A cross-over, post-electroconvulsive therapy comparison of clinical recovery from rocuronium versus succinylcholine

Does the Use of Rocuronium-Sugammadex Instead of Succinylcholine in Electroconvulsive Therapy Affect Seizure Duration?

OBJECTIVE

We compared retrospectively the seizure variables of electroconvulsive therapy (ECT) patients after administration of rocuronium-sugammadex or succinylcholine as a muscle relaxant with propofol anesthesia.

METHODS

The sample comprised 134 ECT patients. The mean age was 33.6±10.48 years. Anesthesia induction was provided with propofol one mg kg-intravenously (IV) followed by succinylcholine 0.5 mg kg-1 IV (n=68) (Group S) or rocuronium 0.3 mg kg-1 IV (n=66) (Group R). For patients who were given rocuronium, reversal of the residual neuromuscular block was accomplished with sugammadex (1.5 mg kg-1 IV). First session seizure variables were compared between the two groups. We also presented the clinical outcome with Clinical Global Impression-Improvement (CGI-I) and overall adverse effects.

RESULTS

EEG seizure durations in Group R (55.09±36.11 s) and Group S (47.00±26.33 s) were comparable and were not significantly different (p=0.432). The clinical efficacy of ECT measured by CGI-I in both groups was comparable (p=0.075). There were no major complications or death during or after ECT.

CONCLUSION

The results of this study show that the use of rocuronium-sugammadex as a neuromuscular blocker instead of succinylcholine during ECT with propofol anesthesia produces similar results in terms of seizure variables and clinical outcomes.

Comparison of hemodynamic changes and serum potassium levels in the use of succinylcholine and cisatracurium in electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is nowadays used commonly as one the most effective treatment methods in psychiatric disorders. In patients undergoing ECT, succinylcholine is usually used. In addition, cisatracurium is occasionally used on a case report basis globally. In this study, we compared the hemodynamic changes and serum potassium levels in the use of succinylcholine and cisatracurium in ECT.

MATERIALS AND METHODS

The current crossover clinical trial was performed on 45 patients who were candidates for ECT between 2017 and 2018. The patients were given succinylcholine or cisatracurium randomly on two separate occasions of ECT. The independent t-test and Chi square Test were used to compare the data.

RESULTS

Comparison of mean systolic blood pressure (P = 0.14), diastolic blood pressure (P = 0.33), and mean arterial pressure (P = 0.23) did not show any significant difference between the two groups. The induced seizure duration (P = 0.002), return of spontaneous respiratory from seizure ending (P = 0.001), and apnea duration (P = 0.01) were significantly higher in the cisatracurium group compared to the succinylcholine group. However, the frequency of tachycardia in cisatracurium group was lower than the succinylcholine group (P < 0.001). In addition, the serum potassium level had a significant difference (P < 0.001) between the two groups.

CONCLUSION

Using cisatracurium can be an alternative to succinylcholine during ECT since it causes less elevation in serum potassium and creates a longer duration of induced seizure, more rapid re emergence of spontaneous breathing at the end of seizure (P = 0.001), and a lower prevalence of tachycardia compared to succinylcholine (P < 0.001).

Minimum Effective Doses of Succinylcholine and Rocuronium During Electroconvulsive Therapy: A Prospective, Randomized, Crossover Trial

BACKGROUND

Neuromuscular blockade is required to control excessive muscle contractions during electroconvulsive therapy (ECT). In a crossover, assessor-blinded, prospective randomized study, we studied the minimum effective dose (MED) of succinylcholine and rocuronium for ECT. The MED was the lowest dose to provide a predefined qualitative measure of acceptable control of muscle strength during induced convulsions.

METHODS

Succinylcholine (0.8 mg kg) or rocuronium (0.4 mg kg) was randomly administered in 227 ECT sessions to 45 patients. The dose was incrementally increased or decreased by 10% based on 2 psychiatrists' (blinded to treatment) assessment of "acceptable" or "not acceptable" control of evoked muscle contractions (sufficient versus insufficient or excessive paralysis). The neuromuscular transmission was monitored quantitatively until full recovery.

RESULTS

In our study, the MEDs of succinylcholine and rocuronium to produce acceptable ECT conditions in 50% of patients (MED50ECT) were 0.85 mg kg (95% confidence interval [CI], 0.77-0.94) and 0.41 mg kg (95% CI, 0.36-0.46) and in 90% of patients (MED90ECT) were 1.06 mg kg (95% CI, 1.0-1.27) and 0.57 mg kg (95% CI, 0.5-0.6), respectively. Nadir twitch height for acceptable muscle activity was 0% (0-4) and 4% (0-30; P < 0.001), respectively, and the time to recovery of the neuromuscular transmission was 9.7 ± 3.5 and 19.5 ± 5.7 minutes, respectively.

CONCLUSIONS

A twitch suppression of >90% is needed for control of motor contractions during ECT. The initial ECT dose of succinylcholine should be selected based on each patient's preprocedural condition, ranging between 0.77 and 1.27 mg kg to produce acceptable muscle blockade in 50% to 90% of patients. Rocuronium-neostigmine combination is a safe alternative if appropriately dosed (0.36-0.6 mg kg) and monitored.

Neuromuscular blocking agents for electroconvulsive therapy: a systematic review

Electroconvulsive therapy (ECT) is the transcutaneous application of small electrical stimuli to the brain to induce generalised seizures for the treatment of selected psychiatric disorders. The clinical indications for ECT as an effective therapeutic modality have been considerably expanded since its introduction. Anaesthesia and neuromuscular blocking agents (NMBAs) are required to ensure patients' safety during ECT. The optimal dose of muscle relaxant for ECT reduces muscle contractions without inducing complete paralysis. Slight residual motor convulsive activity is helpful in ascertaining that a seizure has occurred, while total paralysis prolongs the procedure unnecessarily. Suxamethonium is commonly used, but nondepolarising NMBAs are indicated in patients with certain comorbidities. In this review, we summarise current concepts of NMBA management for ECT.

Comparison of recovery times from rocuronium-induced muscle relaxation after reversal with three different doses of sugammadex and succinylcholine during electroconvulsive therapy

PURPOSE

This study was conducted to compare recovery times from rocuronium-induced muscle relaxation after reversal with three different doses of sugammadex with succinylcholine during electroconvulsive therapy (ECT).

METHODS

Seventeen patients who were scheduled to undergo ECT were studied. Anesthesia was induced by use of propofol (1.0 mg/kg) followed by either succinylcholine (SCC) (1 mg/kg) or rocuronium (0.6 mg/kg). Assisted mask ventilation was initiated with 100% oxygen. After T1 was assessed as being zero by neuromuscular monitoring, an electroshock stimulus was applied bilaterally. Patients receiving rocuronium were infused with 16, 8, or 4 mg/kg sugammadex immediately after the seizure stopped to reverse the muscle relaxation. Neuromuscular monitoring was continued until recovery of the train-of-four ratio to 0.9 at the tibial nerve in the leg. The times to recovery of T1 to 10 and 90% with both relaxants were compared.

RESULTS

The time to recovery of T1 to 90% after 16 mg/kg sugammadex was shorter than that in subjects treated with SCC (p = 0.046), whereas that after 4 mg/kg sugammadex was longer than that in subjects treated with SCC (SCC group: 429 ± 65 s, 16 mg/kg sugammadex group: 387 ± 63 s*, 8 mg/kg sugammadex group: 462 ± 66 s, 4 mg/kg sugammadex group: 563 ± 45 s(*,#); *p < 0.05 compared with SCC, (#)p < 0.01 compared with 16 mg/kg sugammadex).

CONCLUSIONS

This study demonstrates the efficacy of rocuronium-sugammadex as an alternative to SCC for muscle relaxation during ECT, and indicates that 8 mg/kg sugammadex produces equally rapid recovery from rocuronium muscular relaxation compared with spontaneous recovery from 1 mg/kg SCC during ECT.

Rocuronium antagonized by sugammadex for series of electroconvulsive therapy (ECT) in a patient with pseudocholinesterase deficiency

We report the anesthetic management of a patient with catatonic schizophrenia and pseudocholinesterase deficiency, using the nondepolarizing neuromuscular blocking drug, rocuronium, reversed by its specific reversal agent, sugammadex, for a series of electroconvulsive therapy sessions. Rocuronium and sugammadex were used every 48 hours for 8 consecutive times and proved to be an effective and safe combination in a situation where succinylcholine was contraindicated.