The effects of diltiazem on hemodynamics and seizure duration during electroconvulsive therapy

Electroconvulsive therapy (ECT) is often associated with acute hyperdynamic responses, and we hypothesize that diltiazem can blunt this response. We measured the effect of a 10-mg dose of diltiazem on heart rate and mean arterial pressure during ECT. Furthermore, we assessed seizure duration by using both the cuff method and two-lead electroencephalogram. We studied 18 patients with a randomized, double-blinded, placebo-controlled cross-over study design. Diltiazem significantly reduced heart rate and mean arterial pressure just after medication, and it also significantly reduced the increases in these variables after ECT, as compared with the placebo. The use of diltiazem was, however, associated with a shortened seizure duration, possibly making ECT less effective. Because of the reduction in seizure duration, the routine administration of diltiazem may not be advisable because it can possibly interfere with the psychotherapeutic efficacy of ECT. However, diltiazem medication for ECT is potentially useful for reducing tachycardia and hypertension in high-risk patients. IMPLICATIONS: Diltiazem can blunt acute hyperdynamic responses after electroconvulsive therapy, but seizure duration is also significantly reduced, possibly making this therapy less effective.     

Effects of landiolol on hemodynamic response and seizure duration during electroconvulsive therapy

Purpose This study was done to evaluate the effect of landiolol, an ultra-short-acting beta-blocker, on the hemodynamic response and the duration of seizure activity during electroconvulsive therapy (ECT). Methods We designed a prospective, randomized, double-blinded, placebo-controlled, crossover study. Fourteen psychiatric patients participated. Landiolol (0.1 mg·kg⁻¹ or 0.2 mg·kg⁻¹) or saline (placebo) was administered IV 1 min before the induction of anesthesia. Unconsciousness was induced with propofol 1.0 mg·kg⁻¹ IV, and muscle paralysis was produced with succinylcholine 0.6 mg·kg⁻¹ IV. Subsequently, electrical stimulus was administered to elicit a seizure, and the duration of the motor seizure activity was noted. Results The heart rate (HR) and rate-pressure product (RPP) before ECT were significantly decreased in the 0.2 mg·kg⁻¹ landiolol group compared with these parameters in the placebo and 0.1 mg·kg⁻¹ landiolol groups. Both the 0.1 mg·kg⁻¹ and 0.2 mg·kg⁻¹ doses significantly attenuated the degree of tachycardia and RPP after ECT in comparison with the placebo group. Pretreatment with 0.2 mg·kg⁻¹ landiolol resulted in a significantly shorter duration of motor seizure than that in the placebo group (21 ± 13 s vs 27 ± 12 s). Conclusion As the landiolol dose of 0.2 mg·kg⁻¹ caused shorter seizure duration, and because the hemodynamic effects after ECT of the 0.1 mg·kg⁻¹ and 0.2 mg·kg⁻¹ doses were similar, it was concluded that a 0.1 mg·kg⁻¹ landiolol bolus was the appropriate dose pretreatment before ECT.     

Relationship between seizure duration and bispectral index during modified electroconvulsive therapy

BACKGROUND: The relationship between seizure duration and bispectral index (BIS) has not been studied well in modified electroconvulsive therapy (mECT). METHODS: We studied the changes in BIS and recorded the seizure duration during mECT under propofol and suxamethonium anesthesia. We examined the relationship between seizure duration and BIS. RESULTS: The BIS value immediately before turning on the electricity correlated with seizure duration. The range of BIS values that caused effective seizure duration were 53.6-58.8. CONCLUSIONS: Our study shows the possibility of determining the moment of application of electricity in mECT by using BIS values.     

Comparison of methohexital and propofol for electroconvulsive therapy: effects on hemodynamic responses and seizure duration

Electroconvulsive therapy can produce severe disturbances in the cardiovascular system, most commonly a transient period of hypertension. This study was designed to determine whether propofol, in comparison with methohexital, would attenuate this hypertensive response. Fifteen patients were studied during courses of six ECT administrations, each patient receiving propofol or methohexital on different occasions. Arterial pressure, heart rate, and cardiac rhythm were recorded. The induction doses were 1.08 +/- 0.03 mg.kg-1 of methohexital, and 1.60 +/- 0.04 mg.kg-1 of propofol. Systolic pressure, diastolic pressure, and heart rate were consistently lower following propofol than methohexital (P less than 0.005). The mean maximum increase over baseline systolic pressure was 2.1 +/- 2.9 mmHg with propofol, and 26.7 +/- 4.5 mmHg with methohexital (P less than 0.001). Cardiac rhythm abnormalities were infrequent, and their incidence did not differ significantly between the two induction agents (P greater than 0.3). The duration of seizures, as measured clinically, was reduced with propofol (17.9 +/- 2.5 s) in comparison with methohexital (30.9 +/- 2.8 s) (P less than 0.001). Recovery times were similar for the two agents. Since the role of seizure duration in the therapeutic efficacy of ECT remains controversial, propofol may be a useful induction agent for this procedure.     

The effect of remifentanil on seizure duration and acute hemodynamic responses to electroconvulsive therapy

We designed this prospective, randomized, double-blinded, placebo-controlled, crossover study to evaluate the effect of different doses of remifentanil on the acute hemodynamic response and duration of seizure activity after a standardized electroconvulsive therapy (ECT) stimulus. Twenty consenting patients with major depressive disorders receiving maintenance ECT participated in this study. Eighty ECT treatments were evaluated. All patients were premedicated with glycopyrrolate 0.2 mg IV, unconsciousness was induced with methohexital 1 mg/kg IV, and muscle paralysis was produced with succinylcholine 1.2 mg/kg IV. Subsequently, patients received 1 of 3 different doses of remifentanil 25, 50, and 100 microg or saline (control) in a random sequence immediately after methohexital at 4 consecutive ECT treatments. Labetalol, in 5-mg IV boluses, was used as a rescue antihypertensive medication. A fixed suprathreshold electrical stimulus was administered to elicit a seizure, and the times from the stimulus to the cessation of the motor and electroencephalographic (EEG) seizure activity were noted. Pre- and post-ECT blood pressure values were significantly decreased in the 100- microg remifentanil group compared with the control group. The durations of motor (38 +/- 9 s to 43 +/- 15 s) and EEG (55 +/- 29 s to 60 +/- 21 s) seizure activity were not significantly different among the four groups. Similarly, recovery times to eye opening, obeying commands, and discharge from the recovery room did not differ among the four study groups. The requirement for labetalol after ECT was nonsignificantly decreased in the remifentanil groups. In conclusion, remifentanil 100 microg IV attenuated the acute hemodynamic response to ECT. Furthermore, remifentanil had no adverse effect on the duration of ECT-induced seizure activity. Finally, adjunctive use of remifentanil did not prolong recovery times or increase post-ECT side effects. IMPLICATIONS: Remifentanil (100 microg IV) attenuated the acute hemodynamic response after electroconvulsive therapy (ECT) without adversely affecting the length of the ECT-induced seizure activity or prolonging recovery times.     

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.     

Mask ventilation,hypocapnia, and seizure duration in electroconvulsive therapy

Study ObjectiveTo compare the Mapleson D circuit and the bag-valve-mask device for mask ventilation of patients undergoing electroconvulsive therapy (ECT).DesignCross-over study.SettingSingle-center academic medical center.Patients18 patients undergoing ECT for major depressive disorder.InterventionsPatients were randomized to undergo mask ventilation by the Mapleson D circuit or the bag-valve-mask device.MeasurementsEnd-tidal CO₂, seizure duration, and airway pressure values were recorded.Main ResultsEnd-tidal CO₂ was significantly lower with the bag-valve-mask device. When compared with the bag-valve-mask device, ventilation with the Mapleson circuit resulted in rebreathing of CO₂ in nearly all patients, shorter expiratory time, and lower pressure ramp slope.ConclusionsHypocapnia was not associated with longer seizures, and the user-device interaction might affect device performance.     

Low-dose esmolol bolus reduces seizure duration during electroconvulsive therapy: a double-blind, placebo-controlled study

We have measured the effect of a bolus dose of esmolol 80 mg i.v. on heart rate, and systolic (SAP), diastolic (DAP) and mean (MAP) arterial pressures during electroconvulsive therapy (ECT). We also assessed seizure duration using both the cuff method and two-lead EEG. We studied 20 patients in a double-blind, placebo-controlled, within- patient blocked randomized study. No patient was receiving psychotherapeutic drugs or had cardiovascular disease. Esmolol significantly reduced heart rate, SAP and MAP before the stimulus, and also significantly reduced the increases in these variables during the convulsion, compared with placebo. However, seizure duration was also significantly reduced, possibly making ECT less effective. The reduction in seizure duration was 5.83 s when monitored clinically and 9.9 s when measured by the EEG. Because of the reduction in seizure duration, routine administration of esmolol is not advisable because it may interfere with the efficacy of ECT, but administration of esmolol during ECT could be useful to reduce tachycardia and hypertension in high-risk patients.      

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.     

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.     

Adjustment of anaesthesia depth using bispectral index prolongs seizure duration in electroconvulsive therapy

Electroconvulsive therapy (ECT) under propofol anaesthesia induces relatively shorter seizures compared to barbiturate anaesthesia. Since significant correlation between seizure duration and bispectral index (BIS) value immediately before electrical stimulus has been reported among patients, adjustment of anaesthesia depth as determined by BIS may be effective in obtaining a longer seizure length. In the present study, we examined this hypothesis in those patients whose muscular seizure duration was less than 40s. ECT was prescribed to 20 patients suffering from endogenous depression. General anaesthesia was induced with propofol 1 mg/kg. Succinylcholine chloride 1 mg/kg was then given. The efficacy of electrical stimulation was determined using a tourniquet technique, electromyogram, and electroencephalography. When a patient had a seizure less than 40s in their second ECT treatment, the subsequent treatment was modified such that the electrical stimulus was given after waiting for a higher BIS value (+10-20). Intensity of electrical stimulus and anaesthesia conditions were identical in the two treatments. All 20 patients had longer seizures as determined by the electromyogram and/or electroencephalography when the stimulus was delivered at the higher BIS value. Seizure duration measured by muscle movement was 31+/-5 s when the stimulus was delivered without waiting and 46+/-10 s when delivered after waiting. There was a significant difference in seizure duration between the two treatments (P<0.01). Waiting for a recovery in BIS value before electrical stimulation can prolong seizure duration.     

Arterial PaO2 and PaCO2 influence seizure duration in dogs receiving electroconvulsive therapy

The influence of arterial O2 and CO2 tensions on electroconvulsive seizure duration was investigated in five mongrel dogs under consistent anaesthetic conditions. Seizure durations were measured in a randomized protocol of nine possible combinations of arterial gas tension spanning increased, normal or decreased levels of PaO2 and PaCO2. Seizure duration was directly related to PaO2 (p less than 0.00001) and inversely related to PaCO2 (p less than 0.0001). A significant synergism was evident at the extremes of PaO2 and PaCO2, with seizure duration being greater than predicted for hyperoxia-hypocapnia and hypoxia-hypercapnia and shorter than predicted for hypoxia-hypocapnia and hyperoxia-hypercapnia. We conclude that arterial gas tensions strongly influence ECT-induced seizure duration and through this may influence the therapeutic efficacy of electroconvulsive therapy.     

Efficacy and adverse effects of intravenous lignocaine therapy in fibromyalgia syndrome

Background

To investigate the effects of intravenous lignocaine infusions (IV lignocaine) in fibromyalgia.

Methods

Prospective study of the adverse effects of IV lignocaine in 106 patients with fibromyalgia; retrospective questionnaire study of the efficacy of IV lignocaine in 50 patients with fibromyalgia.

Results

Prospective study: Two major (pulmonary oedema and supraventricular tachycardia) and 42 minor side-effects were reported. None had long-term sequelae. The commonest was hypotension (17 cases). Retrospective study: Pain and a range of psychosocial measures (on single 11-point scales) improved significantly after treatment. There was no effect of the treatment on work status. The average duration of pain relief after the 6-day course of treatment was 11.5 ± 6.5 weeks.

Conclusions

Intravenous lignocaine appears to be both safe and of benefit in improving pain and quality of life for patients with fibromyalgia. This needs to be confirmed in prospective randomised controlled trials.

     

Effect of methohexitone and propofol with or without alfentanil on seizure duration and recovery in electroconvulsive therapy

We have studied the effects of methohexitone and propofol with and without alfentanil on seizure duration and recovery in this observer- blinded, prospective, randomized, crossover study involving 24 patients undergoing electroconvulsive therapy (ECT). Each patient had four treatment sessions, and received the following four i.v. regimens in random order: methohexitone 0.75 mg kg-1, methohexitone 0.50 mg kg-1 and alfentanil 10 micrograms kg-1, propofol 0.75 mg kg-1, propofol 0.50 mg kg-1 and alfentanil 10 micrograms kg-1. Additional methohexitone or propofol was given as needed in 10-20-mg increments until loss of consciousness. Suxamethonium 1.0 mg kg-1 i.v. was given for muscular paralysis. Mean motor and EEG seizure durations were longer with methohexitone-alfentanil (44.7 (SD 15.0) and 70.5 (29.7) s) than with methohexitone (37.6 (12.6) and 52.6 (15.3) s) and similarly, seizures were longer with propofol-alfentanil (36.8 (15.2) and 54.5 (20.9) s) than with propofol alone (27.2 (11.9) and 39.2 (3.9) s). Seizures were longest with methohexitone-alfentanil and shortest with propofol. Recovery time was statistically shorter in patients receiving propofol compared with methohexitone-alfentanil and methohexitone alone. Alfentanil with a reduced dose of methohexitone or propofol provided unconsciousness and increased seizure duration in patients undergoing ECT. We conclude that the combination of methohexitone with alfentanil is a good regimen for ECT, especially for patients with short seizure duration.      

Acute hemodynamic responses to electroconvulsive therapy are not related to the duration of seizure activity

Study Objective: To test the hypothesis that the magnitude of the acute hemodynamic response to electroconvulsive therapy (ECT) is related to the duration of the seizure activity in patients receiving different dosages of intravenous (IV) lidocaine.

Design: Randomized, double-blind, placebo-controlled, cross-over study.

Setting: University-affiliated hospital.

Patients: 21 ASA physical status I, II, and III patients undergoing four consecutive maintenance ECT treatments for chronic depression.

Interventions: Patients received lidocaine 50 mg, 100 mg, 200 mg IV, or saline prior to induction of anesthesia via a standardized anesthetic technique.

Measurements and Main Results: Noninvasive blood pressure (BP) and heart rate (HR), as well as the duration of motor and electroencephalographic (EEG) seizure, were measured. The duration of motor and EEG seizures (means ± SD) were 37 ± 13 sec and 64 ± 21 sec, 25 ± 11 sec and 52 ± 43 sec, 17 ± 12 sec and 32 ± 17 sec, 1 ± 3 sec and 18 ± 10 sec in the saline, lidocaine 50 mg, 100 mg, 200 mg groups, respectively. Although the duration of seizure activity was decreased in a dose-related fashion after lidocaine pretreatment, the peak increases in BP and HR were similar in the lidocaine and saline treatment groups.

Conclusions: Despite producing dose-related decreases in the duration of both motor and EEG seizure activity, lidocaine failed to attenuate the acute hemodynamic response to ECT. Thus, the acute hemodynamic response to ECT is not related to the duration of seizure activity.     

Use of lignocaine or nitroglycerine for blunting of hemodynamic stress response during electroconvulsive therapy

Background and aim of studyElectroconvulsive therapy (ECT) is one of the safest methods used for the treatment of patients with mental illness today. It is associated with surge in heart rate and blood pressure for a brief period of time. However, as an extreme complication, the hemodynamic response to ECT can produce myocardial ischaemia and even infarction, as well as transient neurological ischaemic deficits, intracerebral haemorrhages, and cortical blindness. This study is aimed towards finding a reliable drug that can prevent this untoward hemodynamic response in immediate post-ECT period.Place and duration of studyThe study was conducted at Combined Military Hospital Skardu after permission from the hospital ethics committee from January 2011 to December 2011.Study designOne thirty-four American society of Anaesthesiology (ASA) I & II patients of both genders were divided randomly in three groups named A, B and C. Patients were induced short general anaesthesia as per set protocol. Group A patients were given no additional drug, while group B patients had lignocaine 1 mg/kg and group C patients nitroglycerine (NTG) 3 μ/kg respectively just after induction. Heart rate (HR) and mean arterial pressure (MAP) were recorded 2 min after induction of anaesthesia just prior to ECT shock and then 1 min after ECT administration.Operation definitionsSignificant rise in heart rate was defined as an increase in heart rate of 10 or more beats per minute after administration of ECT shock from baseline.Significant rise in MAP was defined as the rise in MAP of 15 mm of Hg or more from the baseline after administration of ECT shock.ResultsThirty-three (75%) of 44 patients in group A showed significant rise in HR as compared to group B where no patient showed a significant increase in HR (p < .05). In terms of MAP 29 (65%) out of 44 patients showed a significant rise in group A and 22 (52%) out of 42 patients in group B showed similar results showing statically insignificant difference between the groups. When comparing patients of groups A and C, only 11 (22%) out of 48 patients showed significant rise in HR and 13 (27%) patients showed significant rise in MAP. The difference was statistically significant in both variables (p < .05).ConclusionNTG provided more hemodynamic stability in post-ECT period as compared to lignocaine which only prevented a surge in HR without any effect on MAP. We conclude that NTG can safely be instituted for anaesthesia in ECT patients for prevention of hemodynamic stress response.     

The timing of electroconvulsive therapy and bispectral index after anesthesia induction using different drugs does not affect seizure duration

STUDY OBJECTIVE: To determine the association between bispectral index (BIS) and seizure duration obtained by electroconvulsive therapy (ECT) administered sooner or later after anesthetic induction. DESIGN: Prospective, randomized, crossover study. SETTING: University-affiliated medical center. PATIENTS: Nine ASA physical status I, II, and III patients undergoing a total of 31 ECTs. INTERVENTIONS: ECT was administered soon (<210 sec) or later (between 210 sec and 360 sec) after anesthetic induction. In each individual patient, drug regimens and ECT machine settings were identical. MEASUREMENTS: BIS immediately before the start of the ECT and the duration of the EEG seizure were recorded, as well as the time period between loss of consciousness and ECT administration. MAIN RESULTS: There was no relationship between BIS level and seizure duration. Moreover, seizure duration was not dependent on the time of ECT administration in the time window between one and 6 minutes after loss of consciousness. CONCLUSION: The hypnotic drug effect measured by the BIS is not correlated to the seizure duration obtained by ECT.     

Intravenous verapamil blunts hyperdynamic responses during electroconvulsive therapy without altering seizure activity

IMPLICATIONS: A dose of 0.1 mg/kg of verapamil, administered immediately before anesthesia, significantly reduces the increase in peak heart rate and mean arterial blood pressure after electroconvulsive therapy. Furthermore, the administration of verapamil does not reduce the duration of the seizure.