Dexmedetomidine in premedication to attenuate the acute hyperdynamic response to ECT: a randomised, double-blind, controlled study

Pharmacological prevention of postictal agitation after electroconvulsive therapy-A systematic review and meta-analysis

Background

Postictal agitation (PIA) after electroconvulsive therapy (ECT) is a serious clinical problem estimated to occur in 7-36% of patients and recur in 19-54% of patients. PIA has the potential to cause dangerous situations for the patient and staff members aside from the financial impact. To date, it is unclear which pharmacological interventions should be used in the management of PIA. This study aimed to systematically review the (preventative) pharmacological treatment options for PIA after ECT.

Method

A systematic search was done in PubMed, EMBASE, PsycINFO, and Web of Science from inception until 10 November 2022. We included randomized trials with any pharmacological intervention or comparison and a predefined outcome measure on PIA. Studies that solely included patients with neurodegenerative disorders or stroke were excluded. Data quality was assessed with the RoB2 and GRADE. Meta-analysis was performed if possible. This study was registered on PROSPERO under CRD42021262323.

Results

We screened 2,204 articles and included 14 studies. Dexmedetomidine was investigated in 10 studies. Alfentanil, lignocaine, esmolol, midazolam, propofol, ketamine, haloperidol, and diazepam were each studied in only one study. Meta-analysis revealed an OR of 0.45 (0.32-0.63), a moderate effect size, in favor of dexmedetomidine than placebo to prevent PIA with very low heterogeneity (I² = 0%). The certainty of the evidence was moderate. The other interventions studied were all found to have low certainty of evidence.

Conclusion

For clinical practice, we believe that our results indicate that dexmedetomidine should be considered for the prevention of PIA in patients that have previously experienced PIA.

A Narrative Overview of Current Anesthetic Drugs in Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a definitive treatment for patients with psychiatric disorders that are severe, acute, or refractory to pharmacologic therapy. Providing anesthesia for ECT is challenging, as the effect of drugs on hemodynamics, seizure duration, comfort, and recovery must be considered. We highlight and aim to review the common anesthetics used in ECT and related evidence. While drugs such as methohexital, succinylcholine, and etomidate have been used in the past, other drugs such as dexmedetomidine, ketamine, and remifentanil may provide a more balanced anesthetic with a greater safety profile in select populations. Overall, it is essential to consider the patient’s co-morbidities and associated risks when deciding on an anesthetic drug.

Premedication with dexmedetomidine for prevention of hyperdynamic response after electroconvulsive therapy: a cross-over, randomized controlled trial

BACKGROUND

Electroconvulsive therapy (ECT) is an effective therapy for psychiatric disorders, but is associated with acute hyperdynamic responses including transient hypertension and tachycardia. This study aimed to assess the effectiveness of premedication with dexmedetomidine for hemodynamic attenuation after ECT and to evaluate its effects on seizure duration, postictal asystole duration, post ECT agitation and recovery time.

METHODS

Twenty-four psychiatric patients who underwent a total of 72 ECT sessions (three sessions per patient) were randomly allocated to receive either dexmedetomidine 0.5 mcg/kg intravenous, dexmedetomidine 1 mcg/kg intravenous, or saline (control group) 15 min before the first ECT session. The patients subsequently received the other two premedication options for their next two ECT sessions. Blood pressure and heart rate were recorded at 5, 10, and 15 min after drug infusion and at 2.5, 5, 7.5, 10, 15, 20, 25, and 30 min after ECT. Asystole duration, seizure duration, post ECT agitation and recovery times were also recorded.

RESULTS

The baseline characteristics were similar between the groups. Systolic blood pressure in both dexmedetomidine groups was significantly lower than that in the control group after ECT (p = 0.002). Diastolic blood pressure and heart rate were significantly lower in the dexmedetomidine 1 mcg/kg group (p = 0.002 and p = 0.013, respectively) compared with the control group. Asystole duration, seizure durations, post ECT agitation and recovery times were similar between the groups.

CONCLUSIONS

Dexmedetomidine 1 mcg/kg administered 15 min before ECT attenuated the hemodynamic response, including suppressing the systolic, diastolic and heart rate increases, during ECT without affecting recovery time. It also did not prolong the post-stimulus asystole duration.

TRIAL REGISTRATION

TCTR20170715003 , registered at Thai Clinical Trials Registry (TCTR), principal investigator: Pattika Subsoontorn, date of registration: 15/07/2017.

Benefits of Dexmedetomidine in Management of Post-ECT Agitation

Electroconvulsive therapy (ECT) is an intervention for patients with a variety of psychiatric conditions. Occasionally, people exhibit dangerous degrees of agitation after this treatment, and some do not respond well to conventional pharmacotherapies. Dexmedetomidine is a central α-2 agonist that can induce significantly calmative effects in persons with post-ECT agitation. The indication for it is in calming individuals with acute and/or recurrent posttreatment agitation. Dexmedetomidine is safe and effective when infused just before, or postictally, at ECT sessions.