Ketofol in electroconvulsive therapy anesthesia: two stones for one bird

Purpose

Propofol and ketamine have become progressively popular in electroconvulsive therapy (ECT) anesthesia, although propofol shortened seizure duration and ketamine might cause cardiotoxicity, psychotic episodes, and delayed recovery. Ketofol is a combination of ketamine and propofol, and the current study was designed to evaluate the effect of ketamine, propofol, and ketofol on hemodynamic profile, duration of seizure activity, and recovery times in patients undergoing ECT.

Methods

Ninety patients (44 women, mean age 27.8?±?7.2 years) in one ECT session were enrolled and randomized to the propofol, ketamine, or ketofol group. Hemodynamic profile duration of seizure activity and recovery times were recorded.

Results

Motor seizure duration in the propofol group was significantly decreased compared to other groups (p?p?=?0.001), and also eye-opening time (p?p?p?p?p?p?Conclusion The ketofol 1:1 mixture is associated with longer mean seizure time than propofol, and shorter mean recovery times than ketamine, with better hemodynamic stability, without any important side effects in ECT anesthesia.     

Propofol alone,sevoflurane alone,and combined propofol-sevoflurane anaesthesia in electroconvulsive therapy

Electroconvulsive therapy is an effective treatment for severe and medication-resistant depression. There have been no reports describing how a volatile anaesthetic affects haemodynamic responses, seizure duration, and recovery characteristics during electroconvulsive therapy. We carried out a repeated-measure crossover study to compare the effects on haemodynamic responses, seizure duration, and recovery characteristics of the following types of anaesthesia in electroconvulsive therapy: propofol alone, sevoflurane alone, and propofol combined with sevoflurane. We recruited 50 patients requiring electroconvulsive therapy for depression. For anaesthesia induction, 1.5 mg/kg propofol (condition P), 5% sevoflurane in oxygen following a vital capacity rapid inhalation induction (condition S), or 1.5 mg/kg propofol followed by 5% sevoflurane in oxygen (condition PS) was administered. Succinylcholine 1.5 mg/kg was then given. Electrical stimulation was administered after fasciculation. Measurements were obtained before anaesthesia induction (baseline), prior to succinylcholine administration, prior to electroconvulsive therapy, and at the peak after electroconvulsive therapy. After electroconvulsive therapy, peak heart rate and peak mean arterial pressure were highest in condition S. Whereas recovery time was longest in condition PS, motor seizure duration was significantly shorter than in either condition P or S. Electroencephalographic seizure duration was significantly shorter in condition PS than in condition P and significantly shorter in condition S than in condition P. Sevoflurane anaesthesia alone is most disadvantageous in terms of haemodynamics. Propofol-sevoflurane anaesthesia is advantageous in terms of haemodynamics, but disadvantageous in terms of seizure duration and recovery time. Propofol alone is most advantageous in terms of seizure duration.     

氯胺酮联合丙泊酚麻醉对抑郁症患者电休克疗效的影响

目的探讨氯胺酮联合丙泊酚麻醉对抑郁症患者电休克(ECT)疗效的影响,并评价其安全性。方法纳入2014年6~7月在我院首次接受改良电休克治疗(MECT)患者127例,男44例,女83例,年龄18~65岁,随机分为氯胺酮组(K组,n=63)和对照组(C组,n=64)。麻醉诱导时K组静脉注射丙泊酚1.5mg/kg、氯胺酮0.3mg/kg;C组静脉注射丙泊酚1.5mg/kg、生理盐水[体重(kg)×0.3÷10]ml。记录MECT期间患者生命体征、抽搐发作时间(SD)、抽搐能量指数(SEI)、呼吸恢复时间、苏醒时间和相关不良反应。于首次MECT前24h、每次MECT后24h采用汉密尔顿抑郁评分(HDRS)评价疗效,简易智力状态检查评分(MMSE)评价认知功能。结果两组患者MECT中生命体征平稳,呼吸恢复时间、苏醒时间、恢复期恶心呕吐、幻觉、头痛或肌肉痛发生率差异无统计学意义。K组MECT治疗后有效率和缓解率分别为90.5%和81.0%,明显高于C组的75.0%和65.6%;K组达到有效及缓解标准需要进行的MECT次数明显少于C组,治疗后认知功能障碍发生率(3.2%)明显低于C组(14.1%)(P0.05)。结论氯胺酮0.3mg/kg联合丙泊酚麻醉用于MECT治疗,可缩短MECT起效时间,改善疗效,减轻认知功能障碍,反复静脉注射小剂量氯胺酮无明显不良反应。     

Comparison of effects of propofol and ketamine–propofol mixture (ketofol) on laryngeal mask airway insertion conditions and hemodynamics in elderly patients: a randomized, prospective, double-blind trial

Purpose

The objective of this study was to compare the effects of ketamine–propofol mixture (ketofol) and propofol on ProSeal laryngeal mask airway (PLMA) insertion conditions and hemodynamics in elderly patients.

Methods

Eighty elderly patients, American Society of Anesthesiologists (ASA) physical status I and II, were randomly divided into two groups to receive either propofol 0.15 ml/kg (n = 40), or ketofol (using a 1:1 single-syringe mixture of 5 mg/ml ketamine and 5 mg/ml propofol) (n = 40) before induction of anesthesia. Sixty seconds after induction, the PLMA was inserted. Heart rate and arterial blood pressure (systolic [S] BP) were recorded prior to the induction of anesthesia, immediately following induction, immediately after PLMA insertion, and 5 and 10 min after PLMA insertion. PLMA insertion conditions were scored according to mouth opening, swallowing, coughing, head and body motion, laryngospasm, and ease of PLMA insertion by the same experienced anesthesiologist, who did not know which agents were used.

Results

There were no differences in PLMA insertion conditions between the groups. The number of patients in need of ephedrine (P = 0.043) and the total dose of ephedrine (P = 0.022) were significantly lower, and apnea duration (P < 0.001) was significantly higher in the ketofol group compared with the propofol group. SBP was significantly higher in the ketofol group than in the propofol group immediately after PLMA insertion and 5 min after PLMA insertion.

Conclusions

The same PLMA insertion conditions were found with ketofol and propofol. The number of patients in need of ephedrine and the total ephedrine dose were lower and apnea duration was increased in the ketofol group.     

Effects of remifentanil and alfentanil on seizure duration, stimulus amplitudes and recovery parameters during ECT

BACKGROUND AND OBJECTIVE: Propofol may decrease seizure duration in electroconvulsive therapy. Although not proven, prolonged seizures may be more efficacious. The goal of this study was to evaluate and compare effects of alfentanil and remifentanil on seizure duration, recovery parameters and degree of stimulus amplitude in patients undergoing electroconvulsive therapy. METHODS: Twenty-four ASA I-II patients enrolled in this prospective, randomized trial, each receiving a total of seven electroconvulsive therapies. Patients were randomized to receive only Propofol, group P (0.75 mg kg-1, n=8), Propofol with alfentanil, group A (10 microg kg-1 alfentanil+0.5 mg kg-1 Propofol, n=8) and Propofol with remifentanil, group R (1 microg kg-1 remifentanil +0.5 mg kg-1 propofol, n=8) via an iv route. Supplemental doses of propofol were given as required to achieve loss of consciousness. Succinylcholine 0.5 mg kg-1 iv was given to all groups for muscular paralysis. We recorded hemodynamic parameters, cortical and motor seizure durations, and recovery parameters. RESULTS: Mean motor seizure duration was found to be significantly longer in patients receiving propofol-remifentanil anesthesia (53.3+/-13.6 s) and propofol-alfentanil anesthesia (52.2+/-0.4 s) compared with propofol anesthesia (37.6+/-9.2 s) (P=0.001). Recovery parameters and stimulus amplitudes were similar in groups A and R; significantly different from group P (P=0.001). CONCLUSIONS: Adding 10 microg kg-1 alfentanil or 1 microg kg-1 remifentanil to reduced doses of propofol provided unconsciousness and increased seizure durations. For patients who need higher stimulus amplitudes for longer seizure durations, combining low-dose propofol with alfentanil or remifentanil may be good alternative regimens for ECT.     

The effects of intravenous lignocaine on haemodynamics and seizure duration during electroconvulsive therapy

Electroconvulsive therapy (ECT) is commonly associated with acute hyperdynamic cardiovascular responses, and we hypothesize that intravenous lignocaine can blunt this response. We have measured the effect of lignocaine 1.5 mg/kg i.v. on heart rate and mean arterial pressure during electroconvulsive therapy. Furthermore, we also assessed seizure duration using both the cuff method and two-lead electroencephalography. We studied 25 patients using a randomized, double-blind, placebo-controlled crossover study design. Patients in the control group were given intravenous saline 0.075 ml/kg, and those in the lignocaine group were given intravenous lignocaine 2% 1.5 mg/kg, and this treatment was conducted one minute before intravenous propofol 1.5 mg/kg to induce unconsciousness. Succinylcholine 1.5 mg/kg was then administered intravenously and electrical stimulation was administered after fasciculation. Measurements were taken at the baseline, prior to succinycholine, prior to electroconvulsive therapy and at the peak response after electroconvulsive therapy. Intravenous lignocaine significantly reduced the increases in heart rate after electroconvulsive therapy, as compared with the placebo. The use of intravenous lignocaine was, however, associated with a remarkably shortened seizure duration. Due to the reduction in seizure duration, routine administration of intravenous lignocaine may not be advisable since it may interfere with the psychotherapeutic efficacy of electroconvulsive therapy. However, intravenous lignocaine medication for electroconvulsive therapy is potentially useful for reducing tachycardia in high-risk patients and reducing the severity of propofol injection pain in comparison with a placebo.     

Dexmedetomidine blunts acute hyperdynamic responses to electroconvulsive therapy without altering seizure duration

Background: This study was designed to evaluate the effect of dexmedetomidine on the acute hyperdynamic response, duration of seizure activity and recovery times in patients undergoing electroconvulsive therapy (ECT).
Methods: Fourteen patients underwent a total of 84 ECT sessions as a crossover design. Patients were randomly allocated to receive either dexmedetomidine (1 μg/kg IV over a period of 10 min) or saline (control). Anaesthesia was induced with propofol 1 mg/kg, and then succinylcholine 0.5 mg/kg IV was administered. Arterial blood pressure and heart rate (HR) were recorded during the study period.
Results: HR in the dexmedetomidine group was lower than that in the control group at 5 and 10 min after the start of study drug infusion, and at 1, 3 and 10 min after the seizure ended ( P <0.05). Peak HR was lower in the dexmedetomidine group compared with that in the control group ( P <0.05). The mean arterial pressure (MAP) values in the dexmedetomidine group were lower at 0, 1, 3 and 10 min after the seizure ended compared with the control group ( P <0.05). Both motor and electroencephalography (EEG) seizure duration in the control group (35.65 ± 14.89 and 49.07 ± 9.94 s, respectively) were similar to that in the dexmedetomidine group (33.30 ± 12.01 and 45.15 ± 17.79 s, respectively) ( P >0.05). Time to spontaneous breathing, eye opening and obeying commands were not different between the groups.
Conclusion: A dexmedetomidine dose of 1 μg/kg IV administered over 10 min before the induction of anaesthesia with propofol may be useful in preventing the acute hyperdynamic responses to ECT without altering the duration of seizure activity and recovery time.     

The comparative effects of propofol versus thiopentone on left ventricular function during electroconvulsive therapy

The purpose of this study was to compare the effect of propofol versus thiopentone on haemodynamics during electroconvulsive therapy (ECT), as estimated by echocardiography. Twenty-eight ASA 1 or 2 patients scheduled for ECT were randomly divided into two groups, to receive propofol 1 mg/kg (propofol group, n = 14) or thiopentone 2 mg/kg (thiopentone group, n = 14). Bilateral ECT was performed after the administration of propofol or thiopentone, succinylcholine and following assisted mask ventilation with 100% oxygen. Cardiac function was examined by transthoracic echocardiography, prior to induction of anaesthesia and throughout ECT until ten minutes after the seizure. In the propofol group, increased end-systolic area (ESA) and decreased fractional area change (FAC) were observed at one minute after the electrical shock compared with the awake condition. In the thiopentone group, increased ESA and decreased FAC were observed from one to three minutes after the electrical shock compared with the awake condition. There was no statistically significant change in afterload in the propofol group during the study. In contrast, increased afterload was observed from one to three minutes after the electrical shock in the thiopentone group (awake condition, 26 +/- 7 mmHg/cm2 [mean +/- SD]; one minute after ECT, 42 +/- 7*; two minutes after ECT, 44 +/- 6*; three minutes after ECT; 40 +/- 5*, respectively) (*P < 0.05). We concluded that a lesser haemodynamic change occurs after propofol anaesthesia (1 mg/kg) compared with thiopentone anaesthesia (2 mg/kg) during ECT.     

小剂量氯胺酮对抑郁大鼠异丙酚麻醉下电休克疗效的影响

目的 评价小剂量氯胺酮对抑郁大鼠异丙酚麻醉下电休克疗效的影响.方法 成年雄性SD大鼠60只,体重200～250 g,采用慢性不可预见轻度应激建立抑郁模型.采用随机数字表法,将大鼠随机分为6组(n=10):对照组(C组)、抑郁组(D组)、异丙酚组(P组)、异丙酚+电休克治疗组(PE组)、氯胺酮+异丙酚组(KP组)和氯胺酮+异丙酚+电休克治疗组(KPE组).C组不作任何处理;P组和PE组腹腔注射异丙酚100mg/kg,KP组和KPE组腹腔注射氯胺酮10 mg/kg和异丙酚80mg/kg,待翻正反射消失后,将电极夹在双侧鼠耳,P组和KP组不通电,PE组和KPE组通电治疗,1次/d,连续7 d.分别于建模前、建模后和治疗结束后,行糖水消耗(SFC)实验,计算SFC百分比;行Morris水迷宫实验,测试学习记忆功能.结果 与C组比较,建模后D组、P组、FE组、KP组及KPE组SFC百分比降低,逃避潜伏期延长,目标象限停留时间缩短(P＜0.05),治疗后KPE组SFC百分比、逃避潜伏期及目标象限停留时间差异无统计学意义(P＞0.05).与D组比较,治疗后KPE组SFC百分比升高(P＜0.05),逃避潜伏期及目标象限停留时间差异无统计学意义(P＞0.05),FE组SFC百分比升高,逃避潜伏期延长,目标象限停留时间缩短(P＜0.05).与PE组比较,治疗后KPE组SFC百分比升高,逃避潜伏期缩短,目标象限停留时间延长(P＜0.05).结论 小剂量氯胺酮不仅可增强异丙酚麻醉下电休克治疗抑郁大鼠的效果,还可进一步减轻电休克所致认知功能损害.

Abstract：

Objective To evaluate the effect of low-dose ketamine on the efficacy of electroconvulsive therapy (ECT) under propofol anesthesia in depressed rats. Methods Sixty adult male SD rats weighing 200-250 g were used in this study. The depression model was established by chronic unpredictable mild stress (CUMS). The animals were then randomly divided into 6 groups (n = 10 each): control group (group C), depression group (group D), propofol group ( group P), propofol + ECT group ( group PE), ketamine + propofol group ( group KP), and ketamine + propofol + ECT group (group KPE). Groups P and KP received intraperitoneal propofol 100 mg/kg and ketamine 10 mg/kg + propofol 80 mg/kg respectively, and groups PE and KPE received ECT after intraperitoneal injection of propofol 100 mg/kg and ketamine 10 mg/kg + propofol 80 mg/kg respectively once a day for 7 consecutive days. All rats underwent sucrose fluid consumption and Morris water maze tests before CUMS, after CUMS, and after treatment. Results Compared with group C, the sucrose consumption percentage was significantly decreased, the escape latency was prolonged, and the time spent in the target quadrant (the original platform quadrant) was shortened after CUMS in D, P, PE, KP and KE groups ( P ＜ 0.05). Compared with group D,the sucrose consumption percentage was significantly increased (P ＜ 0.05), while no significant change in the escape latency and time spent in the target quadrant was found after treatment in group KPE ( P ＞ 0.05 ), and the sucrose consumption percentage was significantly increased, the escape latency was prolonged, and the time spent in the target quadrant was shortened after treatment in group PE ( P ＜ 0.05). Compared with group PE, the sucrose consumption percentage was significantly increased, the escape latency was shortened, and the time spent in the target quadrant was prolonged after treatment in group KPE ( P ＜ 0.05). Conclusion Low-dose ketamine can not only enhance the efficacy of ECT under propofol anesthesia in depressed rats, but also reduce cognitive impairment induced by ECT.     

Use of ketofol to control emergence agitation in children undergoing adenotonsillectomy

ObjectiveTo assess the efficacy and safety of ketofol administration in controlling emergence agitation (EA) after sevoflurane-based anesthesia in children undergoing adenoidectomy or adenotonsillectomy.Subjects and methodsThis double-blinded randomized study involved 90 children (3–6 years) scheduled for elective adenotonsillectomy or adenoidectomy. They were randomly assigned to receive 10 ml of normal saline (control group, C) or, 1 mg/kg propofol in 10 ml saline (group P) or ketofol as 1 mg/kg propofol and 0.25 mg/kg ketamine in 10 ml saline (group K) 10 min before the end of surgery. In PACU, sedation, behavior, pain and severity of EA were assessed using modified Aldrete score, Aono’s scale, Objective Pain Score (OPS) and Pediatric Anesthesia Emergence Delirium (PAED) scale, respectively.ResultsIn ketofol group, OPS was significantly lower compared to propofol and control groups. Recovery criteria were in favor of ketofol and propofol groups including longer time to eye opening (p < 0.001) and time to Aldrete score ⩾ 9 (p = 0.001). Time to discharge from PACU was comparable in the three groups (p = 0.079). EA was significantly more frequent in the control group (p < 0.001), but comparable in ketofol and propofol groups. PAED score was significantly higher in control group compared to ketofol and propofol groups. Ketofol and propofol preserved hemodynamic stability.ConclusionKetofol provides a promising new option for controlling emergence agitation with adequate postoperative sedative and analgesic effect, good recovery criteria and hemodynamic stability compared to propofol and control groups in children undergoing adenoidectomy or adenotonsillectomy.     

Ketamine or alfentanil administration prior to propofol anaesthesia: the effects on ProSeal™ laryngeal mask airway insertion conditions and haemodynamic changes in children

This study was designed to compare the effects of ketamine and alfentanil administered prior to induction of anaesthesia with propofol, on the haemodynamic changes and ProSeal laryngeal mask airway^® (PLMA) insertion conditions in children. Eighty children, aged between 3–132 months, were randomly allocated to receive either alfentanil 20 μg.kg⁻¹ (alfentanil group) or ketamine 0.5 mg.kg⁻¹ (ketamine group) before induction of anaesthesia. Ninety seconds following the administration of propofol 4 mg.kg⁻¹, a PLMA was inserted. In the ketamine group, heart rate and mean arterial pressure were higher during the study period compared with the alfentanil group (p < 0.05). The time for the return of spontaneous ventilation was prolonged in the alfentanil group (p = 0.004). In conclusion, we found that the administration of ketamine 0.5 mg.kg⁻¹ with propofol 4 mg.kg⁻¹ preserved haemodynamic stability, and reduced the time to the return of spontaneous ventilation, compared with alfentanil 20 μg.kg⁻¹ during PLMA placement. In addition, the conditions for insertion of the PLMA with ketamine were similar to those found with alfentanil.     

Propofol [correction of propfol] versus methohexital for electroconvulsive therapy: a meta-analysis

A systematic search (Medline, Cochrane library, Embase, bibliographies, to 5.2000, no language restriction) was performed for published reports of randomized comparisons of propofol and methohexital for anesthesia during electroconvulsive therapy. We analyzed 15 trials with data on 706 patients. The duration of motor seizure was shorter with propofol (range, 18-39 seconds) than with methohexital (range, 26-48 seconds, weighted mean difference 8.4 seconds [95% CI, 6.6-10.0]). With both propofol and methohexital, there was little evidence of an association between dose and duration of motor seizure (for propofol: r2 = 0.25, P = .08; for methohexital: r2 = 0.11, P = .27). Two small trials investigated clinical outcome; results were inconclusive. Data on adverse effects were sparse. Duration of seizure was not proven to be a useful measure of treatment success in the study of electroconvulsive therapy with propofol or methohexital. The impact of the technique of anesthesia on the underlying disease needs to be established.     

Anaesthesia for electroconvulsive therapy: a comparison of sevoflurane with propofol

This study was a prospective audit of patients receiving either intravenous induction of anaesthesia with propofol 2 mg/kg or inhalational induction using 8% sevoflurane for patients undergoing electroconvulsive therapy (ECT). All patients received inhaled 50% nitrous oxide. The anaesthetic agent was determined by psychiatrist preference. Each psychiatrist nominated only one induction technique for all his or her patients. Seventy treatments were studied in each group. Induction time was longer in the sevoflurane group. The time from commencing induction to loss of verbal contact was [mean (SD)] 64 (29.9) seconds for sevoflurane and 36 (33.6) seconds for propofol (P=0.001). Time to loss of eyelash reflex was 82 (32.6)s for sevoflurane and 44 (17.9)s for propofol (P<0.001). The duration of seizure activity was longer in sevoflurane patients, 35 (17.8)s, compared with 20 (9.8)s in the propofol group (P< 0.001). Discharge times were similar Minor adverse effects occurred in three patients, all in the sevoflurane group (one bradycardia and two episodes of post-procedural nausea). There were no major adverse events in either group. Propofol and sevoflurane both appear to be suitable agents for induction of anaesthesia for ECT.     

Ambulatory anesthesia and induced abortion. Comparative study of propofol-alfentanyl and ketamine-midazolam combinations

The use of propofol alone or with alfentanil in the day-case anaesthesia for abortion was compared with that of ketamine with midazolam. Two hundred young women were assigned to two successive series of two groups each. The four groups were: group 1 (2 mg . kg-1 propofol only); group II (0.5 mg . kg-1 ketamine with 0.25 mg . kg-1 midazolam); group III (2 mg . kg-1 propofol with 4 micrograms . kg-1 alfentanil); group IV (1 mg . kg-1 ketamine with 0.1 mg . kg-1 midazolam). All the patients were premedicated one hour before anaesthesia with 0.25 mg . kg-1 midazolam orally. All the patients were asleep at the end of the propofol injection (60 s), and 10 to 15 s later for the ketamine-midazolam groups. The haemodynamic parameters did not vary much during induction with ketamine-midazolam. In the propofol groups, the heart rate remained steady, with an 8 to 12% fall in blood pressure. A fall of the mandible was seen in 40 and 84% of the patients in the propofol groups, with a short apnoea in 32 and 48% of these same patients. Clinical recovery was very quick, less than 12 min for all groups. The four psychomotor and sensory tests were carried out at the 30th min by 95% of the patients in the propofol groups, whereas only 50% of those in the ketamine-midazolam groups did so. Speed and quality were significantly better in the propofol groups. The most frequent adverse effect of propofol was pain during injection in 32 and 14% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dexmedetomidine-ketamine and propofol-ketamine combinations for anesthesia in spontaneously breathing pediatric patients undergoing cardiac catheterization

OBJECTIVE: The purpose of this study was to compare the effects of dexmedetomidine-ketamine and propofol-ketamine combinations on hemodynamics, sedation level, and the recovery period in pediatric patients undergoing cardiac catheterization. DESIGN: Prospective, randomized trial. SETTING: University hospital. PARTICIPANTS: Children (n = 44) undergoing cardiac catheterization. INTERVENTIONS: The dexmedetomidine plus ketamine group (group 1, n = 22) received an infusion over 10 minutes of 1 microg/kg of dexmedetomidine and ketamine, 1 mg/kg, as a bolus, for induction. The patients then received an infusion of 0.7 microg/kg/h of dexmedetomidine and 1 mg/kg/h of ketamine for maintenance. The propofol plus ketamine group (group 2, n = 22) received 1 mg/kg of propofol and 1 mg/kg of ketamine for induction. The patients received 100 microg/kg/min of propofol and 1 mg/kg/h of ketamine by infusion for maintenance. Additional doses of ketamine, 1 mg/kg, were administered when a patient showed discomfort in both groups. MEASUREMENTS AND MAIN RESULTS: Hemodynamic data, respiratory rate, bispectral index, and sedation scores were recorded after induction and every 15 minutes thereafter. The time to reach a Steward recovery score of 6 was recorded. The heart rate in group 1 was significantly lower (average 10-20 beats/min) than group 2 after induction and throughout the procedure. Ketamine consumption in group 1 was significantly more than in group 2 (2.03 mg/kg/h v 1.25 mg/kg/h) for maintenance (p < 0.01). The recovery time was also longer in group 1 than in group 2 (49.54 v 23.16 minutes, respectively; p < 0.01). CONCLUSIONS: The dexmedetomidine-ketamine combination was not superior to a propofol-ketamine combination because of insufficient sedation and analgesia and a longer recovery time.     

The comparative effects of remifentanil or magnesium sulfate versus placebo on attenuating the hemodynamic responses after electroconvulsive therapy

In this prospective, randomized, double-blind, placebo-controlled, crossover study we compared the effects of remifentanil or magnesium sulfate (MgSO4) versus placebo in attenuating the sympathetic response to electroconvulsive therapy. Twenty adults underwent a total of 115 anesthetics for therapeutic electroconvulsive therapy. Patients were randomly allocated twice into each of the three test groups: placebo control, MgSO4 30 mg/kg, or remifentanil 1.0 microg/kg. Systolic and diastolic arterial blood pressures, heart rate, and oxygen saturations were recorded before IV access was established. Anesthesia was induced with thiopental 4 mg/kg. The trial drug was then administered and neuromuscular blockade was followed with succinylcholine 0.5 mg/kg before electroconvulsive therapy was performed. All measurements were repeated at 0, 1, 3 and 10 min after the seizure ended. Remifentanil and MgSO4 produced a statistically significant attenuation of the increase in systolic arterial blood pressure at 0, 1, and 3 min (P < 0.05). Remifentanil, but not MgSO4 or placebo, attenuated the increase in heart rate at 1 and 3 min but not the peak rate. Remifentanil increased the duration of apnea (mean 90 s), with no other adverse respiratory effects. Mean seizure duration time was 33 (+/- 14) s, with no difference among the groups. In conclusion, remifentanil 1.0 microg/kg and MgSO4 30 mg/kg attenuated the systolic arterial blood pressure response to electroconvulsive therapy without reducing the duration of seizure activity. Because MgSO4 has less effect on HR, it might offer advantages over remifentanil in patients at risk for post-electroconvulsive therapy bradycardia.     

Pre-ictal bispectral index has a positive correlation with seizure duration during electroconvulsive therapy

Propofol anesthesia increases the seizure threshold of patients receiving electroconvulsive therapy. Excessive neuronal suppression could result in an unacceptably short seizure. We sought to identify the correlation between the pre-ictal bispectral index (BIS) score and seizure duration in patients receiving electroconvulsive therapy under propofol anesthesia. BIS was monitored in 38 psychotically depressed patients. Anesthesia was induced by a bolus injection of 1 mg/kg of propofol. The duration of muscular and electroencephalographic seizure was measured during the therapy. The BIS immediately before the electrical shock was 54 +/- 13. Both muscular and electroencephalographic seizure durations had a positive correlation with pre-ictal BIS (r = 0.68 and 0.73, respectively; P < 0.01). After the electrically induced seizure, BIS decreased to 30 +/- 8, reflecting post-ictal suppression. BIS scores when the patients had awakened after the seizure had a wide variation (range, 29-81; mean, 45; SD, 13). In conclusion, seizure duration has a positive correlation with BIS immediately before electrical shock; however, BIS may not be an accurate predictor of awakening after electrical shock. IMPLICATIONS: Pre-ictal bispectral index had a positive correlation with seizure duration and could be useful to prevent an unacceptably short seizure in electroconvulsive therapy under propofol anesthesia.     

Effect of divided supplementation of remifentanil on seizure duration and hemodynamic responses during electroconvulsive therapy under propofol anesthesia

Purpose

Although a reduced dose of propofol combined with remifentanil is often used in anesthesia for electroconvulsive therapy (ECT), there have been few studies in which the optimal technique for injection of remifentanil was examined in detail. The aim of this study was to evaluate the effects of single and divided injection of remifentanil combined with propofol on seizure duration and hemodynamic responses during ECT.

Methods

Twenty-six ASA I?CII patients were enrolled in this study and received a total of 78 ECTs. Each patient received propofol 1.2?mg/kg (group P), remifentanil 1???g/kg followed by propofol 0.5?mg/kg (group R1), and remifentanil 1???g/kg followed by propofol 0.5?mg/kg and thereafter remifentanil 2???g/kg (group R2). Succinylcholine 1?mg/kg was used for muscle paralysis after loss of consciousness.

Results

Although mean motor seizure durations were significantly longer in groups R1 and R2 than in group P (P?P?P?Conclusions Divided use of remifentanil at 1 and 2???g/kg combined with propofol 0.5?mg/kg produces an acceptable outcome in both seizure duration and hemodynamic stability during ECT compared with the standard hypnotic doses of propofol alone or remifentanil 1???g/kg followed by propofol 0.5?mg/kg.     

Sevoflurane versus propofol for induction of anaesthesia for electroconvulsive therapy: a randomized crossover trial

Propofol is often used to induce anaesthesia for electroconvulsive therapy. Some patients who receive propofol have fits of poor quality or inadequate duration despite increasing electroconvulsive therapy doses. Sevoflurane has been reported to exhibit pro-convulsant properties in some "at-risk" patients during anaesthesia for other procedures. The purpose of this study was to perform a randomized crossover trial in patients undergoing electroconvulsive therapy, comparing the effects on seizure parameters of propofol versus sevoflurane induction. Patients were randomly allocated to receive either sevoflurane or propofol for their first treatment. In the subsequent treatment the alternative agent was used. Patients in both treatment groups exhibited equally good fits, with those in the sevoflurane group having slightly better morphology, which is the most subjective of the parameters measured. The sevoflurane administrations were associated with slightly higher pulse rates and blood pressures. Sevoflurane provides a suitable alternative to propofol for anaesthesia in patients undergoing electroconvulsive therapy, although the slightly greater pulse rate rise and blood pressure rise should be considered in patients with ischaemic heart disease.     

Addition of ketamine to propofol for initiation of procedural anesthesia in children reduces propofol consumption and preserves hemodynamic stability

Background: There is no ideal anesthesia protocol to perform short invasive procedures in pediatric oncology. The combination of propofol and ketamine may offer advantages over propofol alone.
Methods: In a prospective, randomized, double-blind study, we analyzed 63 consecutive procedures performed in 47 oncology children. All patients received 1 μg/kg fentanyl, followed by propofol 1 mg/kg in group P ( n =33) or propofol 0.5 mg/kg and ketamine 0.5 mg/kg in group PK ( n =30) for the initiation of anesthesia. The need for supplementation with propofol and/or fentanyl to maintain an adequate level of anesthesia was recorded. The hemodynamic and respiratory profile, recovery time and the occurrence of side effects were compared.
Results: Significantly more children required propofol (100% vs. 83.3%) and fentanyl (75.5% vs. 43.3%) rescue doses, and developed hypotension (63.6% vs. 23.4%) and bradycardia (48.5 vs. 23.4%) in group P compared with group PK, with a comparable incidence of respiratory adverse events and recovery times. However, 40% of children in group PK were agitated following recovery compared with 6% in group P.
Conclusions: The combination of propofol and ketamine for invasive procedures in pediatric oncology resulted in reduced propofol and fentanyl consumption and preserved hemodynamic stability, but more children in the combination group recovered with agitation.