P. CHOI ET AL.
Copyright © 2013 SciRes.
34
Cardiova scular Response Modifying Agents
Beta blockers such as labetalol and esmolol, are two of the
most commonly used agents to attenuate the ECT-induced car-
diovascular response. The starting dose of labetalol is 5 - 10 mg
and is given usually 2 minutes prior to induction. The duration
of action is about 4 - 6 hour (Chanpattana, 2001; Mankad et al.,
2009). Esmolol has a faster onset, 30 - 90 seconds, with a shor-
ter duration of action, 10 minutes, thus decreasing the likeli-
hood of post-ictal hypotension. Although both agents possess
anticonvulsant properties, esmolol is reported to shorten seizure
duration more so than labetalol (Mankad et al., 2009).
Nitroglycerine may be given sublingually several minutes
before ECT to attenuate hypertension especially for those pa-
tients suffering from pre-existing ischemic cardiac complica-
tions (Chanpattana, 2001; Mankad et al., 2009).
Calcium channel blockers such as nicardipine and nifedipine
may also be indicated to control mean arterial pressure prior to
ECT. A study showed that nifedipine did not appear to shorten
the duration of the seizure during ECT and was safely used in
conjunction with labetalol to control hypertension (Figiel et al.,
1993). A dose-ranging study found that the optimal dose of ni-
cardicpine was 40 μg/kg IV immediately before the ECT sti-
mulus (Zhang et al., 2005).
Summary
ECT is a safe and proven treatment modality for certain Axis
I psychiatric disorders refractory to pharmacologic intervention.
There must be a basic understanding of the general principles of
the physiologic responses that may arise as well as the pharma-
cologic agents used during this procedure to ensure patient sa-
fety while providing effective ECT. Communication and proper
collaboration between the anesthesiologist, psychiatrist, and the
patient are critical component to safe and successful ECT ad-
ministration.
REFERENCES
Bruce, V., Bailine, S., Petrides, G., et al. (2003). Indications for the use
of propofol in electroconvulsive therapy. Journal of ECT, 19, 129-
132. doi:10.1097/00124509-200309000-00002
Birmaher, B., Brent, D., et al. (1998). Summary of the practice para-
meters for the assessment and treatment of children and adolescents
with depressive disorders. Journal of the American Academy of Child
& Adolescent Psychiatry, 37, 1234-1238.
doi:10.1097/00004583-199811000-00029
Boylan, L., Haskett, R., et al. (2000). Determinants of seizure threshold
in ECT: Benzodiazepine use, anesthetic dosage, and other factors.
Journal of ECT, 16, 3-18. doi:10.1097/00124509-200003000-00002
Calarge, C., Crowe, R., et al. (2003). The comparative effects of sevo-
flurane and methohexital for electroconvulsive therapy. Journal of
ECT, 19, 221. doi:10.1097/00124509-200312000-00008
Chanpattana, W. (2001). Anesthesia for ECT. German Journal of Psy-
chiatry, 4, 33-39.
Choudhury, M., Kapoor, P., et al. (2010). A randomized trial of ane-
sthetic induction agents in patients with coronary artery disease and
left ventricular dysfunction. A n na ls of Cardiac Anaesthesia, 13, 217.
doi:10.4103/0971-9784.69057
Conway, C., & Nelson L. (2001). The combined use of bupropion, li-
thium, and venlafaxine during ECT: A case of prolonged seizure ac-
tivity. Journal of ECT, 17, 216-218.
doi:10.1097/00124509-200109000-00014
Ding, Z., & White, P. (2002). Anesthesia for electroconvulsive therapy.
Anesthesia & Analgesia, 94, 1351-1364.
doi:10.1097/00000539-200205000-00057
Dolenc, T., & Rasmussen, K. (2005). The safety of electroconvulsive
therapy and lithium in combination: A case series and review of the
literature. Journal of ECT, 21, 165-170.
doi:10.1097/01.yct.0000174383.96517.77
Eranti, S., Mogg, A., et al. (2009). Methohexitone, propofol and etomi-
date in electroconvulsive therapy for depression: A naturalistic com-
parison study. Journal of A ffe ctive Disorders, 113, 165-171.
doi:10.1016/j.jad.2008.03.004
Folk, J., Kellner, C., et al. (2000). Anesthesia for electroconvulsive the-
rapy: A review. Journal of ECT, 16, 157-170.
doi:10.1097/00124509-200006000-00007
Hiatt, N. (1963). Comparative results of methohexital sodium and thio-
pental sodium used during out-patient general anesthesia (A double-
blind study). Journal of the American Dental Society of Anesthesiol-
ogy, 10, 94.
Hooten, W., & Rasmussen K. (2008). Effects of general anesthetic agents
in adults receiving electroconvulsive therapy: A systematic review. J
ECT, 24, 208-223. doi:10.1097/YCT.0b013e31815bfe2a
Hoshi, H., Kadoi, Y., et al. (2011). Use of rocuronium-sugammadex, an
alternative to succinylcholine, as a muscle relaxant during electro-
convulsive therapy. Journal of Anesthesia, 25, 286-290.
doi:10.1007/s00540-011-1095-6
Jabre, P., Combes, X., et al. (2009). Etomidate versus ketamine for ra-
pid sequence intubation in acutely ill patients: A multicentre rando-
mised controlled trial. The La nc et , 37 4, 293-300.
doi:10.1016/S0140-6736(09)60949-1
Janis, K., Hess, J., et al. (1995). Substitution of mivacurium for suc-
cinylcholine for ECT in elderly patients. Canadian Journal of Anes-
thesia/Journal canadien d’anesthésie, 42, 612-613.
doi:10.1007/BF03011879
Kenning, T., Mago, R., et al. (2012). Electroconvulsive therapy: A re-
view of its current status. Jefferson Journal of Psychiatry, 19, 1.
Kellner, C., & Bryson, E. (1998). Anesthesia advances add to safety of
ECT. Psychiatric Times, 29, 16-18.
Mayo, C., Kaye, A., et al. (2010). Update on anesthesia considerations
for electroconvulsive therapy. Middle East Journal of Anesthesiology,
20, 493-498.
Morgan, C., Curran, H., et al. (2012). Ketamine use: A review. Addic-
tion, 107, 27-38. doi:10.1111/j.1360-0443.2011.03576.x
Rasmussen, K., Jarvis, M., et al. (1996). Ketamine anesthesia in elec-
troconvulsive therapy. Journal of ECT, 12, 217-223.
Rasmussen, K., Jarvis, M., et al. (1999). Low-dose atropine in electro-
convulsive therapy. Journal of ECT, 15, 213-221.
doi:10.1097/00124509-199909000-00006
Saito, S. (2005). Anesthesia management for electroconvulsive therapy:
Hemodynamic and respiratory management. Journal of Anesthesia,
19, 142-149. doi:10.1007/s00540-004-0288-7
Schak, K., Mueller, P., et al. (2008). The safety of ECT in patients with
chronic obstructive pulmonary disease. Psychosomatics, 49, 208-211.
doi:10.1176/appi.psy.49.3.208
Spitalnic, S., Blazes, C., et al. (2000). Conscious sedation: A primer for
outpatient procedures. Ho spi ta l Ph ys ician, 36 , 22-32.
Taylor, S. (2007). Electroconvulsive therapy: A review of history, pa-
tient selection, technique, and medication management. Southern
Medical Journal, 100, 494-498. doi:10.1097/SMJ.0b013e318038fce0
Uppal, V., Dourish, J., et al. (2010). Anaesthesia for electroconvulsive
therapy. Continuing Education in Anaesthesia, Critical Care & Pain,
10, 192-196. doi:10.1093/bjaceaccp/mkq039
Wagner, K., Mollenberg, O., et al. (2005). Guide to anaesthetic selec-
tion for electroconvulsive therapy. CNS Drugs, 19, 745-747.
doi:10.2165/00023210-200519090-00002
Walder, B., Seeck, M., et al. (2001). Propfol versus methohexital for
electroconvulsive therapy: A meta-analysis. Journal of Neurosurgi-
cal Anesthesiology, 13, 93-98.
doi:10.1097/00008506-200104000-00005
Figiel, G., DeLeo, B., et al. (1993). Combined use of labetalol and
nifedipine in controlling the cardiovascular response from ECT.
Journal of Geriatric Psychiatry and Neurology, 6 , 20-24.
Zhang, Y., White, P., et al. (2005). The use of nicardipine for electro-
convulsive therapy: A dose-ranging study. Anesthesia & Analgesia,
100, 378-381. doi:10.1213/01.ANE.0000144419.44481.59