airway secretions. Commonly administered mask ventilation and hyperventilation without reliable airway protection increase the risk of aerosolization, which poses a serious risk to health care staff [51]. To overcome this drawback, Luccarelli et al. [52] performed ECT without bag-mask ventilation by applying adequate preoxygenation. The use of a second-generation supraglottic airway with a viral filter is also helpful in preventing viral transmission. In addition, Limoncelli et al. [53] reported the use of a Jackson–Rees circuit instead of an ambu-bag to provide leakage-free spontaneous ventilation, thus minimizing air emissions.

DRUGS FOR ECT

Anesthetics

The ideal characteristics of an anesthetic to be used for ECT include rapid onset, attenuation of ECT-induced physiological changes, minimal anticonvulsant effects, and rapid recovery. Although most of the currently available anesthetic agents can be used for ECT, seizure duration, hemodynamic stability, recovery time, antidepressant effect, and cognitive side effects must be considered when selecting this drug. Most anesthetics have a dose-dependent anticonvulsant effect; therefore, the minimum effective dose should be used during ECT [54]. The effects of commonly used anesthetics for ECT are summarized in Table 3.

1. Methohexital

Methohexital is the gold standard drug among the established anesthetics [55,56]. The routine dosage of this agent for ECT is 1.5 ± 0.3 mg/kg, but the Royal College of Psychiatrists (0.75–0.9 mg/kg) and APA (0.75–1.0 mg/kg) have recommended a dose reduction [56]. It remains the drug of choice for ECT except where there are barbiturate contraindications (e.g., acute intermittent porphyria) because they have few hemodynamic effects and low anticonvulsant properties [1,23]. However, methohexital is currently unavailable commercially in Korea.

2. Thiopental sodium and thiamylal

Thiopental sodium (1.5–2.5 mg/kg) and thiamylal (1.5–2.5 mg/kg) reduce the seizure duration and have a slower recovery compared to methohexital (0.5–1.0 mg/kg). Both of these agents also increase the incidence of arrhythmias such as sinus bradycardia and premature ventricular contraction, as well as increase the blood flow in the middle cerebral artery after ECT compared with propofol [57,58]. Moreover, they produce more hemodynamic changes than sevoflurane [59]. Hence, the use of thiopental and thiamylal as intravenous anesthetics for ECT is not advantageous.

3. Etomidate

Etomidate (0.15–0.3 mg/kg) is effective in patients with a short seizure duration (i.e., < 20 s) even under maximum stimulation because it prolongs this duration compared to methohexital, thiopental, or propofol [55,60]. However, etomidate also increases the incidence of confusion, delirium, nausea, and vomiting after ECT compared to other anesthetics such as propofol, methohexital, and thiopental [1,23,60]. Etomidate-induced myoclonic jerks should be differentiated from seizures after ECT, as long-term use of etomidate can cause adrenal insufficiency [61].

4. Propofol

Propofol is the most commonly used intravenous anesthetic owing to its rapid recovery and antiemetic mode of action. However, the seizure duration after ECT is shorter with this drug because it has stronger anticonvulsant effects than other intravenous anesthetics [6163]. Propofol is thus preferred for use in adolescents and young adults receiving ECT because they typically have a lower seizure threshold and longer duration of seizures than adults [64]. The routine dosage of propofol is 1.0–1.5 mg/kg. If the minimum hypnotic dose (0.75 mg/kg) is used, the seizure duration is similar from that seen with methohexital [62]. Although propofol produces a shorter duration of seizures, analysis of the antidepressant effects of ECT, such as the Hamilton rating efficiency and Beck Depression Inventory score, show that the use of propofol has similar outcomes to those achieved with methohexital [65]. As propofol has cardiovascular inhibitory properties, it can suppress acute hemodynamic changes immediately after ECT. Hence, it is preferred in patients with hypertension, tachycardia, or expected hemodynamic changes after ECT [64].

5. Ketamine

Ketamine is an intravenous anesthetic with both hypnotic and analgesic effects. The recommended dose of ketamine (1–2 mg/kg) can help achieve the desired ECT effects, but a low dose of this drug (0.4–0.8 mg/kg) leads to a shorter seizure duration on an EEG compared to methohexital. Because ketamine can also increase blood pressure, heart rate, and intracranial pressure, it is not generally preferred over methohexital or propofol for use in ECT procedures [54,66]. Moreover, it can induce psychiatric side effects such as agitation, confusion, delirium, and disorientation [64,67]. However, as ketamine has antidepressant properties, it is preferred in patients with depression [66].

6. Benzodiazepine

Benzodiazepines, such as midazolam and lorazepam, can alter the threshold and duration of seizures after ECT. In patients who have been taking benzodiazepine over the long term, seizures may not occur owing to its anticonvulsant effects [68]. Recently, remimazolam, a novel ultra-short-acting benzodiazepine, has been approved in many countries. Although there are no published reports on the effects of remimazolam as part of an ECT protocol, it may have anticonvulsant effects similar to those of other benzodiazepine drugs [69].

7. Dexmedetomidine

Dexmedetomidine is rarely used alone; in combination with other intravenous anesthetics, it can reduce the acute hemodynamic changes that are possible after ECT. Moreover, if dexmedetomidine at a 1 µg/kg dose is administered 10 min prior to ECT, it can reduce the extent of post-ECT agitation without affecting seizure duration or patient recovery time [70,71].

8. Inhalation anesthetics

Most ECT procedures are performed outside the operating theatre, and intravenous anesthesia is generally preferred over inhalational anesthesia. However, as possible inhalation anesthetics, sevoflurane (1.7%) and nitrous oxide (50%) can more potently reduce acute hemodynamic changes following ECT than thiopental [59]. The seizure duration and recovery times with these drugs were similar to those with thiopental. Inhalation anesthetics require a longer induction time than intravenous agents but can reduce the risk of uterine contractions after ECT in late pregnancy cases [72].

Neuromuscular blocking agents

Neuromuscular blocking agents are necessary to prevent possible musculoskeletal complications of ECT, such as myalgia, dislocation, and fracture, and are effective because they typically have a fast onset and a short duration of action [36,37].

1. Succinylcholine

Succinylcholine is the oldest and most commonly used neuromuscular blocking agent in ECT protocols [56,73]. The recommended dosage is 0.5 mg/kg, but higher doses (0.75–1.5 mg/kg) are also used in clinical practice [74]. Therefore, higher doses of succinylcholine should be avoided in patients with bradycardia [75]. Even at low concentrations, there is a risk of side effects (e.g., myalgia, malignant hyperthermia, hyperkalemia) in patients who are susceptible to malignant hyperthermia, neuroleptic malignant syndrome, catatonic schizophrenia, or organophosphate poisoning [7678]. Because its duration of action may be prolonged, it must be used cautiously in patients with pseudocholinesterase deficiency or any kind of muscular dystrophy [54].

2. Atracurium and cisatracurium

In patients receiving intravenous atracurium, a 0.3 mg/kg pretreatment leads to significantly more ECT-induced moderate and vigorous convulsions (86 vs. 16%) and a shorter recovery time (4.2 ± 0.4 min vs. 9.2 ± 0.8 min) when compared with patients receiving 0.3 mg/kg [79]. Therefore, a low dose of atracurium is recommended when succinylcholine cannot be used. However, even small doses of atracurium (10–15 mg) can cause delayed recovery in patients with atypical plasma cholinesterase [80]. Clinically, cisatracurium is now starting to replace atracurium, but few studies have addressed its effectiveness using ECT.

3. Vecuronium and rocuronium

Vecuronium and rocuronium are non-depolarizing neuromuscular blocking agents with an aminosteroid structure that can also be used as part of the ECT protocol. Although the long duration of action has been a problem with these treatments, the development of sugammadex could make them useful in ECT. Sugammadex is a cyclodextrin-based compound with an antagonistic mode of action against aminosteroid nondepolarizing neuromuscular blockers. If sugammadex was used in conjunction with rocuronium during ECT, rapid onset of action and recovery could be expected. Hence, this potential drug combination has attracted attention as a possible alternative to succinylcholine [81,82]. In addition, calabadion, a new antagonist of benzylisoquinoline-based neuromuscular blocking agent, and a combination of gantacurium (CW002) and L-cysteine are anticipated to become part of future ECT procedures [83].

Drugs for the treatment of cardiovascular reactions during ECT

As acute cardiovascular reactions following ECT can cause serious complications, cardiovascular drugs are used to relieve acute parasympathetic and sympathetic reactions [29,84]. Some of these agents may affect the duration of seizures; however, the choice of drug should be made carefully [85].

1. Anti-cholinergics

Pretreatment with anticholinergics as part of the ECT protocol has been reported to reduce the incidence of premature atrial contracture, bradycardia, and asystole, as well as decrease secretion and salivation [57]. Glycopyrrolate (0.1–0.3 mg, i.v.) is the preferred agent in this regard because it can reduce salivation and bradycardia after ECT without side effects such as cognitive impairment [86].

2. β-blockers

β-blockers, such as esmolol and labetalol, attenuate the sympathetic and cardiovascular responses following ECT. Pretreatments of ECT patients with esmolol (1.0 mg/kg) or labetalol (0.3 mg/kg) are more effective than those with fentanyl (1.5 mg/kg) or lidocaine (1.0 mg/kg) [27]. Because esmolol can also decrease the duration of seizures, it is recommended to be administered immediately before or immediately after ECT [1,23].

3. Calcium channel blocker

Nicardipine (1.25–5 mg, i.v.) has a rapid hemodynamic control effect without impact on the cardiovascular inhibitory action of methohexital due to its rapid onset. Moreover, small doses of nicardipine have little effect on the duration of seizures [85]. Rebound tachycardia can occur after bolus administration of this drug, but intravenous administration of labetalol can attenuate this. A nicardipine and labetalol combination has also been reported to lower the mean arterial pressure immediately after ECT in comparison to labetalol alone [87].

4. Vasodilators

Nitroglycerin (NTG, 3 μg/kg, i.v.) can reduce hemodynamic changes after ECT compared to esmolol (2 mg/kg, i.v.) [27]. NTG has no effect on the duration of seizures [88]. In addition to the intravenous administration of this drug, a sublingual, patch, and ointment delivery method also reduces the onset of hemodynamic changes after ECT [89,90]. Nitroprusside is preferred in patients with intracranial aneurysms, dissecting aortic aneurysms, or aortic stenosis [9193]. A β-blocker combined with nitroprusside lowers the incidence of tachycardia and hypertension and increases the blood flow velocity in the middle cerebral artery [34]. Nitroprusside also has no effect on seizure duration in ECT [94].

5. Ganglionic blocking agents

Although trimethaphan is not currently the preferred drug in clinical practice, its bolus administration at 5–15 mg can control hemodynamic changes after ECT without affecting the duration of the seizure [95]. Moreover, there were no side effects after ECT, such as rebound hypertension, arrhythmia, or hypotension [1,85].

6. Local anesthetics

Lidocaine can also attenuate the onset of hemodynamic changes after ECT, but it also decreases seizure duration in a dose-dependent manner [27,96].

7. Opioids

Opioids can act as a “seizure enhancers” by reducing the required hypnotic dose. Hence, short-acting opioids are effective in patients with an insufficient duration of seizures following ECT [1]. However, the effects of ECT have not been reported to be greater than those of hypnotics alone [97]. Fentanyl (1.5 μg/kg, i.v.) shortens the seizure duration and does not alleviate ECT-induced hemodynamic changes [27]. Remifentanil (0.05–1.0 μg/kg/min) can prolong the duration of seizure by 27–38 s without impact on hemodynamic changes or recovery time [98,99]. Pethidine and tramadol are not recommended for use with ECT because they may interact with other antidepressants (e.g., monoamine oxidase inhibitors or selective serotonin reuptake inhibitors), potentially leading to hypertensive crises and/or serotonin syndromes [100].

8. Magnesium sulfates

Magnesium sulfates can reduce ECT-related hypertension and have no effect on seizure duration. The combined use of these compounds with remifentanil may delay the recovery of spontaneous respiration but can also prevent tachycardia and hypertension in elderly patients with ischemic heart disease [101].

Postprocedural considerations

ECT is a safe procedure in patients with minimal comorbidities. However, cardiovascular changes and psychiatric complications may occur following treatment. Pulmonary aspiration, respiratory failure, and residual neuromuscular blockade must be considered as possible complications of ECT interventions because neuromuscular blocking agents are used [102]. Although cognitive impairment is common after ECT, it is not permanent. Osler et al. [103] reported that ECT is not associated with dementia. Postictal delirium or agitation may also occur after ECT but should respond to small amounts of midazolam or propofol [104]. An extreme increase in cerebral blood flow due to sympathetic stimulation is also associated with intracranial hemorrhage. Succinylcholine-related myalgia responds well to nonsteroidal anti-inflammatory drugs such as ketorolac [18]. Prophylactic antiemetics may be recommended for high-risk patients or drugs such as sevoflurane and etomidate. Typical physiological changes and adverse events associated with ECT are summarized in Table 4.

CONCLUSION

ECT is a safe and effective treatment for various psychiatric disorders, and accepted indications for its use has steadily increased over time. Anesthesia during ECT should ideally provide deep hypnosis, ensure muscle relaxation to reduce injury, have minimal effects on seizure duration, and allow for rapid recovery to a baseline neurological and cardiopulmonary status. Multiple anesthetic agents are acceptable for use during ECT, and the choice of this drug should be considered for any underlying comorbidities that the patient has.

Notes

FUNDING

None.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

AUTHOR CONTRIBUTIONS

Conceptualization: Hong-Seuk Yang. Data curation: Dong Ho Park, Chang Young Jung. Project administration: Kyoung-Woon Joung, Hong-Seuk Yang. Visualization: Kyoung-Woon Joung. Writing - original draft: Kyoung-Woon Joung. Writing - review & editing: Kyoung-Woon Joung, Dong Ho Park, Chang Young Jung. Investigation: Kyoung-Woon Joung. Resources: Dong Ho Park, Chang Young Jung. Supervision: Hong-Seuk Yang.

REFERENCES

1. Ding Z, White PF. Anesthesia for electroconvulsive therapy. Anesth Analg. 2002; 94:1351–64.
crossref
2. Khan A, Mirolo MH, Hughes D, Bierut L. Electroconvulsive therapy. Psychiatr Clin North Am. 1993; 16:497–513.
crossref
3. McCall WV, Kellner CH, Fink M. Convulsive therapy and the Journal of ECT: 30 years of publication and continuing. J ECT. 2014; 30:1–2.
4. Taylor S. Electroconvulsive therapy: a review of history, patient selection, technique, and medication management. South Med J. 2007; 100:494–8.
crossref
5. Prudic J, Olfson M, Marcus SC, Fuller RB, Sackeim HA. Effectiveness of electroconvulsive therapy in community settings. Biol Psychiatry. 2004; 55:301–12.
crossref
6. Food and Drug Administration, HHS. Neurological devices; reclassification of electroconvulsive therapy devices; effective date of requirement for premarket approval for electroconvulsive therapy devices for certain specified intended uses. Final order. Fed Regist. 2018; 83:66103–24.
7. Hermann RC, Dorwart RA, Hoover CW, Brody J. Variation in ECT use in the United States. Am J Psychiatry. 1995; 152:869–75.
crossref
8. Wang G, Han C, Liu CY, Chan S, Kato T, Tan W, et al. Management of treatment-resistant depression in real-world clinical practice settings across Asia. Neuropsychiatr Dis Treat. 2020; 16:2943–59.
9. Xiang YT, Ungvari GS, Correll CU, Chiu HF, Lai KY, Wang CY, et al. Use of electroconvulsive therapy for Asian patients with schizophrenia (2001-2009): trends and correlates. Psychiatry Clin Neurosci. 2015; 69:489–96.
crossref
10. Lee JR, Park SJ, Lim JG, Yang HS. Ambulatory anesthetic care for electroconvulsive therapy (ECT) in psychiatric patients. Korean J Anesthesiol. 2002; 43:520–4.
crossref
11. Jaffe R. The practice of electroconvulsive therapy: recommendations for treatment, training, and privileging: a task force report of the American Psychiatric Association, 2nd ed. Am J Psychiatry. 2002; 159:331.
crossref
12. Fink M, Kellner CH, McCall WV. Optimizing ECT technique in treating catatonia. J ECT. 2016; 32:149–50.
crossref
13. Shapira B, Calev A, Lerer B. Optimal use of electroconvulsive therapy: choosing a treatment schedule. Psychiatr Clin North Am. 1991; 14:935–46.
14. Gill SP, Kellner CH. Clinical practice recommendations for continuation and maintenance electroconvulsive therapy for depression: outcomes from a review of the evidence and a consensus workshop held in Australia in May 2017. J ECT. 2019; 35:14–20.
crossref
15. Bauer M, Severus E, Köhler S, Whybrow PC, Angst J, Möller HJ; WFSBP Task Force on Treatment Guidelines for Unipolar Depressive Disorders. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders. Part 2: maintenance treatment of major depressive disorder-update 2015. World J Biol Psychiatry. 2015; 16:76–95.
crossref
16. Malhi GS, Bassett D, Boyce P, Bryant R, Fitzgerald PB, Fritz K, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry. 2015; 49:1087–206.
crossref
17. Milev RV, Giacobbe P, Kennedy SH, Blumberger DM, Daskalakis ZJ, Downar J, et al. CANMAT Depression Work Group. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. Can J Psychiatry. 2016; 61:561–75.
crossref
18. Franklin AD, Sobey JH, Stickles ET. Anesthetic considerations for pediatric electroconvulsive therapy. Paediatr Anaesth. 2017; 27:471–9.
crossref
19. Rasmussen K. The practice of electroconvulsive therapy: recommendations for treatment, training, and privileging (second edition). J ECT. 2002; 18:58–9.
crossref
20. Sundsted KK, Burton MC, Shah R, Lapid MI. Preanesthesia medical evaluation for electroconvulsive therapy: a review of the literature. J ECT. 2014; 30:35–42.
21. Tess AV, Smetana GW. Medical evaluation of patients undergoing electroconvulsive therapy. N Engl J Med 2009; 360: 1437-44. Erratum in. N Engl J Med. 2011; 364:1582.
22. Thompson JW, Weiner RD, Myers CP. Use of ECT in the United States in 1975, 1980, and 1986. Am J Psychiatry. 1994; 151:1657–61.
crossref
23. Wagner KJ, Möllenberg O, Rentrop M, Werner C, Kochs EF. Guide to anaesthetic selection for electroconvulsive therapy. CNS Drugs. 2005; 19:745–58.
crossref
24. Lafferty JE, North CS, Spitznagel E, Isenberg K. Laboratory screening prior to ECT. J ECT. 2001; 17:158–65.
crossref
25. Cristancho MA, Alici Y, Augoustides JG, O'Reardon JP. Uncommon but serious complications associated with electroconvulsive therapy: recognition and management for the clinician. Curr Psychiatry Rep. 2008; 10:474–80.
crossref
26. Fernández-Candil J, Castelltort Mascó L, Fàbregas Julià N, Urretavizcaya Sarachaga M, Bernardo Arroyo M, Valero Castell R. Anaesthesia in electroconvulsive therapy. Special conditions. Rev Psiquiatr Salud Ment (Engl Ed). 2020; 13:36–46.
crossref
27. Weinger MB, Partridge BL, Hauger R, Mirow A. Prevention of the cardiovascular and neuroendocrine response to electroconvulsive therapy: I. Effectiveness of pretreatment regimens on hemodynamics. Anesth Analg. 1991; 73:556–62.
28. Castelli I, Steiner LA, Kaufmann MA, Alfillé PH, Schouten R, Welch CA, et al. Comparative effects of esmolol and labetalol to attenuate hyperdynamic states after electroconvulsive therapy. Anesth Analg. 1995; 80:557–61.
crossref
29. Wells DG, Davies GG. Hemodynamic changes associated with electroconvulsive therapy. Anesth Analg. 1987; 66:1193–5.
crossref
30. Mental Health and Drug and Alcohol Office. Guidelines: ECT minimum standards of practice in NSW / NSW Health. North Sydney: Mental Health and Drug and Alcohol Office;2010.
31. Larsen JR, Hein L, Strömgren LS. Ventricular tachycardia with ECT. J ECT. 1998; 14:109–14.
crossref
32. Price JW, Price JR, Perry TL. Excessive hypertension and pulmonary edema after electroconvulsive therapy. J ECT. 2005; 21:174–7.
crossref
33. Ring BS, Parnass SM, Shulman RB, Phelan J, Khan SA. Cardiogenic shock after electroconvulsive therapy. Anesthesiology. 1996; 84:1511–3.
crossref
34. Saito S, Kadoi Y, Iriuchijima N, Obata H, Arai K, Morita T, et al. Reduction of cerebral hyperemia with anti-hypertensive medication after electroconvulsive therapy. Can J Anaesth. 2000; 47:767–74.
crossref
35. Saito S, Miyoshi S, Yoshikawa D, Shimada H, Morita T, Kitani Y. Regional cerebral oxygen saturation during electroconvulsive therapy: monitoring by near-infrared spectrophotometry. Anesth Analg. 1996; 83:726–30.
36. Nott MR, Watts JS. A fractured hip during electro-convulsive therapy. Eur J Anaesthesiol. 1999; 16:265–7.
crossref
37. Sarpel Y, Toğrul E, Herdem M, Tan I, Baytok G. Central acetabular fracture-dislocation following electroconvulsive therapy: report of two similar cases. J Trauma. 1996; 41:342–4.
38. Edwards RM, Stoudemire A, Vela MA, Morris R. Intraocular pressure changes in nonglaucomatous patients undergoing electroconvulsive therapy. Convuls Ther. 1990; 6:209–13.
39. McCormick AS, Saunders DA. Oxygen saturation of patients recovering from electroconvulsive therapy. Anaesthesia. 1996; 51:702–4.
crossref
40. Labbate LA, Miller JP. Midazolam for treatment of agitation after ECT. Am J Psychiatry. 1995; 152:472–3.
41. Narang P, Ianovich F, Sarai SK, Lippmann S. Benefits of dexmedetomidine in management of post-ECT agitation. J ECT. 2017; 33:150–1.
crossref
42. Stein ALS, Sacks SM, Roth JR, Habis M, Saltz SB, Chen C. Anesthetic management during electroconvulsive therapy in children: a systematic review of the available literature. Anesth Analg. 2020; 130:126–40.
43. Wachtel LE. Treatment of catatonia in autism spectrum disorders. Acta Psychiatr Scand. 2019; 139:46–55.
crossref
44. Gilot B, Gonzalez D, Bournazeau JA, Barriére A, Van Lieferinghen P. [Case report: electroconvulsive therapy during pregnancy]. Encephale. 1999; 25:590–4. French.
45. Rose S, Dotters-Katz SK, Kuller JA. Electroconvulsive therapy in pregnancy: safety, best practices, and barriers to care. Obstet Gynecol Surv. 2020; 75:199–203.
crossref
46. Echevarría Moreno M, Martin Muñoz J, Sanchez Valderrabanos J, Vázquez Gutierrez T. Electroconvulsive therapy in the first trimester of pregnancy. J ECT. 1998; 14:251–4.
47. Brown NI, Mack PF, Mitera DM, Dhar P. Use of the ProSeal laryngeal mask airway in a pregnant patient with a difficult airway during electroconvulsive therapy. Br J Anaesth. 2003; 91:752–4.
crossref
48. Leiknes KA, Cooke MJ, Jarosch-von Schweder L, Harboe I, Høie B. Electroconvulsive therapy during pregnancy: a systematic review of case studies. Arch Womens Ment Health. 2015; 18:1–39.
crossref
49. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020; 75:785–99.
crossref
50. Gil-Badenes J, Valero R, Valentí M, Macau E, Bertran MJ, Claver G, et al. Electroconvulsive therapy protocol adaptation during the COVID-19 pandemic. J Affect Disord. 2020; 276:241–8.
crossref
51. Ramakrishnan VS, Kim YK, Yung W, Mayur P. ECT in the time of the COVID-19 pandemic. Australas Psychiatry. 2020; 28:527–9.
crossref
52. Luccarelli J, Fernandez-Robles C, Fernandez-Robles C, Horvath RJ, Berg S, McCoy TH, et al. Modified anesthesia protocol for electroconvulsive therapy permits reduction in aerosol-generating bag-mask ventilation during the COVID-19 pandemic. Psychother Psychosom. 2020; 89:314–9.
crossref
53. Limoncelli J, Marino T, Smetana R, Sanchez-Barranco P, Brous M, Cantwell K, et al. General anesthesia recommendations for electroconvulsive therapy during the Coronavirus disease 2019 pandemic. J ECT. 2020; 36:152–5.
crossref
54. MacPherson RD. Which anesthetic agents for ambulatory electro-convulsive therapy? Curr Opin Anaesthesiol. 2015; 28:656–61.
crossref
55. Avramov MN, Husain MM, White PF. The comparative effects of methohexital, propofol, and etomidate for electroconvulsive therapy. Anesth Analg. 1995; 81:596–602.
crossref
56. Cook A, Stevenson G, Scott AI. A survey of methohexitone use by anesthetists in the clinical practice of ECT in Edinburgh. J ECT. 2000; 16:350–5.
crossref
57. Mokriski BK, Nagle SE, Papuchis GC, Cohen SM, Waxman GJ. Electroconvulsive therapy-induced cardiac arrhythmias during anesthesia with methohexital, thiamylal, or thiopental sodium. J Clin Anesth. 1992; 4:208–12.
crossref
58. Saito S, Kadoi Y, Nara T, Sudo M, Obata H, Morita T, et al. The comparative effects of propofol versus thiopental on middle cerebral artery blood flow velocity during electroconvulsive therapy. Anesth Analg. 2000; 91:1531–6.
crossref
59. Tanaka N, Saito Y, Hikawa Y, Nakazawa K, Yasuda K, Amaha K. [Effects of thiopental and sevoflurane on hemodynamics during anesthetic management of electroconvulsive therapy]. Masui. 1997; 46:1575–9. Japanese.
60. Trzepacz PT, Weniger FC, Greenhouse J. Etomidate anesthesia increases seizure duration during ECT. A retrospective study. Gen Hosp Psychiatry. 1993; 15:115–20.
61. Eranti SV, Mogg AJ, Pluck GC, Landau S, McLoughlin DM. Methohexitone, propofol and etomidate in electroconvulsive therapy for depression: a naturalistic comparison study. J Affect Disord. 2009; 113:165–71.
crossref
62. Fredman B, d'Etienne J, Smith I, Husain MM, White PF. Anesthesia for electroconvulsive therapy: effects of propofol and methohexital on seizure activity and recovery. Anesth Analg. 1994; 79:75–9.
63. Geretsegger C, Rochowanski E, Kartnig C, Unterrainer AF. Propofol and methohexital as anesthetic agents for electroconvulsive therapy (ECT): a comparison of seizure-quality measures and vital signs. J ECT. 1998; 14:28–35.
64. Bailine SH, Petrides G, Doft M, Lui G. Indications for the use of propofol in electroconvulsive therapy. J ECT. 2003; 19:129–32.
crossref
65. Fear CF, Littlejohns CS, Rouse E, McQuail P. Propofol anaesthesia in electroconvulsive therapy. Reduced seizure duration may not be relevant. Br J Psychiatry. 1994; 165:506–9.
66. Parashchanka A, Schelfout S, Coppens M. Role of novel drugs in sedation outside the operating room: dexmedetomidine, ketamine and remifentanil. Curr Opin Anaesthesiol. 2014; 27:442–7.
67. Kavalali ET, Monteggia LM. How does ketamine elicit a rapid antidepressant response? Curr Opin Pharmacol. 2015; 20:35–9.
crossref
68. Boylan LS, Haskett RF, Mulsant BH, Greenberg RM, Prudic J, Spicknall K, et al. Determinants of seizure threshold in ECT: benzodiazepine use, anesthetic dosage, and other factors. J ECT. 2000; 16:3–18.
crossref
69. Sneyd JR, Rigby-Jones AE. Remimazolam for anaesthesia or sedation. Curr Opin Anaesthesiol. 2020; 33:506–11.
crossref
70. Mizrak A, Koruk S, Ganidagli S, Bulut M, Oner U. Premedication with dexmedetomidine and midazolam attenuates agitation after electroconvulsive therapy. J Anesth. 2009; 23:6–10.
crossref
71. Qiu Z, Zhou S, Zhang M, Guo N, Huang P, Xiang P, et al. Preventive effect of dexmedetomidine on postictal delirium after electroconvulsive therapy: a randomised controlled study. Eur J Anaesthesiol. 2020; 37:5–13.
crossref
72. Ishikawa T, Kawahara S, Saito T, Otsuka H, Kemmotsu O, Hirayama E, et al. [Anesthesia for electroconvulsive therapy during pregnancy--a case report]. Masui. 2001; 50:991–7. Japanese.
73. Fink M, Bailine S. Electroconvulsive therapy and managed care. Am J Manag Care. 1998; 4:107–12. quiz 113-4.
74. Fredman B, Smith I, d'Etienne J, White PF. Use of muscle relaxants for electroconvulsive therapy: how much is enough? Anesth Analg. 1994; 78:195–6.
75. Tang WK, Ungvari GS. Asystole during electroconvulsive therapy: a case report. Aust N Z J Psychiatry. 2001; 35:382–5.
crossref
76. Cooper RC, Baumann PL, McDonald WM. An unexpected hyperkalemic response to succinylcholine during electroconvulsive therapy for catatonic schizophrenia. Anesthesiology. 1999; 91:574–5.
crossref
77. Jaksa RJ, Palahniuk RJ. Attempted organophosphate suicide: a unique cause of prolonged paralysis during electroconvulsive therapy. Anesth Analg. 1995; 80:832–3.
78. Kelly D, Brull SJ. Neuroleptic malignant syndrome and mivacurium: a safe alternative to succinylcholine? Can J Anaesth. 1994; 41:845–9.
crossref
79. Lui PW, Ma JY, Chan KK. Modification of tonic-clonic convulsions by atracurium in multiple-monitored electroconvulsive therapy. J Clin Anesth. 1993; 5:16–21.
crossref
80. Hickey DR, O'Connor JP, Donati F. Comparison of atracurium and succinylcholine for electroconvulsive therapy in a patient with atypical plasma cholinesterase. Can J Anaesth. 1987; 34:280–3.
81. Postaci A, Tiryaki C, Sacan O, Ornek D, Kalyoncu M, Dikmen B. Rocuronium-sugammadex decreases the severity of post-electroconvulsive therapy agitation. J ECT. 2013; 29:e2–3.
crossref
82. Wolkenstein K, Ali S, Chacko R, Nabi Q, Carter L. Rocuronium-sugammadex and intubation used for an electroconvulsive therapy patient. J ECT. 2020; 36:e15–6.
crossref
83. de Boer HD, Carlos RV. New drug developments for neuromuscular blockade and reversal: gantacurium, CW002, CW011, and Calabadion. Curr Anesthesiol Rep. 2018; 8:119–24.
crossref
84. Weinger MB, Partridge BL, Hauger R, Mirow A, Brown M. Prevention of the cardiovascular and neuroendocrine response to electroconvulsive therapy: II. Effects of pretreatment regimens on catecholamines, ACTH, vasopressin, and cortisol. Anesth Analg. 1991; 73:563–9.
85. Saito S. Anesthesia management for electroconvulsive therapy: hemodynamic and respiratory management. J Anesth. 2005; 19:142–9.
crossref
86. Kelway B, Simpson KH, Smith RJ, Halsall PJ. Effects of atropine and glycopyrrolate on cognitive function following anaesthesia and electroconvulsive therapy (ECT). Int Clin Psychopharmacol. 1986; 1:296–302.
crossref
87. Avramov MN, Stool LA, White PF, Husain MM. Effects of nicardipine and labetalol on the acute hemodynamic response to electroconvulsive therapy. J Clin Anesth. 1998; 10:394–400.
crossref
88. O'Flaherty D, Husain MM, Moore M, Wolff TR, Sills S, Giesecke AH. Circulatory responses during electroconvulsive therapy. The comparative effects of placebo, esmolol and nitroglycerin. Anaesthesia. 1992; 47:563–7.
89. Parab AL, Chaudhari LS, Apte J. Use of nitroglycerin ointment to prevent hypertensive response during electroconvulsive therapy--a study of 50 cases. J Postgrad Med. 1992; 38:55–7.
90. Villalonga A, Planella T, Castillo J, Hernández C, Cabrer C, Mañalich M, et al. [Nitroglycerin spray in the prevention of hypertension induced by electroconvulsive therapy]. Rev Esp Anestesiol Reanim. 1989; 36:264–6. Spanish.
91. Devanand DP, Malitz S, Sackeim HA. ECT in a patient with aortic aneurysm. J Clin Psychiatry. 1990; 51:255–6.
92. Drop LJ, Bouckoms AJ, Welch CA. Arterial hypertension and multiple cerebral aneurysms in a patient treated with electroconvulsive therapy. J Clin Psychiatry. 1988; 49:280–2.
93. Levin L, Wambold D, Viguera A, Welch CA, Drop LJ. Hemodynamic responses to ECT in a patient with critical aortic stenosis. J ECT. 2000; 16:52–61.
crossref
94. Sudha S, Andrade C, Anand A, Guido S, Venkataraman BV. Nitroprusside and ECS-induced retrograde amnesia. J ECT. 2001; 17:41–4.
crossref
95. Petrides G, Maneksha F, Zervas I, Carasiti I, Francis A. Trimethaphan (Arfonad) control of hypertension and tachycardia during electroconvulsive therapy: a double-blind study. J Clin Anesth. 1996; 8:104–9.
crossref
96. Fu W, Stool LA, White PF, Husain MM. Acute hemodynamic responses to electroconvulsive therapy are not related to the duration of seizure activity. J Clin Anesth. 1997; 9:653–7.
crossref
97. MacPherson R, Marroquin-Harris M, Gálvez V, Tor P, Loo C. The effect of adjuvant remifentanil with propofol or thiopentone on seizure quality during electroconvulsive therapy. Anaesth Intensive Care. 2016; 44:278–80.
crossref
98. Akcaboy ZN, Akcaboy EY, Yigitbasł B, Bayam G, Dikmen B, Gogus N, et al. Effects of remifentanil and alfentanil on seizure duration, stimulus amplitudes and recovery parameters during ECT. Acta Anaesthesiol Scand. 2005; 49:1068–71.
crossref
99. Andersen FA, Arsland D, Holst-Larsen H. Effects of combined methohexitone-remifentanil anaesthesia in electroconvulsive therapy. Acta Anaesthesiol Scand. 2001; 45:830–3.
crossref
100. Baldo BA, Rose MA. The anaesthetist, opioid analgesic drugs, and serotonin toxicity: a mechanistic and clinical review. Br J Anaesth. 2020; 124:44–62.
crossref
101. van Zijl DH, Gordon PC, James MF. The comparative effects of remifentanil or magnesium sulfate versus placebo on attenuating the hemodynamic responses after electroconvulsive therapy. Anesth Analg. 2005; 101:1651–5.
crossref
102. Park MJ, Kim H, Kim EJ, Yook V, Chung IW, Lee SM, et al. Recent updates on electro-convulsive therapy in patients with depression. Psychiatry Investig. 2021; 18:1–10.
crossref
103. Osler M, Rozing MP, Christensen GT, Andersen PK, Jørgensen MB. Electroconvulsive therapy and risk of dementia in patients with affective disorders: a cohort study. Lancet Psychiatry. 2018; 5:348–56.
crossref
104. Tzabazis A, Schmitt HJ, Ihmsen H, Schmidtlein M, Zimmermann R, Wielopolski J, et al. Postictal agitation after electroconvulsive therapy: incidence, severity, and propofol as a treatment option. J ECT. 2013; 29:189–95.

Table 1.
Factors Affecting Seizure Thresholds
Factors that increase the seizure threshold
 Age
 Skull thickness
 Bilateral stimulation
 Repeated stimulation
 Drugs
  Use of barbiturates, benzodiazepines, or anticonvulsants
Factors that decrease the seizure threshold
 Genuine seizure
 Hyperventilation/hypocapnia
 Female sex
 Hyperoxia
 Drugs
  Use of caffeine, antidepressants, or clozapines
Table 2.
Currently Used Indications for Electroconvulsive Therapy
Major depression, single, or recurrent episodes
Bipolar major depression, depressed, or mixed type
Schizophrenia
Catatonia
Schizophreniform or schizoaffective disorder
Atypical psychosis
Other psychiatric conditions
 Obsessive compulsive disorder
 Pregnancy depression, severe postpartum depression, or psychosis
Miscellaneous conditions
 Parkinson's disease
 Neuroleptic malignant syndrome
 Status epilepticus
 Delirium
 Dementia with behavioral disturbances
 Secondary catatonia
 Dopa-responsive dystonia (Segawa syndrome)
 Self-injurious behavior in autism
Table 3.
Effects of Commonly Used Anesthetics in Electroconvulsive Therapy Protocols and Comparisons of the Physiologic Changes Before and After Electrical Stimulation (Before/After)
Heart rate Blood pressure Cerebral blood flow Seizure duration Others
Methohexital → / ↑ ↓ / ↑↑ NE Standard anesthetics for ECT
 Thiopental ↑ / ↑ ↓ / ↑↑ ↓ / ↑↑ Histamine release
 Etomidate → / ↑ → / ↑↑ NE Injection pain, slow recovery
 Propofol ↓ / ↑→ ↓ / ↑ ↓ / ↑ Injection pain
 Ketamine ↑ / ↑ ↓ / ↑↑ ↓ / ↑↑ ↑↓ Psychotic action
Benzodiazepine → / ↑ ↓ / ↑ NE ↓↓ Long acting
 Sevoflurane ↑ / ↑ ↓ / ↑ ↓ / ↑↑ ↓↓ Slow induction

ECT: electroconvulsive therapy, NE: not evaluated.

Table 4.
Physiologic Changes and Adverse Events Associated with Electroconvulsive Therapy
Central nervous system Increases in the cerebral blood flow, intracranial pressure, and cerebral metabolic rate
Dizziness, headache, amnesia, agitation, cognitive impairment, delirium, cerebral hemorrhage
Cardiovascular system Increases in blood pressure, heart rate, and cardiac output
Arrhythmia, hypertension, myocardial infarction, stress-induced cardiomyopathy
Musculoskeletal system Tonic - clonic seizure
Myalgia, dislocation, fracture
Others Increased salivation
Nausea, vomiting, dental fractures, lacerations of the gum, gingiva, and tongue
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