Comparison of two esmolol bolus doses on the haemodynamic response and seizure duration during electroconvulsive therapy

The Cardiovascular Side Effects of Electroconvulsive Therapy and Their Management

ABSTRACT

Electroconvulsive therapy (ECT) remains stigmatized in the broader medical community because of misunderstandings about treatment procedures, mortality rates, and cardiovascular complications. Electroconvulsive therapy causes periprocedural hemodynamic variability because of the surges in parasympathetic and sympathetic nervous systems after the administration of the electrical charge. Patients experience an increase in cardiac workload, which is potentially dangerous for patients with preexisting heart disease. Several findings suggest that cardiac complications occur most frequently in patients with underlying cardiovascular disease. We describe the cardiovascular complications that may result from ECT treatment and offer insight on how to mitigate these concerns if they occur. PubMed was queried using terms "electroconvulsive therapy" and "cardiovascular adverse effects." A table is provided with the common cardiovascular side effects of ECT and the most recent evidence-based treatment strategies to manage them. Generally, ECT is a safe procedure in which complications are minor and manageable. Most major complications caused by ECT are related to the cardiovascular system; however, with an appropriate pre-ECT evaluation and a comprehensive multidisciplinary team approach, the cardiovascular complications can be well managed and minimized. Providing proper cardiac clearance can prevent cardiac complications and provide timely care to treatment-resistant populations who are at risk for excessive morbidity and suicide.

The Effects of Remifentanil on Hemodynamic Response Attenuation After Electroconvulsive Therapy Under Sevoflurane Anesthesia

PURPOSE

We evaluated the effects of a single loading dose of remifentanil (1 μg/kg) administered as an adjunct to sevoflurane, on the duration of seizure activity, recovery times, and hemodynamic profiles, during electroconvulsive therapy.

METHODS

The patients were randomly allocated to receive sevoflurane-saline (Group SS) or sevoflurane-remifentanil (Group SR). Sevoflurane (8%) was initiated for anesthesia induction in both groups until loss of consciousness was achieved. Remifentanil was then administered to Group SR via a 1-μg/kg intravenous bolus. Patients in Group SS received saline in the same manner. Mean arterial pressure (MAP) and heart rate (HR) were recorded before anesthetic induction (T1), at the loss of consciousness (T2), and at 0, 1, 3, and 10 minutes after the electrical stimuli were completed (T3, T4, T5, and T6, respectively).

RESULTS

Compared with the baseline values, HR increased significantly in Group SS at times T2 and T4 to T6 and decreased significantly in Group SR at time T2. When the groups were compared, we found that HR decreased significantly in Group SR at T2 and T4 to T6. Compared with baseline, MAP increased in Group SS between T3 and T6, and MAP decreased in Group SR at T2 and increased at T3 to T4. Mean arterial pressure decreased to a greater extent in Group SR than in Group SS during the T2 to T6 period. There were no group differences in seizure duration or recovery time.

CONCLUSIONS

The addition of 1-μg/kg remifentanil to anesthetic induction with sevoflurane attenuated the acute hemodynamic response to electroconvulsive therapy under sevoflurane anesthesia without adversely affecting the duration of seizure activity or the recovery profile.

Outcome of four pretreatment regimes on hemodynamics during electroconvulsive therapy: A double-blind randomized controlled crossover trial

Context:

Electroconvulsive therapy (ECT) is associated with tachycardia and hypertension.

Aims:

The aim of this study was to compare two doses of dexmedetomidine, esmolol, and lignocaine with respect to hemodynamics, seizure duration, emergence agitation (EA), and recovery profile.

Methodology:

Thirty patients undergoing ECT were assigned to each of the following pretreatment regimes over the course of five ECT sessions in a randomized crossover design: Group D1 (dexmedetomidine 1 μg/kg), Group D0.5 (dexmedetomidine0.5 μg/kg), Group E (esmolol 1 mg/kg), Group L (lignocaine 1 mg/kg), and Group C (saline as placebo) before induction. Heart rate (HR), mean arterial pressure (MAP), seizure duration, EA, and time to discharge were evaluated.

Results:

Groups D1, D0.5, and esmolol had significantly reduced response of HR, MAP compared to lignocaine and control groups at 1, 3, 5 min after ECT (P < 0.05). Motor seizure duration was comparable in all groups except Group L (P = 0.000). Peak HR was significantly decreased in all groups compared to control. Total propofol requirement was reduced in D1 (P = 0.000) and D0.5 (P = 0.001) when compared to control. Time to spontaneous breathing was comparable in all the groups (P > 0.05). Time to eye opening and time to discharge were comparable in all groups (P > 0.05) except Group D1 (P = 0.001). EA score was least in Group D1 (P = 0.000).

Conclusion:

Dexmedetomidine 1 μg/kg, 0.5 μg/kg, and esmolol produced significant amelioration of cardiovascular response to ECT without affecting seizure duration, results being best with dexmedetomidine 1 μg/kg. However, the latter has the shortcoming of delayed recovery.

Beta-blocking agents during electroconvulsive therapy: a review

Electroconvulsive therapy (ECT) is associated with at least transient episodes of hypertension and tachycardia. Beta-blocking agents may be indicated to prevent cardiovascular complications and may shorten seizure duration. This review evaluates studies that used beta-blocking agents during ECT to determine which agent has the most favourable outcomes on cardiovascular variables and seizure duration. A Medline database search was made using the combined keywords 'adrenergic beta-antagonists' and 'electroconvulsive therapy'. The search was restricted to double-blind randomized controlled trials and yielded 29 original studies. With the use of esmolol, significant attenuating effects were found on cardiovascular parameters in the first 5 min after stimulation; its shortening effects on seizure duration may be dose-related. With the use of labetalol, findings on cardiovascular effects were inconsistent during the first minutes after stimulation but were significant after 5 min and thereafter; seizure duration was scarcely studied. Landiolol attenuates heart rate but with inconsistent findings regarding arterial pressure (AP); seizure duration was mostly unaffected. Esmolol appears to be effective in reducing the cardiovascular response, although seizure duration may be affected with higher dosages. Landiolol can be considered a suitable alternative, but effects on AP need further investigation. Labetalol has been studied to a lesser extent and may have prolonged cardiovascular effects. The included studies varied in design, methodology, and the amount of exact data provided in the publications. Further study of beta-blocking agents in ECT is clearly necessary.

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 x kg(-1) or 0.2 mg x kg(-1)) or saline (placebo) was administered IV 1 min before the induction of anesthesia. Unconsciousness was induced with propofol 1.0 mg x kg(-1) IV, and muscle paralysis was produced with succinylcholine 0.6 mg x 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 x kg(-1) landiolol group compared with these parameters in the placebo and 0.1 mg x kg(-1) landiolol groups. Both the 0.1 mg x kg(-1) and 0.2 mg x kg(-1) doses significantly attenuated the degree of tachycardia and RPP after ECT in comparison with the placebo group. Pretreatment with 0.2 mg x 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 x kg(-1) caused shorter seizure duration, and because the hemodynamic effects after ECT of the 0.1 mg x kg(-1) and 0.2 mg x kg(-1) doses were similar, it was concluded that a 0.1 mg x kg(-1) landiolol bolus was the appropriate dose pretreatment before ECT.

The use of nicardipine for electroconvulsive therapy: a dose-ranging study

A wide variety of vasoactive drugs have been used to treat the acute hypertensive response to electroconvulsive therapy (ECT). We designed this randomized, double-blind, saline-controlled, crossover study to compare three different doses of nicardipine when administered before the ECT stimulus. Twenty-five patients undergoing a series of 4 ECT treatments received bolus injections of either saline or nicardipine 20, 40, or 80 mug/kg IV in a random sequence during a standardized methohexital (1 mg/kg) and succinylcholine (1 mg/kg) anesthetic technique. The mean arterial blood pressure (MAP) and heart rate values were recorded at specific time intervals, as were the duration of seizure activity and the need for rescue labetalol. Both the 40 and 80 mug/kg doses of nicardipine reduced the percentage increase in MAP above the baseline value compared with the saline group (7% and 7% versus 30%, respectively). Nicardipine 40 and 80 mug/kg were also associated with a significant reduction in the need for labetalol (7 +/- 3 mg and 5 +/- 0 mg versus 22 +/- 10 mg in the saline group). Compared with the 40 mug/kg dose, nicardipine 80 mug/kg was associated with a more rapid heart rate at the time the ECT stimulus was applied. The 80 mug/kg dose was also associated with a reduced MAP value on awakening compared with the baseline value (91 +/- 12 mm Hg versus 102 +/- 8 mm Hg). We conclude that a bolus injection of nicardipine 40 mug/kg IV immediately before the ECT stimulus was optimal for controlling the acute hemodynamic response to ECT treatments.

Landiolol attenuates acute hemodynamic responses but does not reduce seizure duration during maintenance electroconvulsive therapy

Maintenance electroconvulsive therapy (mECT) is an outpatient procedure that requires further consideration in terms of management of ambulatory anesthesia. Although many adjunctive drugs for stabilizing hemodynamic changes during ECT have been reported, side-effects of these drugs may delay recovery and discharge from hospital. The effects of landiolol, a novel ultra-short-acting beta-adrenergic blocker, have been measured on seizure duration, hemodynamic changes, recovery from anesthesia, and cognitive function during mECT under propofol anesthesia. A total of 10 patients with depression in the remission phase, were studied in a randomized, double-blind, placebo-controlled, crossover manner. Administration of 0.1 mg/kg of landiolol immediately before anesthesia significantly blunted the increase in heart rate and blood pressure during convulsions compared with placebo; landiolol was not associated with excessive hypotension or bradycardia. Landiolol did not affect seizure duration, recovery from anesthesia, or cognitive function before or after ECT. These results suggest that landiolol can be used effectively and safely during mECT.

Interactions between psychotropics, anaesthetics and electroconvulsive therapy: implications for drug choice and patient management

Despite many predictions that electroconvulsive therapy (ECT) would be replaced by pharmacotherapy, ECT has remained an invaluable adjunct in the management of severe psychiatric disease. Both pharmacotherapy and ECT continue to be used extensively, and will frequently be administered concurrently. The majority of patients requiring ECT will need anaesthesia; therefore, interactions could conceivably occur between the psychotropic drugs, ECT and the anaesthetic agents utilised. In managing an anaesthetic for ECT the effects of the anaesthetic agents and other medications on seizure intensity are important determinants influencing outcome. With regard to the antidepressants, tricyclic antidepressants (TCAs) and ECT can be combined safely and beneficially. More care is required when ECT is administered in the setting of a monoamine oxidase inhibitor (MAOI), especially the older irreversible varieties and in patients recently placed on MAOI therapy. Of the anticonvulsants and mood stabilisers, lithium and ECT given concurrently add significant risk of delirium and/or organic syndromes developing. Possible concerns with valproate, carbamazepine, lamotrigine, gabapentin and topiramate are that they may inhibit seizure activity. Additionally, carbamazepine may prolong the action of suxamethonium (succinylcholine). The combination of antipsychotics and ECT is well tolerated, and may in fact be beneficial. As regards the anxiolytics, benzodiazepines have anticonvulsant properties that might interfere with the therapeutic efficacy of ECT. CNS stimulants on the other hand may prolong seizures as well as produce dysrhythmias and elevate blood pressure. Calcium channel antagonists should be used with great care to avoid significant cardiovascular depression. The anaesthesiologist should therefore remain vigilant at all times, as untoward responses during ECT might occur suddenly due to interactions between psychotropics, anaesthetic agents and/or ECT.

Hemodynamic responses to ECT in a patient with critical aortic stenosis

We present a case study of a 46-year-old woman with a psychotic depressive illness of 2 months' duration with the coexisting medical diagnoses of critical aortic stenosis, severe labile hypertension, renal failure necessitating hemodialysis of 7-years' duration, and systemic lupus. Because of unresponsiveness to an antidepressant drug regimen, severe motor retardation, mutism, and refusal of food and fluids by mouth, an urgent indication for electroconvulsive therapy (ECT) was established. However, the patient refused ECT, and to allow its initiation, a court order was obtained. In view of the coexisting diagnoses of critical aortic stenosis, labile hypertension, and renal failure, ECT represented a substantially increased risk in this patient because of severe arterial hypertension and tachycardia. The patient was successfully managed during each ECT, using a combination of metoprolol by mouth, which was supplemented by i.v. esmolol immediately prior to the application of the ECT stimulus, and sodium nitroprusside, which was infused for several minutes prior to the seizure and thereafter to attenuate arterial hypertension. Nevertheless, sudden death, a well-known complication of critical aortic stenosis, occurred 96 hours after the fourth ECT.

Effects of nicardipine and labetalol on the acute hemodynamic response to electroconvulsive therapy

STUDY OBJECTIVE

To examine the acute hemodynamic effects of intravenous (i.v.) nicardipine and its ability to attenuate the hyperdynamic response to electroconvulsive therapy (ECT), when used alone or in combination with labetalol.

DESIGN

Prospective, randomized, double-blind, positive-control, clinical investigation.

SETTING

University hospital.

PATIENTS

36 patients undergoing ECT.

INTERVENTIONS

In a series of three studies, the hemodynamic effects of nicardipine were assessed prior to, during, and after ECT. After administration of glycopyrrolate 0.1 mg i.v., placebo (saline) or nicardipine was administered by rapid infusion (1, 2.5, 5, 10, and 15 mg) or bolus injection (1.25, 2.5, and 5 mg), either alone or in combination with labetalol 10 mg i.v. Unconsciousness was induced with methohexital 1 mg/kg i.v.; succinylcholine 1.2 to 1.5 mg/kg i.v. was administered for muscle relaxation. A bilateral electrical stimulus was delivered and the durations of motor and electroencephalographic (EEG) seizures were noted.

MEASUREMENTS AND MAIN RESULTS

Mean arterial pressure (MAP) and heart rate (HR) values were recorded at 1- to 5-minute intervals throughout the study period. When administered as a rapid infusion, nicardipine 5 mg i.v. produced a significant decrease in MAP; however, nicardipine dosages of 10 to 15 mg i.v. did not produce a significantly greater decrease in MAP than 5 mg. Bolus administration of nicardipine 1.25 to 5 mg produced a rapid onset of its hemodynamic effects without exacerbating the cardiovascular depressant effects of methohexital. However, the decrease in MAP was accompanied by an increase in HR after administration of the 5 mg i.v. bolus dose. The acute hyperdynamic response to ECT was most effectively controlled by nicardipine 2.5 to 5 mg i.v. bolus, in combination with labetalol 10 mg i.v. Seizure duration was not significantly altered by the use of nicardipine as part of the anesthetic regimen for ECT.

CONCLUSION

Nicardipine 2.5 mg i.v. bolus in combination with labetalol 10 mg i.v. was the most effective pretreatment regimen for preventing the acute hyperdynamic response to ECT. However, this combination produced a 20% decrease in MAP immediately prior to ECT and a lower MAP at the time of discharge.

Trimethaphan (Arfonad) control of hypertension and tachycardia during electroconvulsive therapy: a double-blind study

STUDY OBJECTIVE

To ascertain the optimal dose of trimethaphan camsylate administered by intravenous (i.v.) bolus injection for the control of hypertension and tachycardia during electroconvulsive therapy (ECT).

DESIGN

Prospective, double blind, within-subject study.

SETTING

Treating room of the psychiatric unit of the University Hospital at Stony Brook, NY.

SUBJECTS

Patients undergoing ECT for major psychiatric illnesses.

MEASUREMENTS AND MAIN RESULTS

Fifteen ASA status I or II patients received in a random sequence placebo, or 5, 10, or 15 mg boluses of trimethaphan during their second to fifth treatments. Blood pressure (BP) and heart rate (HR) were recorded every 30 seconds by automated oscillometric recorder. Recordings taken before administration, during seizure, 5, and 20 minutes after seizure were examined. All doses ameliorated BP (systolic, diastolic, and mean), HR, and rate pressure product (RPP) increases during the seizure, compared with placebo. The group that received 15 mg exhibited smaller increases in RPP, i.e., 67.7% increase compared with 155.4%, 110.9%, and 98.7% increases for the placebo, 5, and 10 mg, respectively. The 10 mg and 15 mg doses caused a faster return to baseline than did the 5 mg dose or placebo. No rebound hypertension, prolonged hypotension, arrhythmias, or other side effects were noted. Trimethaphan did not alter seizure duration.

CONCLUSIONS

Trimethaphan is safe, practical, and effective in the management of the hyperdynamic response to ECT. An i.v. bolus injection of 15 mg is more effective than 10 mg or 5 mg.

The effect of esmolol pretreatment on the incidence of regional wall motion abnormalities during electroconvulsive therapy

Electroconvulsive therapy (ECT) is associated with dramatic increases in arterial blood pressure and heart rate (HR) that may precipitate new left ventricular regional wall motion abnormalities (RWMAs) suggestive of myocardial ischemia. The purpose of this study was to investigate the effect of pretreatment with esmolol on the incidence of RWMAs after ECT. Thirteen patients served as their own controls and, in a random fashion, received a standard succinylcholine/methohexital anesthetic for one of two ECT sessions, and an identical anesthetic with esmolol 1 mg/kg for their other ECT session. Systolic (SBP), diastolic (DBP), mean arterial pressures (MAP) and HR were recorded after drug administration and before ECT and at 1-, 2-, 4-, 5-, 10-, and 15-min intervals after ECT. Echocardiograms were obtained at baseline, after drug administration, 1 min after ECT, and at recovery 15 min later. All patients had significant increases in SBP, DBP, and MAP at 1, 2 and 4 min after ECT versus baseline, whereas HR was significantly faster at all times in the control sessions. HR was significantly slower after anesthetic induction until 2 min after ECT in the esmolol versus the control group (P < 0.05). New RWMAs were seen in only 1 of 26 (4%) ECT sessions, despite the presence of baseline RWMAs in 31% of the patients. We conclude that contrary to previously reported data, new RWMAs after ECT are uncommon. Consequently, this study was unable to demonstrate any beneficial effect of pretreatment with esmolol on the incidence of ECT-induced RWMAs.

Comparative effects of esmolol and labetalol to attenuate hyperdynamic states after electroconvulsive therapy

We studied 18 patients (age range, 53-90 yr) with at least one cardiovascular risk factor who were treated with electroconvulsive therapy (ECT) and compared effects of five pretreatments: no drug; esmolol, 1.3 or 4.4 mg/kg; or labetalol, 0.13 or 0.44 mg/kg. Each patient received all five treatments, during a series of five ECT sessions. Pretreatment was administered as a bolus within 10 s of induction or anesthesia. Doses of methohexital and succinylcholine were constant for the series of treatments and the assignment to no drug or to drug and dose was determined by randomized block design. Measurements of systolic and diastolic blood pressure (SBP, DBP) and heart rate (HR) were recorded during the awake state and 1, 3, 5, and 10 min after the seizure. The deviation of ST segments from baseline was measured by an electrocardiogram (ECG) monitor equipped with ST-segment analysis software. The results (mean +/- SEM) show that without pretreatment, there were significant (P < 0.05) peak increases in SBP and HR (55 +/- 5 mm Hg and 37 +/- 6 bpm, respectively), recorded 1 min after the seizure. Comparable reductions (by approximately 50%) in these peak values were achieved after esmolol (1.3 mg/kg) or labetalol (0.13 mg/kg), and cardiovascular responses were nearly eliminated after the same drugs in doses of 4.4 and 0.44 mg/kg, respectively. The deviation of ST-segment values from baseline in any lead was not measurably influenced by either antihypertensive drug. SBP values were lower after labetalol 10 min after the seizure, but not after esmolol. Asystolic time after the seizure was not significantly longer with either drug.(ABSTRACT TRUNCATED AT 250 WORDS)