Anesthetic Induction Agents Research Articles

Hypotension following pre-hospital rapid sequence induction of anaesthesia: a retrospective database analysis

AbstractIntroductionRecent trends in Pre-Hospital Emergency Medicine (PHEM) have demonstrated the potential benefit of using fentanyl, ketamine and rocuronium for pre-hospital rapid sequence induction of anaesthesia (RSI). Isolated cases of potentially significant hypotension have been reported. This study aimed to establish a potential link between the incidence of hypotension and the dose and combination of anaesthetic induction agents used.MethodsA retrospective database review was undertaken of all cases attended by the Great North Air Ambulance Service requiring RSI during a 25-month period. The blood pressure (BP) before and after RSI and doses of drugs were recorded. Cases were divided into three groups based on changes in BP: group 1 (increase in BP post induction >20% or more), group 2 (between 20% increase and 20% fall in BP) and group 3 (fall in BP of 20% or more).Results105 cases were included in the analysis. Group 1 included 11 cases (range 23% to 106% increase in BP), group 2 included 57 cases (19% increase to 18% decrease) and group 3 included 37 cases (20% fall to 63% fall in BP).There was no statistically significant link to rocuronium (p=0.46) or ketamine (p=0.054) but the dose of fentanyl administered was highly significant (p<0.001).DiscussionThis review showed a potential link between fentanyl dose and the degree of hypotension during RSI. Although this is a small study with some limitations it gives an indication that dose ratios in RSI may need to be reviewed.

English

Post-operative sore throat significantly impact patients’ satisfaction during post-operative period. Many factors can contribute to postoperative sore throat and the incidence varies with the method of airway management. To determine the predictors and incidence of postoperative sore throat. In this facility based cross sectional study, 245 elective gynecologic and general surgical patients who had had surgery at Jimma University Teaching Hospital between February 01 and April 30, 2015 were interviewed during postoperative period  between 6 and 24 h using a structured questionair. After outliers and missing value checked the data manually entered into SPSS Version 20 IBM. In addition to descriptive analysis odds ratio with 95% confidence interval was used in bivariate and multivariate logistic regression analysis to determine the effect of predictors on the postoperative sore thoat and hoarsness of voices. A total of 245 surgical patients was interviewed with a complete response rate of 228(93.1%). Their age ranges from 18 to 87years, with a majority between 31 and 40 years. From a total respondent 120 (52.6%) were females, 171(75%) American Society of Anesthesiologist class-I, 137(60.1%) cannot read and write, and 108 (47.4%) were farmer. Majority 47(20.6%) of surgery was orthopedics surgery; followed by 25(11%) breast surgery, 23(10.1%) hysterectomy and others. One hundred twenty nine (56.6%) participants had suffered postoperative sore throat and 68 of them had had hoarseness of voices. The sore throat was found to be more common with certain patient, anesthetic and surgical related factors; difficulty level of intubation, duration of ETT in trachea, being not premedicated with opioid, unexperienced anesthetists, other than ketamine anesthetic  induction agent,  bleeding on tip of laryngoscope/ETT, perioperative hypotension and higher estimated blood loss during surgery. Significant incidence of postoperative sore throat and hoarseness of voice were seen during study period in the study area. Awareness creation on the predisposing factors and appropriate care especially during endotracheal intubation would help in reducing or avoiding the incidence of postoperative sore throat.   Key words: Endotracheal intubation, elective surgery, postoperative complications, sore throat.

Abstract PR447

Background & Objectives: The hemodynamic response to laryngoscopy and intubation is associated with reflex sympathetic response resulting in undesirable increase in heart rate and blood pressure.1 Several techniques have been proposed to attenuate these sympathetic responses. Etomidate is an intravenous anesthetic induction agent remarkable for its minimal cardiovascular effects and rapid onset of action.2 Sevoflurane is relatively cardiostable inhaled anesthetic3 that is pleasant smelling and relatively non irritating to the airways.4 The objective of the study was to compare the effects of Etomidate, a cardiostable intravenous anesthetic induction agent with Sevoflurane, a relatively cardiostable inhaled anesthetic in attenuating the hemodynamic response to laryngoscopy and intubation. Materials & Methods: After obtaining approval from hospital ethics committee and informed consent from the patients, 66 ASA I and II status normotensive patients (n=33 in each group), aged 18 to 60 years scheduled for elective surgical procedures were allocated randomly into 2 groups to receive 4 % sevoflurane / 100% oxygen (S GROUP) or etomidate 0.4mg/kg for induction (E GROUP). 2 micrograms/kg of fentanyl was administered prior to induction and vecuronium for muscle relaxation. Hemodynamic parameters were recorded before induction, post induction, immediately after intubation and 1, 2, 3, 5 minutes from onset of laryngoscopy. Statistical analysis was carried out using Z test for proportions, independent sample t-test and paired t test (two sided). Statistical level of significance was set at P value < 0.05. Results: Demographic profiles of two groups were comparable. Maximum pressor response was observed immediately after intubation. The rise in heart rate, systolic, diastolic and mean arterial blood pressure was statistically significant in etomidate group than in sevoflurane group. The hemodynamic response to laryngoscopy and intubation was effectively decreased by sevoflurane -fentanyl induction and was highly significant on comparison(P<0.001)Conclusion: Sevoflurane inhalational induction is rapidly gaining popularity due to its smooth induction characteristics devoid of airway complications. Sevoflurane induction can be a better alternative to etomidate in attenuating hemodynamic responses to laryngoscopy and intubation in high risk patients with hypertension and coronary artery diseases.

Injectable anaesthetic induction agents

Several drugs are available in the market to induce anaesthesia. However none of them fulfil the criteria of the ideal induction agent. It is therefore important to understand the properties of each drug in order to select the most appropriate anaesthetic induction technique for the clinical situation. The aim of this article is to review the injectable anaesthetic induction agents available for companion animals.

Perioperative complications of obese patients.

The perioperative care of obese patients can often be challenging, as the presence of comorbidities is common in this patient population. In this article, we present recent data on perioperative complications of obese patients and discuss relevant details for daily practice, including drug dosing, airway management, and mechanical ventilation. The volatile agent desflurane reduces extubation time, without major effects on postoperative anesthesia care unit discharge time, incidence of postoperative nausea and vomiting, or postoperative pain scores compared with other volatile anesthetics. Lean body weight is the most appropriate dosing scalar for most drugs used in anesthesia, including opioids and anesthetic induction agents. Compared with the operational theatre, airway complications occur 20-fold more often in the ICU, with poor outcome. Individual titration of positive end-expiratory pressure (PEEP) after lung recruitment improves gas exchange and lung mechanics intraoperatively, but data on patient outcome are lacking. Intensive care physicians who treat obese patients need to be trained in the management of the difficult airway. The application of PEEP and the use of recruitment maneuvers may lead to improved intraoperative oxygenation, but current data do not allow recommending the use of high PEEP combined with lung recruitment maneuvers in this population.

Does intravenous induction dosing among patients undergoing gastrointestinal surgical procedures follow current recommendations: a study of contemporary practice

Study objectiveIt is recommended to correct intravenous induction doses by up to 50% for patients older than 65 years. The objectives were to determine (a) the degree to which anesthesia providers correct induction doses for age and (b) additionally adjust for American Society of Anesthesiologists physical status (ASA-PS) class (severity of illness) and (c) whether postinduction hypotension is more common among patients aged >65. DesignRetrospective chart review. SettingAcademic medical center. PatientsA total of 1869 adult patients receiving general anesthesia for GI surgical procedures from February 2013 to January 2014. MeasurementsPatients were divided into 3 age groups (age <65, 65-79, ≥80 years) and then further stratified into ASA-PS class (I/II vs III/IV). Multiple pairwise comparisons were conducted using Welch t tests for continuous variables to determine whether dosing was different for the older groups vs the younger group; separate analyses were performed within and across ASA-PS class. This approach was also used to determine differences in mean arterial pressure change in the older groups vs the younger group, whereas the rates of hypotension among different age groups were compared by Cochran-Armitage trend test. Main resultsNo significant decrease in dosing between age groups was observed for fentanyl and midazolam. For propofol, there was a significantly lower dosing for older patients: 17% for patients aged 65-79 and 29% for those aged >80, which was still in less than the recommendations. An inverse relationship was observed between propofol dosing and ASA-PS class, but no consistent relationship was noted for fentanyl and midazolam. There were a significantly larger drop in mean arterial pressure and a greater likelihood of hypotension following induction in patients aged 65-79 years and >80 years as compared with those aged <65 years. ConclusionsThis study shows that the administered dose of anesthetic induction agents is significantly higher than that recommended for patients older than 65 years. This failure to age-adjust dose may contribute to hypotensive episodes.

The role of etomidate as an anaesthetic induction agent for critically ill patients.

Etomidate is an anaesthetic induction agent which may be favoured in critically ill patients because of its cardiovascular stability. However, etomidate causes adrenocortical suppression which may be particularly harmful in these patients. This article reviews current evidence and debates the use of etomidate in critical illness.

Rapid sequence induction via an intraosseous needle.

The use of the intraosseous (IO) route for drug administration has been widely reported in the prehospital and military trauma setting, for use in paediatric patients and for use in the cardiac arrest scenario for rapid access. We wish to highlight its use for rapid sequence induction (RSI) in the adult population in a case of difficult intravenous access. A patient presented to our hospital as a stand-by call to the Emergency Department resuscitation area. He was peri-arrest with cardiogenic shock. He was cyanosed with unrecordable oxygen saturations and blood pressure but was very combative. Intubation to facilitate oxygenation was required urgently due to his rapidly deteriorating condition. Multiple attempts at securing intravenous access had been unsuccessful. An EZ-IO (Prometheus Medical Ltd, Hereford, UK) Intraosseous Vascular Access System was inserted in his right proximal tibia. Rapid sequence induction was performed using fentanyl 200mg, ketamine 100mg and suxamethonium 100mg. No fasciculations were observed. We waited 30 s and attempted direct laryngoscopy, which obtained a Grade I Cormack-Lehane View. Intubation was secured at first attempt. The induction process felt very similar in nature and speed to a standard intravenous induction. Post intubation, rapid intravenous access was secured in the right external jugular and then a femoral central line sited. The intraosseous route for drug administration has been used for many years. Studies comparing the pharmacokinetic data of intraosseous versus central venous drug delivery have primarily been undertaken in animals. One study has compared intraosseous versus intravenous rocuronium in anaesthetised swine. They compared electromyographic data obtained following tibial intraosseous administration to that of peripheral intravenous administration and demonstrated no statistically significant difference in the onset time between the two groups. They also demonstrated that the duration of paralysis with the intraosseous route was longer than with the intravenous. They concluded that rocuronium could be administered via the intraosseous route in the same doses as when using the intravenous route. With regard to human studies, a prospective, randomised crossover study has compared the delivery of intraosseous to intravenous morphine in adults and demonstrated that there was no statistically significant difference in the majority of the pharmacokinetic data including the maximum plasma concentration, time to maximum concentration and area under plasma concentration time curve. The majority of reports of using intraosseous for RSI have come from military and trauma experience. A recent observational study has been published in the Emergency Medicine Journal looking at whether RSI via IO was comparable to the intravenous route in terms of grade of view and number of attempts at intubation. The study demonstrated that in the 34 patients who received RSI via IO for trauma they had a 97% first pass intubation rate and that 91% of patients had a Grade 1 Cormack-Lehane view. They were unable to compare this directly to RSI via the intravenous route, as intraosseous access is often the preferred route of access in a military trauma setting. A further military study retrospectively reviewed 830 adult trauma cases and found that 1014 IO devices were inserted over a 60-month period. They demonstrated that the devices were used to infuse anaesthetic induction drugs, analgesia, tranexamic acid, blood and blood products, and intravenous fluids. Of the 1205 times that the IO route was used to infuse drugs, anaesthetic induction agents were the most common drug given, being used for this purpose in 61.8% of cases. With regard to complications, there were no serious complications reported and 14 minor complications that included failure to correctly place IO device, failure to infuse drug, or fracture of needle. This is similar to a Danish study that looked at complications associated with intraosseous access. They showed that serious complications such as compartment syndrome or osetomyelitis are very rare and that problems such as difficulty penetrating periosteum, difficulty aspirating bone marrow and difficulties injecting or infusing fluids or drugs are more common. One of the concerns with the use of the intraosseous route in awake patients is the side effects of pain on insertion and pain on injection. Reports have

Midazolam regulated caspase pathway, endoplasmic reticulum stress, autophagy, and cell cycle to induce apoptosis in MA-10 mouse Leydig tumor cells.

PurposeMidazolam is widely used as a sedative and anesthetic induction agent by modulating the different GABA receptors in the central nervous system. Studies have also shown that midazolam has an anticancer effect on various tumors. In a previous study, we found that midazolam could induce MA-10 mouse Leydig tumor cell apoptosis by activating caspase cascade. However, the detailed mechanism related to the upstream and downstream pathways of the caspase cascade, such as endoplasmic reticulum (ER) stress, autophagy, and p53 pathways plus cell cycle regulation in MA-10 mouse Leydig tumor cells, remains elusive.MethodsFlow cytometry assay and Western blot analyses were exploited.ResultsMidazolam significantly decreased cell viability but increased sub-G1 phase cell numbers in MA-10 cells (P<0.05). Annexin V/propidium iodide double staining further confirmed that midazolam induced apoptosis. In addition, expressions of Fas and Fas ligand could be detected in MA-10 cells with midazolam treatments, and Bax translocation and cytochrome c release were also involved in midazolam-induced MA-10 cell apoptosis. Moreover, the staining and expression of LC3-II proteins could be observed with midazolam treatment, implying midazolam could induce autophagy to control MA-10 cell apoptosis. Furthermore, the expressions of p-EIF2α, ATF4, ATF3, and CHOP could be induced by midazolam, indicating that midazolam could stimulate apoptosis through ER stress in MA-10 cells. Additionally, the expressions of cyclin A, cyclin B, and CDK1 could be inhibited by midazolam, and the phosphorylation of p53, P27, and P21 could be adjusted by midazolam, suggesting that midazolam could manage cell cycle through the regulation of p53 pathway to induce apoptosis in MA-10 cells.ConclusionMidazolam could induce cell apoptosis through the activation of ER stress and the regulation of cell cycle through p53 pathway with the involvement of autophagy in MA-10 mouse Leydig tumor cells.

Propofol Effect on Stress Response and Free Radicals in Patient during Surgery and Sedation Procedure

BACKGROUND: Propofol is an intravenous anesthetic used worldwide as an anesthesia induction and maintenance agent. Propofol also used as sedation agent in Intensive Care Unit (ICU). Despite it’s usual anesthesia properties, propofol has an unique pharmacologic characteristic, especially as antioxidant and stress response reduction. These advantages suggested propofol has positive effects when used as an anesthesia agent in surgery or sedation in ICU in conditions when high stress and free radical level are released.CONTENT:Stress response and free radical can be elevated in various conditions including surgery or during care in ICU, especially critical ill patient. Cortisol is a major stress hormone that influences metabolism, cardiovascular and central nervous system, either in acute or chronic phase. Oxidative stress was marked by free radical elevation called Radical Oxygen Species (ROS). Combination of both elements (cortisol and ROS) can worsen patient condition. Propofol with anti-stress and antioxidant properties could be used to reduce stress response and attenuate free radical level in order to improve patient condition.SUMMARY: The anti-stress and antioxidant properties of Propofol are interesting, because these benefits can be added as adjunctive therapy when propofol was used as an anesthetic agent in surgery and a sedation in ICU.KEYWORDS: propofol, stress response, antioxidant

Evaluation of Etomidate for Seizure Duration in Electroconvulsive Therapy

The optimum induction agent for anesthesia for electroconvulsive therapy (ECT) has been long debated. Ideal agent should be short acting with minimal suppression of seizure potentials. Recent studies have suggested longer seizure duration with etomidate in comparison to propofol, thiopental, and methohexital. The aim of the present meta-analysis was to pool data available from studies comparing systematically the efficacy of etomidate against other induction agents in terms of seizure duration (both electroencephalography (EEG) and motor). We searched the PubMed, Embase, and Cochrane registry for trials evaluating etomidate against methohexital, propofol, or thiopental for duration of EEG or motor seizure in patients undergoing ECT. Specific adverse effects reported were also identified. Seventeen trials were identified involving 704, 84, 2491, and 258 setting of ECT using etomidate, methohexital, thiopental, and propofol, respectively. In the etomidate group, pooled EEG seizure duration was longer by 2.23 seconds (95% confidence interval [CI], -3.62 to 8.01; P = 0.456) than methohexital, longer by 17.65 seconds (95% CI, 9.72-25.57; P < 0.001) than propofol, and longer by 11.81 seconds (95% CI, 4.26-19.35; P = 0.003) than thiopental. Pooled motor seizure duration was longer in etomidate group by 1.45 seconds (95% CI, -4.79 to 7.69; P = 0.649) than methohexital, longer by 11.13 seconds (95% CI, 6.64-15.62; P < 0.001) than propofol, and longer by 3.60 seconds (95% CI, 2.15-5.06; P < 0.001) than thiopental. Myoclonus (6 trials) and painful injection (4 trials) were commonest adverse effects with etomidate. Etomidate is clearly better in terms of seizure duration potential (both motor and EEG) than propofol and thiopental. Superiority/inferiority over methohexital could not be demonstrated with the presently available literature.

Barbiturate Induction for the Prevention of Emergence Agitation after Pediatric Sevoflurane Anesthesia.

Emergence agitation (EA) is a common and troublesome problem in pediatric patients recovering from general anesthesia. The incidence of EA is reportedly higher after general anesthesia maintained with sevoflurane, a popular inhalational anesthetic agent for pediatric patients. We conducted this prospective, randomized, double-blind study to test the effect of an intravenous ultra-short-acting barbiturate, thiamylal, administered during induction of general anesthesia on the incidence and severity of EA in pediatric patients recovering from Sevoflurane anesthesia. Fifty-four pediatric patients (1 to 6 years of age) undergoing subumbilical surgeries were randomized into 2 groups. Patients received either intravenous thiamylal 5mg/kg (Group T) or inhalational Sevoflurane 5% (Group S) as an anesthetic induction agent. Following induction, general anesthesia was maintained with Sevoflurane and nitrous oxide (N2O) in both groups. To control the intra- and post-operative pain, caudal block or ilioinguinal/iliohypogastric block was performed. The incidence and severity of EA were evaluated by using the Modified Objective Pain Scale (MOPS: 0 to 6) at 15 and 30 min after arrival in the post-anesthesia care unit (PACU). Fifteen minutes after arrival in the PACU, the incidence of EA in Group T (28%) was significantly lower than in Group S (64%; p = 0.023) and the MOPS in Group T (median 0, range 0 to 6) was significantly lower than in Group S (median 4, range 0 to 6; p = 0.005). The interval from discontinuation of Sevoflurane to emergence from anesthesia was not significantly different between the 2 groups. Thiamylal induction reduced the incidence and severity of EA in pediatric patients immediately after Sevoflurane anesthesia.

Post-electroconvulsive therapy recovery and reorientation time with methohexital and ketamine: a randomized, longitudinal, crossover design trial.

Methohexital, a barbiturate anesthetic commonly used for electroconvulsive therapy (ECT), possesses dose-dependent anticonvulsant properties, and its use can interfere with effective seizure therapy in patients with high seizure thresholds. Ketamine, an N-methyl-d-aspartate antagonist with epileptogenic properties not broadly used for ECT inductions, is a commonly used induction agent for general anesthesia. Recent studies suggest that the use of ketamine is effective in allowing successful ECT treatment in patients with high seizure thresholds without an increase in adverse effects. In this preliminary study, we directly compared the recovery and reorientation times of subjects receiving ketamine and methohexital for ECTs. Twenty patients were randomized in a crossover design to receive methohexital and ketamine for ECT inductions in alternating fashion in 6 trials. Primary outcome measures were recovery time (voluntary movement, respiratory effort, blood pressure, consciousness, and O2 saturation) and reorientation time. Secondary outcome measures were individual recovery variables, adverse effect occurrence, and seizure duration. Overall recovery time was not significantly different between the 2 treatment arms (F(1, 17) = 0.72; P = 0.41). Reorientation time was faster in the methohexital arm (F(1, 17) = 9.23; P = 0.007). Ketamine inductions resulted in higher number of adverse effects, higher subject dropout rates, and a longer reorientation time with respect to methohexital inductions. No significant difference in postanesthesia recovery time was found between the ketamine and methohexital arms. Intolerability to ketamine affected a significant proportion of subjects and suggests that ketamine should remain as an alternative or adjunctive agent for patients with high seizure thresholds.

Comparison of the hemodynamic effects of propofol and ketamine as anesthetic induction agents during high-dose remifentanil administration: a single-center retrospective comparative study.

BackgroundWe hypothesized that ketamine, when administered as the anesthetic induction agent, may prevent cardiovascular depression during high-dose remifentanil administration, unlike propofol. To test our hypothesis, we retrospectively compared the hemodynamic effects of ketamine, during high-dose remifentanil administration, with those of propofol.MethodsThirty-eight patients who underwent oral surgery at the Nagasaki University Hospital between April 2014 and June 2015 were included in this study. Anesthesia was induced by the following procedure: First, high-dose remifentanil (0.3-0.5 µg/kg/min) was administered 2-3 min before anesthesia induction; next, the anesthetic induction agent, either propofol (Group P) or ketamine (Group K), was administered. Mean arterial pressure (MAP) and the heart rate were recorded by the automated anesthesia recording system at four time points: immediately before the administration of high-dose remifentanil (T1); immediately before the administration of propofol or ketamine (T2); 2.5 min (T3), and 5 min (T4) after the administration of the anesthetic induction agent.ResultsIn Group P, the MAP at T3 (75.7 ± 15.5 mmHg, P = 0.0015) and T4 (68.3 ± 12.5 mmHg, P < 0.001) were significantly lower than those at T1 (94.0 ± 12.4 mmHg). However, the MAP values in the K group were very similar (P = 0.133) at all time points. The heart rates in both Groups P (P = 0.254) and K (P = 0.859) remained unchanged over time.ConclusionsWe showed that ketamine, when administered as the anesthetic induction agent during high-dose remifentanil administration, prevents cardiovascular depression.

Is Two Better Than One? Anticipation of a Favorable Hemodynamic Profile by Combining the Hypnotic Drugs for Induction of Anesthesia.

Is Two Better Than One? Anticipation of a Favorable Hemodynamic Profile by Combining the Hypnotic Drugs for Induction of Anesthesia.

Etomidate in pediatric anesthesiology: Where are we now?

Etomidate is an intravenous anesthetic agent released for clinical use in the United States in 1972. Its popularity in clinical practice is the result of its beneficial effects on intracerebral dynamics with limited effects on hemodynamic function. These properties have made it a safe and effective anesthetic induction agent in both adult and pediatric patients with altered myocardial performance, congenial heart disease, or hypovolemia. However, recent concern has been expressed regarding its effects on the endogenous production of corticosteroids and the impact of that effect on patient outcomes. The following manuscript reviews clinical reports regarding etomidate use in the pediatric population and discusses recent concerns regarding its effects on corticosteroid metabolism and the implications of such effects for clinical use.

Effectiveness of Midazolam in the Prevention of Etomidate Induced Myoclonus

Introduction: Etomidate, the imidazole derivative, is an intravenous anaesthetic induction agent, having stable hemodynamic profile, minimal respiratory side effects and histamine release. It is extremely useful in hemodynamically compromised patients. But the most common problem associated with its induction is myoclonus. Objective: To determine the effect of pretreatment with midazolam on the frequency of myoclonus after etomidate induction. Methods: Two hundred and fifty patients fulfilling the inclusion and exclusion criteria, scheduled for elective surgical procedures, were included. After all monitoring and intravenous access, the patients were given intravenous midazolam 0.05 mg/kg and after ninety seconds anesthesia induction was done with etomidate, and the myoclonic movements were noted for a minute after etomidate injection. The movement were recorded and graded on a scale of 0 to 3. Results: Myoclonus was developed in 15.45% (38/246) cases while in 84.55% (208/246) patients abnormal muscle movements was not observed after etomidate injection. Mild myoclonus (grade 1) was observed in 23 (9.3%) cases, moderate myoclonus (grade 2) in 11 (4.5%) and severe (grade 3) in 4 (1.6%) cases. Summary: The incidence of myoclonus was lowered significantly (15.45%) after 0.05mg/kg midazolam pretreatment.

Etomidate is still a valid anesthetic for electroconvulsive therapy.

Komatsu et al have recently written that the use of etomidate as an anesthetic induction agent for surgery is associated with increased 30-day mortality and cardiovascular morbidity, compared with propofol. Etomidate has long been recognized as suppressing adrenocortical function and, as an infusion over days, has been indicted in increasing intensive care unit patient mortality. Even in single doses, etomidate causes a reduction in cortisol production, although recovery from single-dose suppression is generally prompt. In prospectively evaluating etomidate as an anesthetic for electroconvulsive therapy, Lebowitz et al, in a pilot study, found that 3 times per week, etomidate did not cause adrenocortical suppression that lasted until the following treatment. The steroid responses did not differ from those of methohexital, and no patient demonstrated evidence of cortisol deficiency. Consequently, concerns raised by Komatsu et al about etomidate's safety seem unwarranted when used for electroconvulsive therapy, and their study's conclusions likely relate to issues with their retrospective methodology.

Intramuscular administration of alfaxalone for sedation in rabbits

Alfaxalone is a neuroactive steroid derivative of pregnanedione that was recently reintroduced to the market for use as an induction agent in small animal anaesthesia. The aim of this study...

Dosing and effectiveness of ketamine anesthesia for electroconvulsive therapy (ECT): a case series.

To provide additional data about the clinical efficacy and dosing range for ketamine used as the induction agent in electroconvulsive therapy (ECT). We reviewed the clinical data in our academic hospital ECT service over the last four years for patients who had received ketamine as the sole, or adjunctive, anesthesia induction agent. We extracted clinical data about antidepressant response as well as absolute and weight-based dosing for ketamine. We found nine patients who were treated with ketamine as the anesthetic at some point during the course of their treatment (eight as the sole agent, one as adjunctive). The median induction dose for ketamine was 1.1 mg/kg. For most patients, there was demonstrable clinical benefit. Ketamine has a role as an alternative induction anesthetic agent in ECT. Our case series adds to the literature on the concomitant use of ECT and ketamine.