Anaesthesia in electroconvulsive therapy. Special conditions

Anesthetic care for electroconvulsive therapy

Counselling and medication are often thought of as the only interventions for psychiatric disorders, but electroconvulsive therapy (ECT) has also been applied in clinical practice for over 80 years. ECT refers to the application of an electric stimulus through the patient’s scalp to treat psychiatric disorders such as treatment-resistant depression, catatonia, and schizophrenia. It is a safe, effective, and evidence-based therapy performed under general anesthesia with muscle relaxation. An appropriate level of anesthesia is essential for safe and successful ECT; however, little is known about this because of the limited interest from anesthesiologists. As the incidence of ECT increases, more anesthesiologists will be required to better understand the physiological changes, complications, and pharmacological actions of anesthetics and adjuvant drugs. Therefore, this review focuses on the fundamental physiological changes, management, and pharmacological actions associated with various drugs, such as anesthetics and neuromuscular blocking agents, as well as the comorbidities, indications, contraindications, and complications of using these agents as part of an ECT procedure through a literature review and our own experiences.

Sugammadex in systemic mastocytosis : Case report and a systematic review of literature

Perioperative management in patients suffering from systemic mastocytosis is challenging. Most recommendations regarding anesthetic management in these patients are based on clinical reports, and there are controversies about the use of rocuronium and sugammadex. We present a case report of a patient with systemic mastocytosis who was given sugammadex for rocuronium reversal. Tryptase levels were monitored during the first postoperative 24 h, without evidence of elevation. We also performed a systematic review to provide an overview of current evidence regarding the safety of using sugammadex in patients suffering from systemic mastocytosis. The search strategy included PubMed and Google Scholar. All studies published up to and including January 2021 concerning anesthetic management in systemic mastocytosis were included. Of the 122 articles located, 9 articles were included: 2 reviews and 7 case reports. Data from reviewed studies confirm that sugammadex can safely be administered in patients suffering from systemic mastocytosis.

Evaluating Factors Affecting the Time Interval Between Propofol Injection and Induction of Electro-convulsion and Relationship Between These Factors and Duration of Convulsion

Background

Current evidence on the effect of anesthetic-ECT time interval (AETI) is controversial. This study aimed to investigate the factors affecting the time interval between propofol injection and electro-convulsion induction and the relationship between these factors and the duration of convulsion.

Methods

In this study, 102 patients (616 sessions of ECT) were studied. Demographic and clinical data (age, gender, receiving or not receiving medications that affected the seizure threshold, the total number of ECT sessions, clinical severity of admission scores, clinical diagnosis, propofol dose, seizure duration, and AETI) were collected in special forms and analyzed by appropriate statistical methods.

Results

Sessions with long-term AETI had longer seizure time than sessions with short-term AETI (33.47 ± 8.46 vs. 28.68 ± 9.74, P value < 0.05). The duration of seizures was significantly longer in the group with long AETI in sessions 1, 2, and 4 than in the other group (P value < 0.05). There was a significant relationship between the duration of seizures and propofol dose, AETI, and receiving drugs effective in the seizure threshold (P value < 0.05).

Conclusions

The results showed that increasing AETI and injecting a lower dose of propofol to induce anesthesia would increase the duration of seizures. Also, taking medications that would affect the seizure threshold reduces the duration of seizures.

Challenges and pitfalls in anesthesia for electroconvulsive therapy

Electroconvulsive therapy (ECT) refers to the application of electricity to the patients' scalp to treat psychiatric disorders, most notably, treatment-resistant depression. It is a safe, effective, and evidence-based therapy that is performed with general anesthesia. Muscle relaxation is used to prevent injuries related to the tonic-clonic seizure caused by ECT. Hypnotics are administered to induce amnesia and unconsciousness, so that, patients do not experience the period of muscle relaxation, while the generalized seizure is left unnoticed. For the anesthesiologist, ECT is associated with the challenges and pitfalls that are related to informed consent, social acceptance of ECT, airway management (especially in COVID-19 patients), and the interaction between ventilation and anesthetics from one viewpoint, and seizure induction and maintenance from another. The exact mode of action of the therapy is as unknown as the optimal choice or combination of anesthetics used.

Electroconvulsive therapy protocol adaptation during the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, electroconvulsive therapy units have had to confront challenges such as the infectious hazard due to aerosol-generating ventilation, or the lack of staff and material resources. Our objective was to elaborate a protocol to make ECT during the COVID-19 pandemic a safer procedure for patients and professionals.

METHODS

A multidisciplinary workgroup (including mental health, anesthesia, preventive medicine, and occupational risk professionals) was formed in the Hospital Clínic de Barcelona, in March 2020. A core group conducted a review of the scientific literature and healthcare organizations' guidelines and wrote a protocol draft. Then, a discussion with the workgroup was made until consensus was reached. The protocol has been continuously updated. Discussions were made by group e-mailing and video conferencing.

RESULTS

The protocol includes the following main areas: (1) ECT unit's structural and functional considerations; (2) SARS-CoV-2 screening protocol; (3) ECT clinical practice adaptation (personal protective equipment, airway management, recovery room, and maintenance of the facilities); (4) management of COVID-19 cases; and (5) protocol assessment.

LIMITATIONS

The literature review was not systematic; the consensus was not based on a structured methodology. For other ECT units, local advisories may not be valid, and resource shortages (such as anesthetist availability, or the lack of respirators and PCR tests) may impede or prevent their implementation.

CONCLUSIONS

During the COVID-19 pandemic, ECT should continue to be advocated as an essential medical procedure. It is recommended that each ECT unit develop its own protocol. This proposal may be used as a reference.