Anesthesia For Electroconvulsive Therapy Research Articles

Comparison of Effects of Propofol Combined with Different Doses of Esketamine for ECT in the Treatment of Depression: A Randomized Controlled Trial Protocol.

Major depressive disorder (MDD) is a common mood disorder. Electroconvulsive therapy (ECT) has a significant effect on treatment-resistant MDD. Esketamine may have potential advantages in improving the efficacy of ECT, and the strong affinity of this compound for NMDAR renders it a viable therapeutic option for the management of depression. This study aims to compare the effects of different doses of esketamine combined with propofol anesthesia versus propofol anesthesia alone in ECT, aiming to provide further insights for optimizing ECT and enhancing comprehensive treatment outcomes for depression. This study was a prospective, randomized, controlled, double-blind trial involving subjects and evaluators. One hundred eleven patients scheduled for ECT were randomly assigned to three groups. In Group P, propofol at 1mg/kg was administered intravenously. In Group P+E, propofol at a dosage of 0.5mg/kg and esketamine at a dosage of 0.5mg/kg was administered intravenously. Patients in Group P+SE received propofol at a dosage of 0.75mg/kg and esketamine at a dosage of 0.25mg/kg. The same anesthesia protocol was used for the same patient until the end of the last treatment. The primary outcome measures were the Hamilton depression scale (HAMD) and the Patient Health Questionnaire-9 (PHQ-9), the Columbia-Suicide Severity Rating Scale (C-SSRS), and the Digit symbol substitution test (DSST). Secondary outcomes included length of hospital stay, readmission rate, hemodynamic status, recovery, and adverse events. This study aimed to compare the effects of propofol combined with different doses of esketamine for ECT. The results may provide a better choice for ECT anesthesia.

A comparison of the effects of succinylcholine and rocuronium on recovery time from anesthesia and vital signs in electroconvulsive therapy

Aims: Electroconvulsive therapy (ECT) is based on stimulation of brain tissue with an electrical current and the induction of generalized convulsions. The aim of this study was to compare the use of rocuronium as a muscle relaxant and sugammadex as an antidote during ECT with succinylcholine in terms of its effect on adequate anesthesia, hemodynamics, and recovery. Methods: This study was planned as a single-center prospectively collected and retrospectively analyzed observational cohort study. Patients were divided into two groups as group S (succinylcholine) and group R+S (rocuronium and sugammadex). Patients were premedicated with 0.5 mg of atropine I.M. half an hour before the procedure. Propofol 1mg/kg was administered as an induction agent in both groups, succinylcholine 1mg/kg in Group S, and rocuronium 0.4mg/kg in Group R+S. Sugammadex 2mg/kg was administered as a rocuronium antidote. Vital signs were monitored throughout the procedure with ECG, spo2, and blood pressure monitoring. Results: There was a statistically significant difference between the two groups (Group S and Group R+S) in the time to return for spontaneous respiration (p=0.002). The mean SSS value was 111.78 seconds in Group S and 88.82 seconds in Group R+S. There was a statistically significant difference between the spontaneous eye-opening times between Group S and Group R+S. (p=0.017) The mean SGA value was 211.42 seconds in Group S and 173.12 seconds in Group R+S. There was a statistically significant difference between Group S and Group R+S in the duration of modified Aldrete score 9 (p=0.000<0.05). The mean duration of MAS 9 was 542.60 seconds in Group S and 410.54 seconds in Group R+S. Conclusion: In conclusion, although the high cost of rocuronium sugammadex limits its routine use in ECT anesthesia, it can be used as an ideal alternative agent in cases where succinylcholine is contraindicated or anticholinesterases are not suitable because it shortens the recovery time and the time to return of spontaneous respiration compared to succinylcholine.

Clinical efficacy of adjunctive esketamine anesthesia in electroconvulsive therapy for major depressive disorders: A pragmatic, randomized, controlled trial

Electroconvulsive therapy (ECT) is an effective treatment for depression, and esketamine has been shown to have antidepressant effects. However, it is currently unclear whether adjunctive esketamine can enhance the clinical efficacy of ECT in real-world clinical practice. In this pragmatic clinical trial, patients with major depression were randomly assigned into two groups: patients received 0.25 mg/kg esketamine plus propofol (esketamine group) or the same volume of saline (control group) plus propofol. Results indicated that there was no difference in response and remission rates between the two groups. However, patients receiving esketamine had a higher remission rate of SI and lower psychotic scores. Patients receiving esketamine also required a lower electric dose, but the seizure duration and cognitive function were comparable between the two groups. Diastolic blood pressure increased after esketamine injection, but there was no increased risk of hypertension. Furthermore, incidence of delirium and confusion were comparable between the groups. Conclusively, adjunctive esketamine anesthesia does not provide any advantage in improving the response and remission rates of ECT. However, it can improve remission of SI and alleviate accompanying psychotic symptoms in depressive patients. With adjunctive usage, the adverse cardiovascular and neuropsychiatric events associated with esketamine appear to be tolerable.

Comparative efficacy and tolerability of different anesthetics in electroconvulsive therapy for major depressive disorder: A systematic review and network meta-analysis

Electroconvulsive therapy (ECT) is one of the most effective treatments for major depressive disorder. Modern ECT is conducted with anesthesia, however, the optimal anesthetic agent for ECT is yet to be understood. This study is aimed to compare the effects of different anesthetic agents on antidepressant efficacy and tolerability in depressed individuals undergoing ECT. We searched MEDLINE, EMBASE, the CENTRAL and PsycINFO for randomized controlled trials from database inception until Nov 13, 2022 (PROSPERO: CRD42022375407). Global and local inconsistencies, heterogeneity and publication bias were assessed. Rankings were calculated with the surface under the cumulative ranking curve. A total of 33 studies involving 1898 patients were enrolled. Remission rates were higher for ketamine anesthesia as compared to adjunctive ketamine and propofol. In terms of ranking, ketamine was found to be first in terms of response/remission rates and depressive scores after the 1st, 3rd and 6th ECT and at the end of ECT session, while a higher incidence of adverse events was also observed. No significant advantage of any anesthetic was revealed for the cognitive function after ECT. In summary, based on current evidence, no specific anesthetic is recommended for ECT anesthesia. However, despite more side effects, ketamine monoanesthesia seems to reveal a potential benefit in improving antidepressant efficacy of ECT, and further studies are needed to investigate the relationship between anesthetic agents and the therapeutic effect of ECT.

Practice of anaesthesia for electroconvulsive therapy

Electroconvulsive therapy (ECT) is an established therapeutic method for the treatment of severe mental disorders refractory to pharmaco- and psychotherapy. ECT is a first-line treatment option in delusional disorders, severe depression with acute suicidal tendency or life-threatening catatonia. Usually, ECT is performed as a treatment series. Under short-term anaesthesia and muscle relaxation, tonic-clonic seizures are induced using an external stimulation electrode. Convulsion can be exerted by uni- or bipolar stimulation using an electric charge up to 1000millicoulomb (mC) with an amperage of 900mA. Muscular relaxation is necessary to prevent injuries caused by uncontrolled movements during convulsion. During paralysis, consciousness is blocked by general anaesthesia, although ECT is associated with antegrade amnesia for seizure induction and the seizure itself. In the context of ECT, the ideal hypnotic should be characterised by rapid onset, short duration of action and negligible anticonvulsive effects (i.e., least possible impact on seizure quality and duration). As mutual awareness of psychiatric and anaesthesiologic techniques is essential for safe and effective conduction of ECT, this article presents ECT both from the psychiatrist's and the anaesthesiologist's perspective.

Individualized ECT Succinylcholine Dosing in a Morbidly Obese Patient

Abstract Background: Electroconvulsive therapy (ECT) is a well-established, rapid, safe, and highly efficacious treatment modality. Anesthesia for ECT provides amnesia and paralysis most commonly with methohexital and succinylcholine (SUX) respectively. Guidelines commonly recommend 0.5-1 mg/kg of SUX based on total body weight (TBW). Studies which established these ranges did not take into consideration body weight and BMI. The lack of information on SUX dosing of morbidly obese patients during ECT could place these patients at a higher risk during this relatively safe procedure. Methods: We present the case of a 48-year-old woman diagnosed with schizoaffective disorder-bipolar type with a 20-year deteriorating, medication refractory course that responded briskly to an initial series of thrice weekly ECTs. Her medical history was significant for morbid obesity (BMI 43), obstructive sleep apnea, and smoking. In the first nine months of treatment the patient received 17 ECTs with severe hypoxic episodes occurred during 4 treatments. The medications given during these 4 ECTs included intravenous administration of methohexital or ketamine, followed by a SUX dose of 1 mg/kg TBW. Results: We suspected her hypoxic episodes were due to inadequate ventilation. She was given an intravenous injection of 90 mg methohexital followed by a SUX dose, correlating to 0.5 mg/kg TBW or 1 mg/kg ideal body weight (IBW) which was about half of what was used in the 4 ECTs complicated by hypoxia. The ECT treatment proceeded uneventfully. Conclusions: This lower dose SUX strategy warranted adoption for the subsequent 27 ECTs which were uneventful. The 4 ECTs with severe hypoxia (higher SUX) were associated with longer anesthesia time averaging 44 minutes. Compared to 9 randomly selected ECTs with the lower dose SUX strategy averaging 19 minutes. The shorter anesthesia time was also associated with quicker and smoother recovery in the post-anesthesia recovery room. Research Category and Technology and Methods Clinical Research: 2. Electroconvulsive Therapy (ECT) Keywords: ECT, Succinylcholine, Obese, Anesthesia

Evaluation of the Efficacy of the ECT Patients Preparation Checklist in Reducing the Cancellation Rate in an Academic Hospital

Background: Electroconvulsive therapy (ECT) is a vital treatment strategy for psychiatric patients, and cancellation of the procedure negatively impacts the recovery process. However, it may happen due to the lack of optimal conditions at admission. Methods: This retrospective study occurred at Shafa Hospital, an academic center affiliated with the Guilan University of Medical Sciences (GUMS). The ECT anesthesia team developed an ECT patient preparation checklist, which was shared with psychiatrists. The rate and some related factors of case cancellation were compared between the two years before presenting the checklist, from May 2019 to May 2020, and the next year, from June 2020 to May 2021. The patients’ files were reviewed, and the required information was documented. Results: One hundred fifty-one cancellations were recorded during the two years of study, 82 cases in the first year and 69 in the second year. The most common reason for the cancellation was inadequate consultations followed by abnormal lab tests. In comparing the number of cancellations between the two years, before and after the checklist was provided, no significant difference was observed in terms of age (P = 0.288), gender (P = 0.24), psychiatric disorder (P = 0.399), and the number of ECT sessions (P = 0.36). However, the number of cancellations due to incomplete consultation significantly decreased after developing the checklist (P = 0.049), while unstable hemodynamics and changing patients’ conditions on an intended day also increased (P = 0.024). Residency visits did not significantly affect the number of cancellations over 2 years (P = 0.139). Conclusions: This study concluded that preparing ECT patients according to the checklist led to better conditions and fewer cancellations. However, preventable causes still exist.

Differences in Cognitive Adverse Effects and Seizure Parameters Between Thiopental and Propofol Anesthesia for Electroconvulsive Therapy.

Electroconvulsive therapy (ECT) is a well-established treatment option in case of severe and treatment-resistant psychiatric conditions. In this retrospective study, we compared the 2 anesthetics propofol and thiopental in terms of seizure quality, cognitive adverse effects, and clinical outcome. Data collection was performed retrospectively by a chart review, including patient files and medical records. A total of 64 patients (female = 60.9%) treated with ECT within the period of February 2019 to March 2020 were included. Of these, 35 (54.7%) received thiopental for ECT narcosis and 29 (45.3%) were treated with propofol. Six hundred sixteen ECT treatments (mean number per case, 9.6) were performed in total. The mean electroencephalogram seizure duration (38.3 vs 28.1 seconds, t = 3.534, degrees of freedom [ df ] = 62, P < 0.001) and motor seizure duration (21.5 vs 12.0, t = 4.336, df = 62, P < 0.001) as well as postictal suppression index and heart rate increase were significantly higher in the thiopental group. Mean stimulation energy needed per session was higher in the propofol group (88.6% vs 73.0%, Mann-Whitney U test, P = 0.042). The ECT series was more likely to be interrupted due to cognitive adverse effects in the thiopental group ( P = 0.001, Pearson χ 2 = 10.514, df = 1). Number of patients achieving remission was significantly higher in the thiopental group (31.4% vs 6.9%, P = 0.015, χ 2 = 5.897, df = 1). Thiopental led to better seizure duration and quality and was associated with a higher rate of remission. As a downside, thiopental was also associated with a greater risk of cognitive adverse effects.

Strategies from A Multi-National Sample of Electroconvulsive Therapy (ECT) Services: Managing Anesthesia for ECT during the COVID-19 Pandemic

Electroconvulsive therapy (ECT) is important in the management of severe, treatment-resistant, and life-threatening psychiatric illness. Anesthesia supports the clinical efficacy and tolerability of ECT. The COVID-19 pandemic has significantly disrupted ECT services, including anesthesia. This study documents strategies for managing ECT anesthesia during the pandemic. Data were collected between March and November 2021, using a mixed-methods, cross-sectional, electronic survey. Clinical directors in ECT services, their delegates, and anesthetists worldwide participated. One hundred and twelve participants provided quantitative responses to the survey. Of these, 23.4% were anesthetists, and the remainder were ECT clinical directors. Most participants were from Australia, New Zealand, North America, and Europe. Most were located in a public hospital, in a metropolitan region, and in a ‘medium/high-risk’ COVID-19 hotspot. Half of the participants reported their services made changes to ECT anesthetic technique during the pandemic. Services introduced strategies associated with anesthetic induction, ventilation, use of laryngeal mask airways, staffing, medications, plastic barriers to separate staff from patients, and the location of extubation and recovery. This is the first multi-national, mixed-methods study to investigate ECT anesthesia practices during the COVID-19 pandemic. The results are vital to inform practice during the next waves of COVID-19 infection, ensuring patients continue to receive ECT.

Airway Complications in Pregnant Patients Undergoing Electroconvulsive Therapy: A Retrospective Case-Control Study.

Electroconvulsive therapy (ECT) is an evidence-based treatment for severe depression and bipolar disorder in pregnant women. Electroconvulsive therapy involves induction of general anesthesia, muscle relaxation, and positive-pressure ventilation. Airway manipulation may lead to complications such as vocal cord injury, aspiration, inability to ventilate, and death. The purpose of this study was to determine whether there were differences in the incidence of airway complications in pregnant patients who underwent mask ventilation (MV) versus endotracheal intubation (ETI) compared with nonpregnant control subjects. We conducted a single-center retrospective chart review of all adult pregnant patients who underwent anesthesia for ECT from June 1, 2011, to June 30, 2020. Each ECT treatment delivered to a pregnant patient was matched with 2 ECT treatments delivered to a nonpregnant female control subject. Charts were queried for airway management (MV vs ETI), gestational age, and airway complications. Each ECT treatment was considered an independent event. Seventy-six ECT treatments from 11 pregnant patients were matched with 154 ECT treatments from 13 nonpregnant patients. In pregnant patients, airway management consisted of MV in 57 of the 76 treatments: 12 of 12 in the first trimester, 33 of 44 in the second trimester, and 12 of 20 in the third trimester. All 154 ECT treatments in the control group used MV. No airway complications were experienced in pregnant or nonpregnant patients with MV or ETI. No airway complications were observed in pregnant patients undergoing MV or ETI regardless of gestational age.

The superiority of ketofol and etomidate against propofol or thiopental anesthesia for ECT.

Most anesthetic drugs used for electroconvulsive therapy (ECT) have dose-dependent anticonvulsive effects, counter-acting seizure induction, lowering seizure quality. However, a consummate drug for ECT anesthesia has not yet been established. Therefore, in this study, we aimed to investigate the effects of etomidate, thiopental, propofol and co-administration of ketamine-propofol (ketofol) on seizure quality and hemodynamic safety. Registries of 121 patients (1077 sessions) were retrospectively evaluated. The effects of anesthetics on ECT-related parameters (stimulation charge, central seizure duration, number of failed stimulation trials, mean arterial pressure, and peak heart rate) were analyzed via linear mixed-effects models. Overall, the seizure duration decreased, and the stimulation charge increased in time with continuing sessions within a course of ECT. The decrease in seizure duration and the increase in required stimulation charge was significantly lower with etomidate and ketofol. Additionally, ketofol was significantly related to a lower number of failed stimulation trials compared to propofol. Ketofol and propofol use was associated with a significantly lower postictal mean arterial pressure. Ketofol and etomidate were equivalently superior in the rate of decrease in seizure duration and the required elevation in stimulus charge, which would interpret into valuable clinical guidance, especially for "seizure resistant" patients, and their use may potentially lower ECT related cognitive side effects.

Dexmedetomidine vs Propofol as an Adjunct to Ketamine for Electroconvulsive Therapy Anaesthesia.

Objective:Electroconvulsive therapy is an effective non-pharmacological treatment for refractory mental illness, where a generalized seizure is induced under general anaesthesia. An ideal combination of the anaesthetic drugs should keep the patient paralyzed and unconscious for a few minutes, while allowing rapid recovery, supporting peri-procedural hemodynamic and respiratory stability, and permitting an effective treatment. We examined whether dexmedetomidine is advantageous over propofol as an adjunct to ketamine during electroconvulsive therapy.Methods:Sixty patients were randomly assigned to receive either ketamine-propofol or ketamine-dexmedetomidine. Periprocedural hemodynamic and respiratory parameters, recovery metrics, seizure length, side effects, and cost of treatment were compared between the 2 groups. Results:Hemodynamic response, respiratory status, and side effect profiles in ketamine-dexmedetomidine and ketamine-propofol groups were similar. Ketamine-dexmedetomidine combination showed a slight advantage with returning to baseline mean arterial pressure levels sooner. Seizures lasted longer in ketamine-dexmedetomidine group (41.8 seconds vs 25.4 seconds, P = .001). Recovery time was similar in 2 groups (P = .292); however, time to eye opening and following orders was longer in ketamine-dexmedetomidine (P < .001 and P = .003). The cost of treatment for ketamine-dexmedetomidine was much higher than ketamine-propofol (P < .001). Conclusions:Ketamine-dexmedetomidine induction led to longer seizures during electroconvulsive therapy compared to ketamine-propofol. We observed slightly better hemodynamic stability with dexmedetomidine compared to propofol. Despite dexmedetomidine’s disadvantages with a longer duration of administration, possible higher cost, and minor delay in initial recovery, it should be considered as a feasible agent for electroconvulsive therapy anaesthesia.

Low-dose ketamine does not improve the speed of recovery from depression in electroconvulsive therapy: a randomized controlled trial.

Objective:Electroconvulsive therapy (ECT) is a well-established therapeutic intervention for major depressive disorder. Recent literature has shown that the anesthetic agent ketamine has some antidepressant properties at low doses and may be an alternative therapy for treatment-resistant major depressive disorder. We hypothesized that the use of low-dose ketamine as an anesthetic adjunct in ECT would more rapidly improve depression while maintaining hemodynamic stability than ECT with propofol alone.Methods:Institutional ethics approval was obtained, and the use of ketamine in this study was approved by Health Canada. This is a randomized, double-blinded, placebo-controlled trial that involved ketamine administration at 0.5 mg/kg IV in addition to propofol anesthesia for ECT. The primary outcome was the number of ECT treatments required to achieve a 50% reduction in the Montgomery-Asberg Depression Rating Scale (MADRS). Secondary outcomes included the number of ECT treatments required to achieve a 25% reduction in MADRS score, as well as any differences in the Clinical Global Impression Scale for Severity, hemodynamic variables, and seizure duration. Adverse events were recorded for safety assessment.Results:A total of 45 patients completed the study. No difference was found between groups with respect to the primary or secondary outcomes. The ketamine group showed a trend towards a decreased dose of propofol required to achieve adequate anesthesia. No adverse events were reported.Conclusion:Low-dose ketamine does not improve psychiatric outcomes in the setting of propofol-based anesthesia for ECT. Specifically, ketamine did not reduce the number of ECT sessions necessary to achieve a 50 or 25% reduction in MADRS scores. Reassuringly, the fact that no differences in hemodynamic variables or unexpected adverse events occurred suggests that low-dose ketamine may be safely used in this setting should clinical indications warrant its use.Clinical trial registration:ClinicalTrials.gov, NCT02579642

Comparison of Motor Seizure Duration of Ketofol and Propofol for Electroconvulsive Therapy

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.

A Narrative Overview of Current Anesthetic Drugs in Electroconvulsive Therapy.

Electroconvulsive therapy (ECT) is a definitive treatment for patients with psychiatric disorders that are severe, acute, or refractory to pharmacologic therapy. Providing anesthesia for ECT is challenging, as the effect of drugs on hemodynamics, seizure duration, comfort, and recovery must be considered. We highlight and aim to review the common anesthetics used in ECT and related evidence. While drugs such as methohexital, succinylcholine, and etomidate have been used in the past, other drugs such as dexmedetomidine, ketamine, and remifentanil may provide a more balanced anesthetic with a greater safety profile in select populations. Overall, it is essential to consider the patient’s co-morbidities and associated risks when deciding on an anesthetic drug.

Anesthesia for Electroconvulsive Therapy: A Niche Role for Sevoflurane.

Anesthesia for electroconvulsive therapy (ECT) usually involves the intravenous (IV) administration of drugs such as methohexital, thiopental, propofol, etomidate, or ketamine. Sevoflurane is an inhalational anesthetic agent that has been available for the past 3 decades. Although many studies have examined sevoflurane in the context of ECT, treatment guidelines make either no mention or only passing mention of its potential use in the ECT procedure. A recent systematic review and meta-analysis identified 12 randomized clinical trials (pooled N = 377) of sevoflurane vs IV anesthetics in patients receiving ECT. The meta-analysis found that sevoflurane was associated with shorter EEG seizure duration than barbiturate, ketamine, or propofol anesthesia; that the postictal suppression index did not differ significantly between sevoflurane and propofol; that sevoflurane increased heart rate more than did the IV anesthetics; that sevoflurane increased mean arterial pressure more than did barbiturates and propofol but less than did ketamine; and that, overall, adverse events did not differ significantly between sevoflurane and IV anesthetics. Other known disadvantages of sevoflurane include the need for additional anesthesia instrumentation, the potentiation of action of nondepolarizing muscle relaxants, and the increased complexity of the ECT procedure. These findings and considerations do not encourage the use of sevoflurane for ECT anesthesia. However, there may be a niche role for sevoflurane in patients who are afraid of needlesticks or who are too agitated for an IV line to be set up while they are conscious and in patients who characteristically experience prolonged ECT seizures. Sevoflurane could also be useful in the final trimester of pregnancy because it may inhibit ECT-induced uterine contractions. Importantly, undesired effects of sevoflurane on seizure duration and the hemodynamic response to ECT can be attenuated by discontinuing its administration after induction.

Assessment of effect of propofol and ketamine in electroconvulsive therapy anesthesia

Background: Ketamine is in clinical use since 1970. It is a unique intravenous (IV) anesthetic that produces a wide spectrum of pharmacological effects including sedation, catalepsy, somatic analgesia, bronchodilation, and sympathetic nervous system stimulation. Materials and Methods: The present study was conducted in the Department of Anesthesiology of MGM Medical College, Navi Mumbai. 100 patients who were scheduled for ECT treatment were enrolled. The study population was randomly assigned to receive one of three anesthetic agents (Ketamine, Propofol, or Ketofol). After premedication with intravenous atropine sulfate (0.25 mg), propofol (10 mg/ml), ketamine (10 mg/ml), or ketofol was administered slowly (20 mg/10 s) until the patient no longer responded to his/her name being called loudly and showed loss of the eyelash reflex. Results: We found that both ketamine and Ketofol have an increased mean seizure duration compared to propofol.Conclusion:We found that both Ketamine and Ketofol have an increased mean seizure duration compared to propofol.

Challenges and pitfalls in anesthesia for electroconvulsive therapy.

Electroconvulsive therapy (ECT) refers to the application of electricity to the patients' scalp to treat psychiatric disorders, most notably, treatment-resistant depression. It is a safe, effective, and evidence-based therapy that is performed with general anesthesia. Muscle relaxation is used to prevent injuries related to the tonic-clonic seizure caused by ECT. Hypnotics are administered to induce amnesia and unconsciousness, so that, patients do not experience the period of muscle relaxation, while the generalized seizure is left unnoticed. For the anesthesiologist, ECT is associated with the challenges and pitfalls that are related to informed consent, social acceptance of ECT, airway management (especially in COVID-19 patients), and the interaction between ventilation and anesthetics from one viewpoint, and seizure induction and maintenance from another. The exact mode of action of the therapy is as unknown as the optimal choice or combination of anesthetics used.

Effects of Ketamine Anesthesia on Efficacy, Tolerability, Seizure Response, and Neurocognitive Outcomes in Electroconvulsive Therapy: A Comprehensive Meta-analysis of Double-Blind Randomized Controlled Trials.

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.

Propofol and Ketamine in Electroconvulsive Therapy Anesthesia: A Randomised Controlled Study

Propofol and Ketamine in Electroconvulsive Therapy Anesthesia: A Randomised Controlled Study