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Journal of Anesthesia, Analgesia and... Feb 2024Electroconvulsive therapy (ECT) endures as a definitive treatment for refractory depression and catatonia and is also considered an effective treatment for a number of...
BACKGROUND
Electroconvulsive therapy (ECT) endures as a definitive treatment for refractory depression and catatonia and is also considered an effective treatment for a number of other severe psychiatric disorders (Lisanby, N Engl J Med 357:1939-1945, 2007)(Weiner and Prudic, Biol Psychiatry 73:105-106, 2013). GA is an essential component of the ECT procedure for various reasons (Lee, Jenkins and Sparkle, Life 11, 2021). Monitoring anesthetic effects on the brain is desirable as anesthetic agents affect seizure duration and recovery (Rasulo, Hopkins, Lobo, et al, Neurocrit Care 38:296-311, 2023) (Jones , Nittur , Fleming and Applegate, BMC Anesthesiol 21:105, 2021) (Soehle , Kayser , Ellerkmann and Schlaepfer, BJA 112:695-702, 2013). Perioperative anesthetic effects on consciousness can be assessed with brain function monitoring using raw electroencephalogram (EEG) traces and processed EEG indices.
OBJECTIVE
We examined the usefulness and utility of the SedLine anesthetic effect monitor during ECT procedures. We hypothesized that the seizure duration as measured by the EEG tracing of the ECT machine is equivalent to the duration assessed by the SedLine EEG tracing. A secondary objective was to describe the SedLine patient state indices (PSI) at different phases of treatment.
METHODS
Following IRB approval, we analyzed the data of the electronic medical records of 45 ECT treatments of 23 patients in an urban VA medical center between July 01, 2021, and March 30, 2022. We compared the seizure duration in minutes and seconds as measured either by the ECT machine EEG tracing or the SedLine EEG tracing. We then collected SedLine processed EEG indices at four different stages during the treatment. Appropriate comparative and observational statistical analyses were applied.
RESULTS
There was no significant difference in measured seizure duration between the two methods examined (p < 0.05). We observed a lag of the SedLine PSI value at the time before stimulus delivery and limited PSI utility during the course of ECT.
CONCLUSION
The SedLine EEG tracing can be an alternative to the machine EEG tracing for the determination of seizure duration. The SedLine processed EEG indices are not consistently useful before and after ECT delivery. Anesthetic effect monitoring during ECT is feasible.
PubMed: 38321515
DOI: 10.1186/s44158-024-00143-9 -
Pharmacopsychiatry Jul 2023The effectiveness of ECT relies on the induction of a generalized cerebral seizure. Among others, seizure quality (SQ) is potentially influenced by the anesthetic drug...
INTRODUCTION
The effectiveness of ECT relies on the induction of a generalized cerebral seizure. Among others, seizure quality (SQ) is potentially influenced by the anesthetic drug used. Commonly used anesthetics comprise barbiturates, etomidate, propofol, and esketamine, with different characteristics and impacts on seizure parameters. So far, no studies have compared the influence of methohexital vs. a combination of propofol/esketamine on established SQ parameters.
METHODS
This retrospective longitudinal study compared eight established SQ parameters (PSI, ASEI, MSC, midictal amplitude, motor and electroencephalography (EEG) seizure duration, concordance, PHR) before and after the change from propofol/esketamine to methohexital in 34 patients under maintenance ECT. Each patient contributed four measurements, two before and two after the anesthesia change. Anesthesia dose, stimulus dose, electrode placement, and concomitant medication remained unchanged throughout the analyzed treatments.
RESULTS
Under methohexital (=88.97 mg), ASEI (=0.039 to 0.013) and midictal amplitude (=0.022 to<0.001) were significantly lower, whereas seizure duration (motor and EEG) was significantly longer when compared to propofol/esketamine (M=64.26 mg/51.18 mg; =0.012 to<0.001). PSI, MSC, seizure concordance, and PHR were not affected by the anesthetic used.
DISCUSSION
Although to what extent these parameters correlate with the therapeutic effectiveness remains ambiguous, a decision for or against a particular anesthetic could be considered if a specific SQ parameter needs optimization. However, no general superiority for one specific substance or combination was found in this study. In the next step, anesthetic effects on treatment response and tolerability should be focused on.
Topics: Humans; Propofol; Methohexital; Anesthetics, Intravenous; Retrospective Studies; Longitudinal Studies; Electroconvulsive Therapy; Seizures; Electroencephalography; Anesthesia
PubMed: 37116539
DOI: 10.1055/a-2058-9010 -
Journal of Affective Disorders Jun 2023The ideal hypnotic agent for electroconvulsive therapy (ECT) is still under debate and previous studies comparing etomidate and methohexital have produced conflicting...
Comparison of etomidate and methohexital as anesthetic agents for continuation and maintenance electroconvulsive therapy: A retrospective analysis of seizure quality and safety.
BACKGROUND
The ideal hypnotic agent for electroconvulsive therapy (ECT) is still under debate and previous studies comparing etomidate and methohexital have produced conflicting results. This retrospective study compares etomidate and methohexital as anesthetic agents in continuation and maintenance (m)ECT with regard to seizure quality and anesthetic outcomes.
METHODS
All subjects undergoing mECT at our department between October 1st, 2014 and February 28th, 2022 were included in this retrospective analysis. Data for each ECT session were obtained from the electronic health records. Anesthesia was performed with either methohexital/succinylcholine or etomidate/succinylcholine. Standard seizure quality parameters, anesthesiological monitoring data, pharmacological interventions and side-effects were recorded.
RESULTS
573 mECT treatments in 88 patients were included (methohexital n = 458, etomidate n = 115). Seizures lasted significantly longer after using etomidate (electroencephalography: +12.80 s [95 %-CI:8.64-16.95]; electromyogram +6.59 s [95 %-CI:4.14-9.04]). Time to maximum coherence was significantly longer with etomidate (+7.34 s [95 %-CI:3.97-10.71]. Use of etomidate was associated with longer procedure duration (+6.51 min [95 %-CI:4.84-8.17]) and higher maximum postictal systolic blood pressure (+13.64 mmHg [95 %-CI:9.33-17.94]). Postictal systolic blood pressure > 180 mmHg, the use of antihypertensives, benzodiazepines and clonidine (for postictal agitation), as well as the occurrence of myoclonus was significantly more common under etomidate.
CONCLUSIONS
Due to longer procedure duration and an unfavorable side effect profile, etomidate appears inferior to methohexital as an anesthetic agent in mECT despite longer seizure durations.
Topics: Humans; Etomidate; Methohexital; Retrospective Studies; Anesthetics, Intravenous; Electroconvulsive Therapy; Succinylcholine; Seizures; Electroencephalography
PubMed: 36863475
DOI: 10.1016/j.jad.2023.02.085 -
The Journal of ECT Jun 2023Etomidate and methohexital are the 2 commonly used anesthetics for electroconvulsive therapy (ECT) in the United States. The objective of this study was to examine how...
OBJECTIVE
Etomidate and methohexital are the 2 commonly used anesthetics for electroconvulsive therapy (ECT) in the United States. The objective of this study was to examine how anesthetic choice between etomidate and methohexital is associated with real-world clinical outcomes.
METHODS
This naturalistic retrospective cohort study examined longitudinal electronic health records for 495 adult patients who received 2 or more ECT treatments from 2010 to 2019 in Kaiser Permanente North California, a large integrated health care system. Study outcomes included 12-month posttreatment depression remission as measured by the 9-item Patient Health Questionnaire, psychiatric and all-cause emergency department visits, and psychiatric and all-cause hospitalizations.
RESULTS
Anesthetic choice was not significantly related to depression severity, emergency department visits, or psychiatric hospitalizations at 12 months after completing ECT. In exploratory analyses, we found that etomidate compared with methohexital was associated with higher rates of patient discomfort adverse effects-postictal agitation, phlebitis, and myoclonus (2.4% vs 0.4%; P < 0.001).
CONCLUSIONS
We present the first large comparison of etomidate and methohexital as anesthetics for ECT and their associations with real-world outcomes. Our study showed no significant difference on depression remission, emergency department visits, or hospitalizations 12-months posttreatment. Thus, clinicians should focus on other patient or treatment characteristics when deciding on anesthetics for ECT. Further investigation is needed to confirm our exploratory findings that etomidate use was correlated with a higher rate of patient discomfort adverse effects relative to methohexital.
Topics: Adult; Humans; Anesthetics, Intravenous; Etomidate; Methohexital; Electroconvulsive Therapy; Propofol; Retrospective Studies
PubMed: 36729716
DOI: 10.1097/YCT.0000000000000895 -
Journal of the American Heart... Oct 2022Background Methohexital and propofol can both be used as sedation for direct current cardioversion (DCCV). However, there are limited data comparing these medications in... (Randomized Controlled Trial)
Randomized Controlled Trial
Background Methohexital and propofol can both be used as sedation for direct current cardioversion (DCCV). However, there are limited data comparing these medications in this setting. We hypothesized that patients receiving methohexital for elective DCCV would be sedated more quickly, recover from sedation faster, and experience less adverse effects. Methods and Results This was a prospective, blinded randomized controlled trial conducted at a single academic medical center. Eligible participants were randomly assigned to receive either methohexital (0.5 mg/kg) or propofol (0.8 mg/kg) as a bolus for elective DCCV. The times from bolus of the medication to achieving a Ramsay Sedation Scale score of 5 to 6, first shock, eyes opening on command, and when the patient could state their age and name were obtained. The need for additional medication dosing, airway intervention, vital signs, and medication side effects were also recorded. Seventy patients who were randomized to receive methohexital (n=37) or propofol (n=33) were included for analysis. The average doses of methohexital and propofol were 0.51 mg/kg and 0.84 mg/kg, respectively. There were no significant differences between methohexital and propofol in the time from end of injection to loss of conscious (1.4±1.8 versus 1.1±0.5 minutes; =0.33) or the time to first shock (1.7±1.9 versus 1.4±0.5 minutes; =0.31). Time intervals were significantly lower for methohexital compared with propofol in the time to eyes opening on command (5.1±2.5 versus 7.8±3.7 minutes; =0.0005) as well as at the time to the ability to answer simple questions of age and name (6.0±2.6 versus 8.6±4.0 minutes; =0.001). The methohexital group experienced less hypotension (8.1% versus 42.4%; <0.001) and less hypoxemia (0.0% versus 15.2%; =0.005), had lower need for jaw thrust/chin lift (16.2% versus 42.4%; =0.015), and had less pain on injection compared with propofol using the visual analog scale (7.2±9.7 versus 22.4±28.1; =0.003). Conclusions In this model of fixed bolus dosing, methohexital was associated with faster recovery, more stable hemodynamics, and less hypoxemia after elective DCCV compared with propofol. It can be considered as a preferred agent for sedation for DCCV. Registration URL: https://www.clinicaltrials.gov/ct; Unique identifier: NCT04187196.
Topics: Electric Countershock; Humans; Hypoxia; Methohexital; Propofol; Prospective Studies
PubMed: 36129031
DOI: 10.1161/JAHA.122.026198 -
BMC Anesthesiology Jul 2022Many of the anaesthetic drugs used for electroconvulsive therapy have anticonvulsant properties and may influence efficacy of electroconvulsive therapy. With this study...
BACKGROUND
Many of the anaesthetic drugs used for electroconvulsive therapy have anticonvulsant properties and may influence efficacy of electroconvulsive therapy. With this study we aim to provide more information on the effect of etomidate and methohexital on seizure duration. We explore the relationship between induction drug, motor and electroencephalography seizure duration. Moreover, we study the relationship of seizure duration and number of therapies.
METHODS
In this retrospective study we collected data from patient records from 2005 until 2016. Inclusion criteria were the use of etomidate and/or methohexital and documentation of dosage, electroconvulsive therapy dosage and seizure duration. Exclusion criteria were missing data on either induction drug, dosage or seizure duration.
RESULTS
Thirty seven patients were analysed. The mean age was 52 years and seventy six percent were female. Most patients were suffering from affective disorders (81%). Motor and electroencephalography seizure duration were analysed in 679 and 551 electroconvulsive therapies, respectively. Compared to methohexital, motor and electroencephalography seizures under etomidate were 7 and 13 s longer, respectively. Furthermore, there was a negative association between seizure duration and number of treatment and a negative association between seizure duration and electroconvulsive therapy dosage.
CONCLUSIONS
This study demonstrates significant longer motor and electroencephalography seizure duration using etomidate compared to methohexital. Etomidate might therefore increase the effectiveness of electroconvulsive therapy. Moreover, we observed a negative association between seizure duration, number of treatment and electroconvulsive therapy dosage. With this study we contribute to the available literature comparing methohexital and etomidate as induction agents for electroconvulsive therapy.
Topics: Anesthetics, Intravenous; Electroconvulsive Therapy; Etomidate; Female; Humans; Male; Methohexital; Middle Aged; Retrospective Studies; Seizures
PubMed: 35790907
DOI: 10.1186/s12871-022-01745-y -
Life (Basel, Switzerland) Sep 2021Electroconvulsive therapy (ECT) is a definitive treatment for patients with psychiatric disorders that are severe, acute, or refractory to pharmacologic therapy.... (Review)
Review
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.
PubMed: 34575130
DOI: 10.3390/life11090981 -
Clinical Neurophysiology Practice 2021The Wada test is used to evaluate language lateralization and memory performance after inactivation of an isolated cerebral hemisphere. Methohexital a short-acting...
OBJECTIVE
The Wada test is used to evaluate language lateralization and memory performance after inactivation of an isolated cerebral hemisphere. Methohexital a short-acting barbiturate has a history of use to induce interictal discharges during intraoperative corticography. We report a new finding of activation of lateralized periodic discharges (LPDs) after Methohexital injection.
METHODS
We retrospectively reviewed 174 consecutive adult patients who underwent Wada testing in preparation for epilepsy surgery (N = 129, 74%) or brain tumor resection (N = 45, 26%) at the University of Michigan to determine the frequency of induced periodic discharges by methohexital.
RESULTS
Four epilepsy patients (2.29%) had methohexital-induced LPDs within a median of 2 s (1-99 s) of the injection and lasting a median of 4 min (3-10 min) after a total of 7 injections. All LPDs occurred ipsilateral to the injection hemisphere in the known region of interictal epileptiform discharges. LPDs were not induced in brain tumor patients. In one patient, LPDs occurred during memory testing, and this patient's memory performance was below expectation based on pre-test neuropsychological testing.
CONCLUSIONS
Methohexital can induce LPDs in ipsilateral hemisphere and that can potentially affect memory performance.
SIGNIFICANCE
This observation indicates that concurrent EEG monitoring during the Wada test is important and that induced discharges should be considered when interpreting Wada test results.
PubMed: 34409239
DOI: 10.1016/j.cnp.2021.07.002