Anesthesia for electroconvulsive therapy

ECT is a simple procedure performed on a highly diverse patient population with severe, drug-resistant depression and other psychiatric disorders (Table 5). Despite its proven effectiveness, ECT remains one of the most controversial treatments in all of medicine (126). When appropriately administered, ECT is an extremely safe and effective procedure in a wide variety of high-risk patient populations (127). Unfortunately, the relapse rate during the 6- to 12-mo period after completion of an acute course of ECT exceeds 50% unless the patient receives maintenance ECT or combination pharmacotherapy (128). The anesthetic management for ECT typically involves the use of an induction dose of an IV anesthetic (e.g., methohexital or propofol) followed by a muscle relaxant (e.g., succinylcholine or mivacurium). A wide variety of cardiovascular drugs (e.g., esmolol or labetalol) are administered to minimize the acute hemodynamic changes produced by the electrical stimulus and the resultant generalized seizure activity. Standard noninvasive monitors are used during the procedure, and the airway is typically managed with a face mask. An antisialagogue (e.g., glycopyrrolate) is used to decrease oral secretion, and a Guedel airway device may be used in patients prone to upper airway obstruction (e.g., those with sleep apnea syndrome or who are morbidly obese). The availability of new brain monitors (e.g., EEG bispectral index, patient state index, auditory evoked potential index) (129) may improve the ability of anesthesiologists to titrate anesthetic drugs to optimize the conditions for ECT. The optimal dosages of the anesthetic, muscle relaxant, and sympatholytic drugs require careful titration to the needs of the individual patient, and further adjustments should be made during the course of a series of ECT treatments on the basis of the patient's earlier responses. In a recent editorial by Kellner (130), a simple modal approach to ECT treatment was advocated. Unfortunately, patients vary widely in their sensitivity to these drugs, depending on their age, body habitus, concurrent drug usage, and underlying medical conditions. Given the large number of elderly patients with underlying cardiovascular diseases (e.g., hypertension, coronary artery disease, and peripheral vascular disease), careful titration of the patients' sympatholytic drugs (e.g., labetalol, esmolol, nicardipine, and clonidine) is also important to obtain the best possible outcome with ECT. The "one size fits all" approach advocated by Kellner (130) is not supported by scientific data and would result in suboptimal care for many patients undergoing ECT treatments in the future. In conclusion, practicing anesthesiologists should be aware of the anesthetic factors that influence the duration of seizure activity, because the effectiveness of ECT treatments is predicated on achieving an adequate EEG seizure (>30 s). Because these patients may be receiving a wide variety of psychotropic and cardiovascular drugs, anesthesiologists should also be aware of potential adverse drug interactions. Despite the advanced age and presence of coexisting medical diseases in many patients undergoing ECT treatments, this therapy has remained remarkably safe and effective for treating severe depression.