What is the recommended premedication regimen for electroconvulsive therapy (ECT)?

Electroconvulsive Therapy Premedication

Standard Premedication Regimen

The recommended premedication for ECT consists of an anesthetic agent (methohexital as first-line), a muscle relaxant (succinylcholine), and anticholinergic medication (atropine or glycopyrrolate), with 100% oxygen ventilation before electrical stimulus. 1

Core Medication Components

Anesthetic Agents

• Methohexital is the primary anesthetic agent of choice 1
• Acceptable alternatives include etomidate, thiopental sodium, and ketamine 1

Muscle Relaxants

• Succinylcholine is the standard muscle relaxant 1
• Alternative agents include atracurium and mivacurium 1

Anticholinergic Premedication

• Intravenous atropine or glycopyrrolate are acceptable anticholinergic medications administered immediately before ECT 1
• These agents prevent bradycardia, arrhythmia, and occasional ECT-induced cardiac asystole 1

Mandatory Anticholinergic Use

Premedication with atropine or glycopyrrolate is required in two specific situations:

• Before seizure threshold determination by dose titration method 1
• Before the first treatment with right unilateral electrode placement 1

The rationale is to protect the cardiovascular system from vagal discharge in instances of incomplete or missed seizures 1

Evidence Supporting Anticholinergic Use

While atropine increases heart rate and reduces dropped beats and premature atrial beats 2, there is documented risk of ventricular tachycardia with atropine premedication 3. Despite this, guidelines consistently recommend anticholinergic premedication for cardiovascular protection 1. When asystole occurs during ECT, intravenous atropine should be employed as premedication in subsequent sessions 4.

Oxygen Administration

Patients must be ventilated with 100% oxygen before administration of the electrical stimulus 1

Pre-Procedure Requirements

Fasting

• Patients should fast for approximately 12 hours before the procedure 1

Anesthesiology Consultation

• Standard procedure always includes consultation with an anesthesiologist, preferably one experienced in treating the patient population 1

Concurrent Psychotropic Medications

Whenever possible, ECT should be administered without concurrent psychotropic medications 1

Medications to Avoid or Discontinue:

• Lithium may cause acute brain syndrome when used concurrently with ECT and should be avoided if clinically possible 1
• Benzodiazepines may increase seizure threshold 1
• Trazodone has been associated with prolonged seizures during ECT 1
• Carbamazepine may cause failure to induce seizures 1
• Theophylline prolongs seizure duration at both therapeutic and toxic levels 1

Antihypertensive Management

• Antihypertensive medications, including calcium channel blockers, should generally be continued through the perioperative period to maintain cardiovascular stability 5
• Abrupt discontinuation may lead to rebound hypertension and increase cardiovascular complications 5

Critical Pitfalls to Avoid

• Do not withhold atropine or glycopyrrolate during seizure threshold determination or first unilateral treatment, as this leaves patients vulnerable to vagally-induced cardiac complications 1
• Avoid using atropine in patients with hypertension, tachycardia, or those at risk for cardiac ischemia, as it increases cardiac work 2
• Do not discontinue antihypertensive medications before ECT, as this can cause hemodynamic instability 5
• Ensure communication between psychiatrist, anesthesiologist, and ECT team regarding all medications to prevent errors 5