Prolonged ECT seizure in a patient taking Nimesulide

Uncommon but serious complications associated with electroconvulsive therapy: recognition and management for the clinician

Electroconvulsive therapy (ECT) is a safe and effective treatment for severe mood disorders. Rarely there can be serious complications, such as postictal agitation, cardiovascular compromise, prolonged seizures, and status epilepticus, all of which are important for the clinician to recognize and treat. Postictal agitation can be severe, requiring emergent intervention and subsequent prophylactic measures to avoid premature ECT discontinuation. Cardiovascular responses to ECT include significant hemodynamic changes that may result in complications, even in patients without preexisting cardiovascular conditions. However, preexisting cardiovascular conditions per se are not contraindications to ECT in patients with disabling psychiatric disease. Recognizing and treating prolonged seizures is essential to prevent progression to status epilepticus. Failure to recognize and treat any of these events may result in increased mortality and morbidity. Understanding such complications and their management strategies avoids unnecessary treatment discontinuation due to manageable ECT complications.

The prevalence of prolonged cerebral seizures at the first treatment in a course of electroconvulsive therapy

BACKGROUND

It has been suggested that prolonged cerebral seizures are more prevalent in contemporary practice than realized partly because they may go undetected in the absence of monitoring by electroencephalogram (EEG). The previous report on this topic from Scotland concerned only patients taking part in research and may not be generalizable to routine clinical practice; moreover, the EEG monitoring was not all carried out at a standardized point in the course of treatment.

OBJECTIVE

We sought to establish the prevalence of prolonged cerebral seizures in a representative sample from routine clinical practice in Edinburgh and do so at the first treatment, when the risk is greatest.

METHOD

Two-channel EEG monitoring was conducted at the first treatment in a new course given to 100 individual consecutive patients.

RESULTS

The titration had to be curtailed for anesthetic reasons in 2 patients, and no cerebral seizure was induced. Electroencephalogram measurement of seizure duration was practicable in only 95 of the remaining patients. Two cerebral seizures longer than 120 seconds were detected. One seizure ended spontaneously after 158 seconds and was associated with a generalized convulsion lasting 77 seconds. One was medically terminated after 180 seconds and was associated with a generalized convulsion lasting 122 seconds; this patient had an encephalopathy during the index illness.

CONCLUSIONS

The prevalence of prolonged seizures in our routine clinical practice was 1% to 2%, depending on the definition of prolonged cerebral seizure activity.