Anesthesia For

Electroconvulsive Therapy
Morgan & Mikhails
Anesthesia for electroconvulsive therapy: gui
delines for daily practice: 7AP111
Helsloot, D.; Lauweryns, J.
European Journal of Anaesthesiology (EJA).
29():106, June 2012.

ECT
Modified ECT including the use of Anaesthesia and
Muscle Relaxants.
The goal is to produce a therapeutic generalized seizure
3060 sec in duration.
Amount of current delivered is more important than
lenght of seizure.

Contraindications To ECT
Contraindications :
recent myocardial infarction (usually <3 months),
a recent stroke (usually <1 month), an intracranial
mass, or increased ICP from any cause.
Relative contraindications
include angina, poorly controlled heart failure,
significant pulmonary disease, bone fractures,
severe
osteoporosis, pregnancy, glaucoma, and retinal
detachment .

What are the important considerations in

selecting anesthetic agents?
only a short-acting induction agent is
necessary.
most induction agents (barbiturates,
etomidate, benzodiazepines, and propofol)
have anticonvulsant properties, small doses
must be used.
Seizure threshold is increased and seizure
duration is decreased by all of these agents .

Physiological Response To
ECT
Central Nervous System
1. Increase in intracranial pressure
2. Increased regional cerebral blood flow, cerebral
oxygen consumption, and glucose utilization.
3. Increase in blood-brain barrier permeability.
4. Headache, confusion, and transient memory loss
are common in the immediate post-treatment
period.

 Cardiovascular system
1. Initial brief parasympathetic response: lasts for 10-15seconds,
bradycardia, hypotension or even asystole may occur.
2. Sustained sympathetic response, peaking at 3-5 minutes,
associated with release of catecholamines, a rise in systolic
blood pressure (30-40%), and a rise in heart rate (more than
20%)(6)
3. Increased myocardial oxygen consumption.
4. The above effects predispose to cardiac dysrhythmias,
myocardial ischemia and infarction (especially with pre-existing
cardiac dysfunction).
5. Even in normal hearts, ventricular dysfunction has been noted
for up to 6 hrs after a treatment.
6. Very rarely, cardiac rupture has been reported.

 Other Effects
1.
2.
3.
4.
5.

Increase in intraocular pressure

Increase in intragastric pressure
Nausea
Myalgia and feeling of general illnease
Damage to crowns, veneers, bridges, implants or
intraosseous denture supports
6. Oral cavity damage to tongue and gums

Preoperative Anaesthetic
Considerations
Assessment for the presence of ischemic heart
disease, cardiac failure, severe valvular heart
disease, uncontrolled hypertension, severe
chronic obstructive pulmonary disease, gastrooesophageal reflux and previous anaesthetic
history.
Any known allergies to drugs should be
documented.
Dentition should be thoroughly examined for
caries or loose teeth.
Any artificial work on the teeth e.g. crowns,
veneers, bridges, implants or intraosseous
denture supports should be documented.

 Essential investigations should include; a full

blood count, urea and electrolytes.
Glycosylated haemoglobin should be checked in
diabetic patients
12 lead ECG should be done on all patients
above the age of 60 years.
Pregnancy testing, sickle cell test and INR should
be done as indicated
Lithium levels checked if the patient has been on
long term Lithium treatment.

Psychotropic medications and

Anaesthesia
Tricyclic antidepressants can cause postural hypotension in the
elderly, widening of the QRS complex, and prolongation of the QT
interval.
Hypertensive crisis can be precipitated with use of indirectly acting
sympathomimetic drugs.
Direct acting sympathomimetics should be used cautiously.
Monoamine Oxidase inhibitors too show a profound pressor effect
with both direct and indirectly acting sympathomimetic agents and
have traditionally been stopped at least 2 weeks prior to ECT.
Selective serotonin re-uptake inhibitors interact with meperidine and
tramadol, and may cause serotonin syndrome (symptoms include
hyper-reflexia, agitation, and hyperthermia) and may precipitate
syndrome of inappropriate secretion of antidiuretic hormone (SIADH).
Lithium has a narrow therapeutic index and can trigger nephrogenic
diabetes insipidus.

Conduct Of Anesthesia
The aim is to provide a short duration of
unconsciousness and adequate muscle relaxation.
the return to consciousness should be rapid, and
full orientation is desirable.
Light general anesthesia with moderate degree of
muscular relaxation while minimizing the
aforementioned physiological and physical effect
Many anesthetic agents however have
anticonvulsant properties
The choice of drugs is therefore a balance between
providing adequate anesthesia without adversely
affecting the efficacy of ect

Anesthesia for electroconvulsive therapy: gui

delines for daily practice: 7AP111
Helsloot, D.; Lauweryns, J.
European Journal of Anaesthesiology (EJA).
29():106, June 2012.

methohex
ital

propofol

thiopent
al

ketamin
e

midazola
m

etomidat
e

sevoflur
ane

class of
drugs

barbiturate

phenol

barbiturat
e

pencyclidi
ne
derivate

benzodiaz
epin

carboxyla
ted
imidazole

inhalation
agent

dose

0,5-1
mg/kg

1-1,5
mg/kg
(0,75-2)

1,5-2,5
mg/kg

2-4 mg/kg
(0,7-2,8)

0,5-5 mg

0,15-0,3
mg/kg

3,4%

onset

+++++

+++++

+++

++

+++

+++

siezure
threshol
d

seizure
duration

Higher doses reduce seizure duration

Ketamine increases seizure duration, but is generally not used
because it also increases the incidence of delayed awakening,
nausea, and ataxia and is also associated with hallucinations
during emergence.
Use of etomidate also prolongs recovery

Opioid
Short-acting opioids, such as alfentanil, are not
given alone because they do not consistently
produce amnesia.
Alfentanil (10-20mcg/kg) or remifentanil
(1mcg/kg) can be used along with the induction
agent to increase the seizure duration and reduce
haemodynamic response.

Muscle Relaxants
Complete paralysis may be associatited prolonged apnea
The adequacy of muscle relaxation should be ascertained
before applying ect stimulus. these process is done by testing
for a reduction in deep tendon reflexs and muscle tone
It is not essential to have complete muscular paralysis.
Indeed, the reduced or modified muscular contractions in
response to the electrical stimulation, along with EEG
monitoring, are used to monitor seizure duration
A short-acting agent, such as succinylcholine (0.250.5
mg/kg), is most often selected.
Non-depolarising agents such as atracurium (0.3-0.5mg/kg),
mivacurium ((0.08-0.2mg/kg) or rocuronium (0.3- 0.6mg/kg),
can be used safely

 Anti-cholinergic agents: Glycopyrrolate (100-600 mcg) can

be used to minimise the parasymapathetic stimulation
seen with ECT
Atropine (300-600mcg) has been used for the same
reason but it has the disadvantage of causing a high peak,
prolonged tachycardia, and crosses the blood brain barrier.
Sympathetic stimulation can be attenuated by the use of
Beta-blockers, such as esmolol (1.0- 2.0mg/kg), labetolol
(0.05-0.4mg/kg), or verapamil (0.1mg/kg).
Hyperventilation can increase seizure duration and is
routinely employed in some centers. Intravenous caffeine,
125250 mg (given slowly), has also been reported to
increase seizure duration

Terimakasih