Reconsideration of Augmentation Strategies in Electroconvulsive Therapy: Effects of the Concurrent Use of a Reduced Dose of Propofol with Divided Supplemental Remifentanil and Moderate Hyperventilation on Electroconvulsive Therapy-Induced Seizure Production and Adverse Events

Abstract

Background: Although several treatment strategies to enhance the efficacy of electroconvulsive therapy (ECT) have been discussed, there have been no reports on the combined use of these treatments. The purpose of this study was to evaluate the efficacy and safety of concurrent use of moderate hyperventilation and a reduced dose of propofol combined with divided remifentanil in ECT practice. Methods: Sixty patients scheduled to receive a total of 300 ECT treatments were randomly assigned to have the three interventions: a standard dose (1 mg/kg) of propofol (group P/N); a standard dose of propofol and moderate hyperventilation with end-tidal pressure of carbon dioxide (ETCO2) of 30 - 35 mmHg (group P/H); and a reduced dose (0.5 mg/kg) of propofol with divided supplemental remifentanil and moderate hyperventilation (group RP/H). Patients in group RP/H received remifentanil 1 μg/kg followed by propofol 0.5 mg/kg for unconsciousness and thereafter remifentanil 1 μg/kg immediately before the ECT stimulus. Results: Patients in group RP/H showed significantly longer durations of electroencephalographic (EEG) seizures in the early phase of ECT course (P < 0.01 and 0.05) and lower electrical stimulus in the late phase of ECT course (P < 0.05 in each) than those in groups P/N and P/H, respectively. Conclusions: The use of a reduced dose of propofol combined with divided supplemental remifentanil under moderate hyperventilation during ECT can offer advantages over the use of a standard dose of propofol with or without moderate hyperventilation in terms of more seizure augmentation and/or lower electrical stimulus.

Share and Cite:

Nishikawa, K. and Yamakage, M. (2015) Reconsideration of Augmentation Strategies in Electroconvulsive Therapy: Effects of the Concurrent Use of a Reduced Dose of Propofol with Divided Supplemental Remifentanil and Moderate Hyperventilation on Electroconvulsive Therapy-Induced Seizure Production and Adverse Events. Open Journal of Anesthesiology, 5, 219-226. doi: 10.4236/ojanes.2015.510040.

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1] American Psychiatric Association (2001) The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training and Privileging. American Psychiatric Press Inc., Washington DC.
[2] Colanda, C.C. and McDall, M.V. (1996) A Statistical Model Predicting the Seizure Threshold for Right Unilateral ECT in 106 Patients. Convulsive Therapy, 12, 3-12.
[3] Sackeim, H.A., Devanand, D.P. and Prodic, J. (1991) Stimulus Intensity, Seizure Threshold, and Seizureduration: Impact on the Efficacy and Safety of Electroconvulsive Therapy. Psychiatric Clinics of North America, 14, 803-843.
[4] Avramov, M.N., Husain, M.M. and White, P.F. (1995) The Comparative Effects of Methohexital, Propofol, and Etomidate for Electroconvulsive Therapy. Anesthesia and Analgesia, 81, 596-602.
[5] Ding, Z. and White, P.F. (2002) Anesthesia for Electroconvulsive Therapy. Anesthesia and Analgesia, 94, 1351-1364.
http://dx.doi.org/10.1097/00000539-200205000-00057
[6] Loo, C., Simpson, B. and MacPherson, R. (2010) Augmentation Strategies in Electroconvulsive Therapy. The Journal of ECT, 26, 202-207.
http://dx.doi.org/10.1097/YCT.0b013e3181e48143
[7] Chater, S.N. and Simpson, K.H. (1988) Effect of Passive Hyperventilation on Seizure Duration in Patients Undergoing Electroconvulsive Therapy. British Journal of Anaesthesia, 60, 70-73.
http://dx.doi.org/10.1093/bja/60.1.70
[8] Pande, A.C., Shea, J., Shettar, S., Grunhaus, L.J. and Haskett, R.F. (1990) Effect of Hyperventilation Onseizure Length during Electroconvulsive Therapy. Biological Psychiatry, 27, 799-801.
http://dx.doi.org/10.1016/0006-3223(90)90597-U
[9] Sawayama, E., Takahashi, M., Inoue, A., Nakajima, K., Kano, A., Sawayama, T., Okutomi, T. and Miyaoka, H. (2008) Moderate Hyperventilation Prolongs Electroencephalogram Seizure Duration of the First Electroconvulsive Therapy. The Journal of ECT, 24, 195-198.
http://dx.doi.org/10.1097/YCT.0b013e3181620815
[10] Recart, A., Rawal, S., White, P.F., Byerly, S. and Thornton, L. (2003) The Effect of Remifentanil on Seizure Duration and Acute Hemodynamic Responses to Electroconvulsive Therapy. Anesthesia and Analgesia, 96, 1047-1050.
http://dx.doi.org/10.1213/01.ANE.0000054002.65040.B3
[11] Vishne, T., Aronov, S., Amiaz, R., Etchin, A. and Grunhaus, L. (2005) Remifentanil Supplementation of Propofol during Electroconvulsive Therapy. The Journal of ECT, 21, 235-238.
http://dx.doi.org/10.1097/01.yct.0000180040.06338.ac
[12] Porter, R., Booth, D., Gray, H. and Frampton, C. (2008) Effects of the Addition of Remifentanil to Propofol Anesthesia on Seizure Length and Postictal Suppression Index in Electroconvulsive Therapy. The Journal of ECT, 24, 203-207.
http://dx.doi.org/10.1097/YCT.0b013e3181662ca0
[13] Chen, S.T. (2011) Remifentanil: A Review of Its Use in Electroconvulsive Therapy. The Journal of ECT, 27, 323-327.
http://dx.doi.org/10.1097/YCT.0b013e31821072d2
[14] Nishikawa, K., Higuchi, M., Kawagishi, T., Shimodate, Y. and Yamakage, M. (2011) Effect of Divided Supplementation of Remifentanil on Seizure Duration and Hemodynamic Responses during Electroconvulsive Therapy under Propofol Anesthesia. Journal of Anesthesia, 25, 29-33.
http://dx.doi.org/10.1007/s00540-010-1049-4
[15] Abdallah, C.G., Fasula, M., Kelmendi, B., Sanacora, G. and Ostroff, R. (2012) The Rapid Antidepressant Effect of Ketamine in the Electroconvulsive Therapy Setting. The Journal of ECT, 28, 157-161.
http://dx.doi.org/10.1097/YCT.0b013e31824f8296
[16] Rasmussen, K.G., Kung, S., Lapid, M.I., Oesterle, T.S., Geske, J.R., Nuttall, G.A., Oliver, W.C. and Abenstein, J.P. (2014) A Randomized Comparison of Ketamine versus Methohexital Anesthesia in Electroconvulsive Therapy. Psychiatry Research, 215, 362-365.
http://dx.doi.org/10.1016/j.psychres.2013.12.027
[17] Petrides, G. and Fink, M. (1996) The “Half-Age” Stimulation Strategy for ECT Dosing. Convulsive Therapy, 12, 138-146.
[18] Bayer, J.L., Weiner, R.D. and Glenn, M.D. (1998) Electroconvulsive Therapy: A Programmed Text, 2nd Edition, American Psychiatric Press Inc., Washington DC.
[19] Anderson, F.A., Arsland, D. and Holst-Larsen, H. (2001) Effects of Combined Methohexitone-Remifentanil Anesthesia in Electroconvulsive Therapy. Acta Anaesthesiologica Scandinavica, 45, 830-833.
http://dx.doi.org/10.1034/j.1399-6576.2001.045007830.x
[20] Sackeim, H.A., Prudic, J., Devavand, D.P., Kiersky, J.E., Fitzsimons, L., Moody, B.J., McElhiney, M.C., Coleman, E.A. and Settembrino, J.M. (1993) Effects of Stimulus Intensity and Electrode Placement on the Efficacy and Cognitive Effects of Electroconvulsive Therapy. The New England Journal of Medicine, 328, 839-846.
http://dx.doi.org/10.1056/NEJM199303253281204
[21] Bergsholm, P., Bleie, H., Gran, L. and d’Elia, G. (1993) Cardiovascular Response and Seizure Duration as Determined by Electroencephalography during Unilateral Electroconvulsive Therapy. Acta Psychiatrica Scandinavica, 88, 25-28.
http://dx.doi.org/10.1111/j.1600-0447.1993.tb03409.x
[22] Sackeim, H.A., Prudic, J., Devanand, D.P., Nobler, M.S., Lisanby, S.H., Peyser, S., Fitzsimons, L., Moody, B.J. and Clark, J. (2000) A Prospective, Randomized, Double-Blind Comparison of Bilateral and Right Unilateral Electroconvulsive Therapy at Different Stimulus Intensities. Archives of General Psychiatry, 57, 425-434.
http://dx.doi.org/10.1001/archpsyc.57.5.425
[23] Akcaboy, Z.N., Akcaboy, E.Y., Yigitbasi, B., Bayam, G., Dikmen, B., Gogus, N. and Dilbaz, N. (2005) Effects of Remifentanil and Alfentanil on Seizure Duration, Stimulus Amplitudes and Recovery Parameters during ECT. Acta Anaesthesiologica Scandinavica, 49, 1068-1071.
http://dx.doi.org/10.1111/j.1399-6576.2005.00766.x
[24] Hooten, W.M. and Rasmussen, K.G. (2008) Effects of General Anesthetic Agents in Adults Receiving Electroconvulsive Therapy: A Systematic Review. The Journal of ECT, 24, 208-223.
http://dx.doi.org/10.1097/YCT.0b013e31815bfe2a

Journals Menu
Follow SCIRP
Contact us

Copyright © 2021 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.