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Journal of Psychiatric Research Sep 2020Early studies reported a prolactin surge during electroconvulsive therapy (ECT). The aim of this study is to review and meta-analyze data on ECT-related prolactin... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Early studies reported a prolactin surge during electroconvulsive therapy (ECT). The aim of this study is to review and meta-analyze data on ECT-related prolactin changes.
METHOD
A systematic review and meta-analysis was conducted for trials investigating prolactin changes in ECT-treated patients using standard mean differences (SMD, 95% confidence intervals). Subgroup analyses included comparisons of ECT-related prolactin changes in women vs. men, patients receiving different anesthetics, bilateral vs. unilateral and high-vs. low-dose ECT.
RESULTS
In six trials including 109 ECT-treated patients and 74 controls, prolactin changes were larger in ECT-treated patients than in controls (SMD = 0.89, 95%CI = 0.55, 1.23, p < 0.001 and 1.03, 95%CI = 0.31, 1.75, p = 0.005 for the fixed and random-effect model respectively), despite heterogeneity in the samples (I = 72%, τ = 0.62). Effects were led by differences in patients premedicated with methohexital (SMD = 1.14, 95%CI = 0.7, 1.57, p < 0.001 for both fixed and random-effect model). A meta-regression reported significant age effects (coefficient estimate 2.32, 95%CI = -0.73, 3.91, p < 0.01). Additionally, prolactin changes were larger in ECT-treated women than men (SMD = 0.88, 95%CI = 0.58, 1.18, p < 0.001 and 0.99, 95%CI = 0.22, 1.75, p = 0.012 for the fixed and random effect model). Bilateral ECT-treated patients had larger increase than unilateral ECT-treated patients (SMD = -0.81, 95%CI = -1.35, -0.27, p = 0.003 and -0.86, 95%CI = -1.46, -0.25, p = 0.006 for the fixed and random-effect model). Comparisons between high- and low-dose ECT-treated patients could not be conducted. The quality of the studies was overall poor, with four exceptions.
DISCUSSION
Patients receiving ECT had larger prolactin increases than controls. Increases were larger in methohexital-premedicated patients, women vs. men and patients with bilateral vs. unilateral ECT.
Topics: Electroconvulsive Therapy; Female; Humans; Male; Prolactin
PubMed: 32516627
DOI: 10.1016/j.jpsychires.2020.05.024 -
Scientific Reports Jan 2016The aim of this study was to assess the efficacy and tolerability/acceptability of 6 anesthetic agents in ECT for depressive disorders. We systematically reviewed 14... (Meta-Analysis)
Meta-Analysis Review
The aim of this study was to assess the efficacy and tolerability/acceptability of 6 anesthetic agents in ECT for depressive disorders. We systematically reviewed 14 double-blind randomized controlled trials (610 participants). Efficacy was measured by the mean scores on validated depression scales at 6 ECT (or the nearest score if not available), number of responders at the end of treatment and seizure duration. The acceptability was measured by the proportion of patients who dropped out of the allocated treatment, and the tolerability by the number of serious adverse events and post-treatment cognition assessment. After excluding the trials responsible for heterogeneity, depression scores of patients who were administered methohexital were found to be significantly more improved than those who received propofol (p = 0.001). On the contrary, those who were administered propofol had lower depression scores than those with thiopental at the end of treatment (p = 0.002). Compared to propofol, methohexital was found to be significantly associated with higher seizure duration (p = 0.018). No difference was found for the acceptability profile (all p > 0.05). In summary, ketamine and methohexital may be preferred to propofol or thiopental in regard of effectiveness in depression scores and increased seizure duration. Further studies are warranted to compare ketamine and methohexital.
Topics: Anesthetics; Bayes Theorem; Depressive Disorder, Major; Electroconvulsive Therapy; Electroencephalography; Humans; Ketamine; Methohexital; Randomized Controlled Trials as Topic; Seizures
PubMed: 26806849
DOI: 10.1038/srep19847 -
The Journal of ECT Dec 2015The optimum induction agent for anesthesia for electroconvulsive therapy (ECT) has been long debated. Ideal agent should be short acting with minimal suppression of... (Meta-Analysis)
Meta-Analysis Review
UNLABELLED
The optimum induction agent for anesthesia for electroconvulsive therapy (ECT) has been long debated. Ideal agent should be short acting with minimal suppression of seizure potentials. Recent studies have suggested longer seizure duration with etomidate in comparison to propofol, thiopental, and methohexital. The aim of the present meta-analysis was to pool data available from studies comparing systematically the efficacy of etomidate against other induction agents in terms of seizure duration (both electroencephalography (EEG) and motor).
METHODS
We searched the PubMed, Embase, and Cochrane registry for trials evaluating etomidate against methohexital, propofol, or thiopental for duration of EEG or motor seizure in patients undergoing ECT. Specific adverse effects reported were also identified.
RESULTS
Seventeen trials were identified involving 704, 84, 2491, and 258 setting of ECT using etomidate, methohexital, thiopental, and propofol, respectively. In the etomidate group, pooled EEG seizure duration was longer by 2.23 seconds (95% confidence interval [CI], -3.62 to 8.01; P = 0.456) than methohexital, longer by 17.65 seconds (95% CI, 9.72-25.57; P < 0.001) than propofol, and longer by 11.81 seconds (95% CI, 4.26-19.35; P = 0.003) than thiopental. Pooled motor seizure duration was longer in etomidate group by 1.45 seconds (95% CI, -4.79 to 7.69; P = 0.649) than methohexital, longer by 11.13 seconds (95% CI, 6.64-15.62; P < 0.001) than propofol, and longer by 3.60 seconds (95% CI, 2.15-5.06; P < 0.001) than thiopental. Myoclonus (6 trials) and painful injection (4 trials) were commonest adverse effects with etomidate.
CONCLUSIONS
Etomidate is clearly better in terms of seizure duration potential (both motor and EEG) than propofol and thiopental. Superiority/inferiority over methohexital could not be demonstrated with the presently available literature.
Topics: Electroconvulsive Therapy; Electroencephalography; Etomidate; Humans; Hypnotics and Sedatives; Seizures
PubMed: 25634566
DOI: 10.1097/YCT.0000000000000212 -
Epilepsy & Behavior : E&B May 2021Intraoperative electrocorticography (ECoG) is a useful technique to guide resections in epilepsy surgery and is mostly performed under general anesthesia. In this... (Review)
Review
Intraoperative electrocorticography (ECoG) is a useful technique to guide resections in epilepsy surgery and is mostly performed under general anesthesia. In this systematic literature review, we seek to investigate the effect of anesthetic agents on the quality and reliability of ECoG for localization of the epileptic focus. We conducted a systematic search using PubMed and EMBASE until January 2019, aiming to review the effects of anesthesia on ECoG yield. Fifty-eight studies were included from 1016 reviewed. There are favorable reports for dexmedetomidine and remifentanil during ECoG recording. There is inadequate, or sometimes conflicting, evidence to support using enflurane, isoflurane, sevoflurane, and propofol. There is evidence to avoid halothane, nitrous oxide, etomidate, ketamine, thiopental, methohexital, midazolam, fentanyl, and alfentanil due to undesired effects. Depth of anesthesia, intraoperative awareness, and surgical outcomes were not consistently evaluated. Available studies provide helpful information about the effect of anesthesia on ECoG to localize the epileptic focus. The proper use of anesthetic agents and careful dose titration, and effective communication between the neurophysiologist and anesthesiologist based on ECoG activity are essential in optimizing recordings. Anesthesia is a crucial variate to consider in the design of studies investigating ECoG and related biomarkers.
Topics: Electrocorticography; Electroencephalography; Epilepsy; Humans; Isoflurane; Reproducibility of Results
PubMed: 33819715
DOI: 10.1016/j.yebeh.2021.107902 -
The Cochrane Database of Systematic... 2000Raised intracranial pressure (ICP) is an important complication of severe brain injury, and is associated with a high mortality rate. Barbiturates are believed to reduce... (Review)
Review
BACKGROUND
Raised intracranial pressure (ICP) is an important complication of severe brain injury, and is associated with a high mortality rate. Barbiturates are believed to reduce intracranial pressure by suppressing cerebral metabolism, thus reducing cerebral metabolic demands and cerebral blood volume. However, barbiturates also reduce blood pressure and therefore may adversely effect cerebral perfusion pressure.
OBJECTIVES
To assess the effects of barbiturates in reducing raised intracranial pressure, mortality and morbidity in people with acute traumatic brain injury. To quantify any side effects resulting from the use of barbiturates.
SEARCH STRATEGY
The review draws largely on the search strategy developed for the Cochrane Injuries Group as a whole. However, in addition the Cochrane Library was searched in December 1996 using the text terms "barbiturate*," "pentobarb*," "phenobarb*," "head," and "brain." An updated search was done in April 1999.
SELECTION CRITERIA
Randomised or quasi randomised trials of any one or more of the barbiturate class of drugs (amobarbital, barbital, hexobarbital, mephobarbital, methohexital, murexide, pentobarbital, phenobarbital, secobarbital, thiobarbiturate) where study participants had a clinically diagnosed acute traumatic brain injury of any severity.
DATA COLLECTION AND ANALYSIS
The reviewer extracted the data and assessed the quality of allocation concealment in the trials.
MAIN RESULTS
The pooled relative risk for death (barbiturate vs no barbiturate) was 1.09 (95%CI 0.81 to 1.47). The pooled effect of barbiturates on adverse neurological outcome, measured using the Glasgow Outcome Scale (death, persistent vegetative state or severe disability) was 1.15 (95% 0.81 to 1.64). Two studies examined the effect of barbiturate therapy on intracranial pressure. In the study by Eisenberger et al, a smaller proportion of patients in the barbiturate group had uncontrolled ICP (68% vs 83%). The relative risk for uncontrolled ICP was 0.81 (95%CI 0.62 to 1.06). Similarly, in the study by Ward et al, mean ICP was lower in the barbiturate treated group. Barbiturate therapy results in an increase in the occurrence of hypotension (RR=1.80 95%CI 1.19 to 2.70). For every four patients treated one will develop clinically significant hypotension. Mean body temperature was significantly lower in the barbiturate treated group. Schwartz et al compared pentobarbital with mannitol in the control of intracranial pressure. Pentobarbital was less effective than mannitol for control of raised ICP. 68% of patients in the pentobarbital treated group required a second drug for the treatment of raised intracranial pressure compared to 39% in the mannitol treated group (RR=1.75 95%CI 1.05 to 2.92). There was no substantial difference in mortality between the two study groups (RR=1.18 95%CI 0.73 to 1.92).
REVIEWER'S CONCLUSIONS
There is no evidence that barbiturate therapy in patients with acute severe head injury improves outcome. Barbiturate therapy results in a fall in blood pressure in 1 in 4 treated patients. The hypotensive effect of barbiturate therapy will offset any ICP lowering effect on cerebral perfusion pressure.
Topics: Barbiturates; Brain Injuries; Central Nervous System Agents; Cerebrovascular Circulation; Humans; Intracranial Hypertension; Risk
PubMed: 10796689
DOI: 10.1002/14651858.CD000033 -
The Cochrane Database of Systematic... Apr 2014Depression is a common mental disorder. It affects millions of people worldwide and is considered by the World Health Organization (WHO) to be one of the leading causes... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Depression is a common mental disorder. It affects millions of people worldwide and is considered by the World Health Organization (WHO) to be one of the leading causes of disability. Electroconvulsive therapy (ECT) is a well-established treatment for severe depression. Intravenous anaesthetic medication is used to minimize subjective unpleasantness and adverse side effects of the induced tonic-clonic seizure. The influence of different anaesthetic medications on the successful reduction of depressive symptoms and adverse effects is unclear.
OBJECTIVES
This review evaluated the effects of different regimens of intravenous sedatives and hypnotics on anti-depression efficacy, recovery and seizure duration in depressed adults undergoing ECT.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12); MEDLINE via Ovid SP (from 1966 to 31 December 2012); and EMBASE via Ovid SP (from 1966 to 31 December 2012). We handsearched related journals and applied no language restrictions.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) and cross-over trials evaluating the effects of different intravenous sedatives and hypnotics for ECT. We excluded studies and trials using placebo or inhalational anaesthetics and studies that used no anaesthetic.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trial quality and extracted data. When possible, data were pooled and risk ratios (RRs) and mean differences (MDs), each with 95% confidence intervals (CIs), were computed using the Cochrane Review Manager statistical package (RevMan).
MAIN RESULTS
We included in the review 18 RCTs (599 participants; published between 1994 and 2012). Most of the included trials were at high risk of bias.We analysed the results of studies comparing six different intravenous anaesthetics.Only a few studies comparing propofol with methohexital (four studies) and with thiopental (three studies) could be pooled.No difference was noted in the reduction of depression scores observed in participants treated with propofol compared with methohexital (low-quality evidence). These four studies were not designed to detect differences in depression scores.The duration of electroencephalograph (EEG) and of motor seizures was shorter in the propofol group compared with the methohexital group (low-quality evidence). No difference was seen in EEG seizure duration when propofol was compared with thiopental (low-quality evidence).Time to recovery (following commands) was longer among participants after anaesthesia with thiopental compared with propofol (low-quality evidence).For the remaining comparisons of anaesthetics, only single studies or insufficient data were available. Adverse events were inadequately reported in eligible trials, and none of the included trials reported anaesthesia-related mortality.
AUTHORS' CONCLUSIONS
Most of the included studies were at high risk of bias, and the quality of evidence was generally low. The studies were not designed to detect clinically relevant differences in depression scores. Anaesthetic agents should be chosen on the basis of adverse effect profile, emergence and how these medications affect seizure duration. If it is difficult to elicit an adequately long seizure, methohexital may be superior to propofol (low-quality evidence). If a patient is slow to recover from anaesthesia, propofol may allow a faster time to follow commands than thiopental (low-quality evidence). A factor of clinical concern that was not addressed by any study was adrenal suppression from etomidate. Optimal dosages of intravenous sedatives or hypnotics have not yet been determined.Larger well-designed randomized studies are needed to determine which intravenous anaesthetic medication leads to the greatest improvement in depression scores with minimal adverse effects.
Topics: Adult; Anesthetics, Intravenous; Depression; Electroconvulsive Therapy; Epilepsy, Tonic-Clonic; Etomidate; Humans; Hypnotics and Sedatives; Methohexital; Midazolam; Propofol; Randomized Controlled Trials as Topic; Thiamylal; Thiopental
PubMed: 24723301
DOI: 10.1002/14651858.CD009763.pub2 -
The Journal of Emergency Medicine Jul 2018Per rectum (PR) medication delivery is an alternative to traditional oral (PO), intravenous (IV), or intramuscular (IM) administration of medication for procedural... (Review)
Review
BACKGROUND
Per rectum (PR) medication delivery is an alternative to traditional oral (PO), intravenous (IV), or intramuscular (IM) administration of medication for procedural sedation of pediatric emergency department patients. However, many emergency physicians are unfamiliar with its use, and there are no widely adopted guidelines or reviews dedicated to this topic.
OBJECTIVE
Our aim was to provide emergency physicians with an overview of PR procedural sedation medications in pediatric patients.
METHODS
We performed a PubMed literature search of relevant keywords limited to studies of human subjects published in English between January 1, 1990 and December 31, 2017. We excluded case reports, general review articles, editorial/opinion pieces, correspondence, and abstracts. Two of the authors then conducted a structured review of the selected studies.
RESULTS
A total of 315 PubMed citations meeting the search criteria were found. Twenty-eight articles were included for final detailed review. Only 4 of the 28 included studies were conducted in the emergency department setting. A total of 9 different medications have been studied for PR procedural sedation. Sedation effectiveness ranged from 40% to 98%. No life-threatening complications were reported in any of the included clinical trials. Hypoxia was found to occur in up to 10% of those receiving PR sedation.
CONCLUSIONS
Pediatric procedural sedation with PR medications appears to be feasible, moderately effective, and safe based on our review of the current literature. However, further studies on its applicability in the emergency department setting are needed.
Topics: Administration, Rectal; Chloral Hydrate; Conscious Sedation; Diazepam; Emergency Service, Hospital; Humans; Hypnotics and Sedatives; Ketamine; Methohexital; Midazolam; Pediatrics
PubMed: 29805070
DOI: 10.1016/j.jemermed.2018.04.025 -
Acta Neuropsychiatrica Apr 2018The objective of this review is to investigate existing literature in order to delineate whether the use of anaesthesia and timing of seizure induction in a new and... (Review)
Review
OBJECTIVE
The objective of this review is to investigate existing literature in order to delineate whether the use of anaesthesia and timing of seizure induction in a new and optimised way may improve the efficacy of electroconvulsive therapy (ECT).
METHODS
PubMed/MEDLINE was searched for existing literature, last search on 24 June 2015. Relevant clinical studies on human subjects involving choice of anaesthetic, ventilation and bispectral index (BIS) monitoring in the ECT setting were considered. The references of relevant studies were likewise considered.
RESULTS
Propofol yields the shortest seizures, etomidate and ketamine the longest. Etomidate and ketamine+propofol 1 : 1 seems to yield the seizures with best quality. Seizure quality is improved when induction of ECT is delayed until the effect of the anaesthetic has waned - possibly monitored with BIS values. Manual hyperventilation with 100% O2 may increase the pO2/pCO2-ratio, which may be correlated with better seizure quality.
CONCLUSION
Etomidate or a 1 : 1 ketamine and propofol combination may be the best method to achieve general anaesthesia in the ECT setting. There is a need for large randomised prospective studies comparing the effect of methohexital, thiopental, propofol, ketamine, propofol+ketamine 1 : 1 and etomidate in the ECT treatment of major depressed patients. These studies should investigate safety and side effects, and most importantly have antidepressant efficacy and cognitive side effects as outcome measures instead of seizure quality.
Topics: Anesthesia, General; Anesthetics, Intravenous; Consciousness Monitors; Depressive Disorder, Major; Electroconvulsive Therapy; Humans; Prospective Studies; Retrospective Studies; Seizures; Treatment Outcome
PubMed: 28462732
DOI: 10.1017/neu.2017.12 -
Anesthesia and Analgesia Jan 2020Electroconvulsive therapy (ECT) is indicated in a myriad of pediatric psychiatric conditions in children, and its use is increasing. Literature on the clinical features...
Electroconvulsive therapy (ECT) is indicated in a myriad of pediatric psychiatric conditions in children, and its use is increasing. Literature on the clinical features salient to anesthetic care is lacking. The objective of this systematic review is to describe the available literature on the anesthetic considerations of pediatric ECT. Original publications were screened for inclusion criteria: (1) manuscript written in English; (2) persons under 18 years of age; and (3) use of ECT. Data tabulation included demographic information, details of anesthetic management and ECT procedure, and adverse events. The mean age was 15 years, 90% were 12-17 years of age, and no cases involving children <6 years of age were identified. The psychiatric diagnoses most commonly represented were major depressive disorder (n = 185) and schizophrenia/schizoaffective disorders (n = 187). ECT was also used to treat many neurological disorders. Medical comorbidities were reported in 16% of all cases. Common coexisting conditions included developmental delay (n = 21) and autism (n = 18). Primary ECT indications included severe psychosis (n = 190), symptoms refractory to pharmacotherapy (n = 154), and suicidality (n = 153). ECT courses per patient ranged from 2 to 156. Duration averaged 91.89 ± 144.3 seconds. The most commonly reported induction agents were propofol and methohexital, and the most commonly reported paralytic agent was succinylcholine. Reported adverse events included headache, nausea, sedation, and short-term amnesia, as well as rare cases of benign dysrhythmias and prolonged seizure. Negative perception and diminished access to care result in treatment delays; thus, these children present in an advanced state of disease. In examining the details of modern ECT performed in 592 children, no major anesthetic morbidity was identified. Further study should start with retrospective analysis of anesthesia data during ECT to compare various effects of anesthesia medications and technique on adverse events and outcomes.
Topics: Adolescent; Adolescent Behavior; Age Factors; Anesthesia, General; Anesthetics, General; Brain; Child; Child Behavior; Electroconvulsive Therapy; Female; Humans; Male; Mental Disorders; Neuromuscular Blockade; Neuromuscular Blocking Agents; Risk Factors; Treatment Outcome
PubMed: 31425262
DOI: 10.1213/ANE.0000000000004337 -
The Journal of ECT Sep 2008Our primary objective was to conduct a systematic review to determine the differential effects of general anesthetic agents on electroconvulsive therapy (ECT) induced... (Review)
Review
OBJECTIVES
Our primary objective was to conduct a systematic review to determine the differential effects of general anesthetic agents on electroconvulsive therapy (ECT) induced motor and electroencephalogram seizure duration. Our secondary objective was to determine the differential effects of induction agents on emergence time, recovery time, and the occurrence of adverse cardiac events and drug effects.
MATERIALS AND METHODS
We searched 4 electronic databases for randomized, crossover, and parallel trials. The weighted mean difference was calculated for continuous variables, whereas the risk difference was assessed for dichotomous variables. We combined crossover- and parallel-designed trials using the inverse variance method, and the random-effects model was used throughout.
RESULTS
Forty-one randomized trials involving 14 induction agents were included. The quality of trials was poor. Clinical and statistical heterogeneity were identified throughout. The most commonly studied comparison was methohexital versus propofol, where the mean motor seizure duration with methohexital was longer compared with that of propofol (weighted mean difference, 9.06 seconds; 95% confidence interval, 5.72-12.40). However, combining methohexital or propofol with a short-acting opioid prolonged seizure duration. Small but significant variations in emergence and recovery times were identified. Inadequate data were available to draw conclusions regarding adverse cardiac events and drug effects. No deaths were reported.
CONCLUSIONS
Whereas the relationship between ECT seizure length and efficacy remains unclear, all of the available induction agents in this review would be appropriate for ECT. When the clinician needs to prolong seizure length, methohexital or the addition of a short-acting opioid to methohexital or propofol should be considered. The small variations in emergence and recovery times should not govern the choice of an induction agent.
Topics: Anesthetics, Combined; Anesthetics, General; Cross-Over Studies; Electroconvulsive Therapy; Electroencephalography; Heart; Humans; Randomized Controlled Trials as Topic; Seizures; Time Factors; Treatment Outcome
PubMed: 18628717
DOI: 10.1097/YCT.0b013e31815bfe2a