What is the recommended anesthesia protocol for Electroconvulsive Therapy (ECT)?

Anesthesia Protocol for Electroconvulsive Therapy (ECT)

Pre-Procedure Preparation

Ensure the patient has fasted for approximately 12 hours before the procedure and assemble a specialized team including a psychiatrist, anesthesiologist experienced in ECT, and trained nursing staff. 1

Medication Management Before ECT

• Discontinue benzodiazepines as they increase seizure threshold and may prevent adequate therapeutic seizures 2
• Avoid lithium if clinically possible due to reports of acute brain syndrome when used concurrently with ECT 1, 3
• Discontinue trazodone which has been associated with prolonged seizures during ECT 1, 3
• Stop carbamazepine as it may cause failure to induce seizures 1, 3
• Discontinue theophylline which prolongs seizure duration at both therapeutic and toxic levels 1, 3
• Continue antihypertensive medications including calcium channel blockers through the perioperative period to maintain cardiovascular stability and prevent rebound hypertension 3
• If psychotropic medications cannot be discontinued due to clinical necessity, continue them with appropriate monitoring of seizure adequacy using EEG recordings 2

Pre-Anesthetic Consultation

• Mandatory consultation with an anesthesiologist, preferably one experienced in treating the patient population (adolescents if applicable) 1, 3
• Consult other specialists if concurrent medical pathology exists 1

Anesthetic Regimen

Primary Anesthetic Agent

Administer methohexital 1.0 mg/kg IV as the preferred anesthetic agent. 1, 4

Acceptable alternatives include:

• Etomidate (0.3 mg/kg) - produces longer seizure durations than methohexital but has increased pain on injection and 24% longer wakeup time 4, 5
• Thiopental sodium 1, 4, 3
• Ketamine 1, 4, 3
• Propofol (1.0 mg/kg) - associated with shorter seizures but improved hemodynamics, quicker postanesthesia recovery, and does not compromise antidepressant efficacy; use lowest effective dose 4, 6

Muscle Relaxation

Administer succinylcholine 0.9 mg/kg IV as the standard muscle relaxant. 4

Acceptable alternatives include:

• Atracurium 1, 4, 3
• Mivacurium 1, 4, 3
• Cisatracurium (0.2 mg/kg) 7

Apply the electrical stimulus only when train-of-four monitoring shows zero twitches (complete neuromuscular blockade). 7

Anticholinergic Premedication

Administer intravenous atropine or glycopyrrolate immediately before ECT to prevent bradycardia, arrhythmia, or cardiac asystole. 1, 4, 3

Mandatory anticholinergic administration is required:

• Before seizure threshold determination by dose titration method 1, 4, 3
• Before the first treatment with right unilateral electrode placement 1, 4, 3
• This protects the cardiovascular system from vagal discharge in instances of incomplete or missed seizures 1

Critical pitfall: Withholding atropine or glycopyrrolate during these specific situations leaves patients vulnerable to vagally-induced cardiac complications. 3

Ventilation Protocol

Ventilate the patient with 100% oxygen before administration of the electrical stimulus. 1, 4, 3

Monitoring During the Procedure

Essential Monitoring Parameters

• Use an ECT device with EEG recording capacity to monitor seizure adequacy and detect prolonged seizures 1
• Monitor bispectral index (BIS) targeting values of 70 at time of stimulus application, then 40-50 during post-seizure sedation if additional agents are given 7
• Continuously monitor train-of-four to ensure adequate muscle relaxation 7
• Monitor end-tidal carbon dioxide continuously 7
• Observe seizure duration, airway patency, agitation, vital signs, and adverse effects 1

Seizure Duration Management

Seizures lasting longer than 180 seconds are considered prolonged and must be terminated. 1, 4

Terminate prolonged seizures with:

• Additional methohexital 1, 4
• Diazepam 1, 4
• Lorazepam 1, 4

Prolonged seizures are clinically significant because they cause greater postictal confusion, amnesia, inadequate oxygenation, and increased hypoxia-related cerebral and cardiovascular complications. 1

Special Population Considerations

Adolescents may have lower seizure thresholds and more prolonged seizures than adults during ECT, requiring adjusted anesthetic dosing and consideration of propofol for managing prolonged seizures. 4

• Adolescents are not at increased risk of anesthesia-related complications in the immediate recovery period compared to adults 1
• The anesthesia-related mortality rate in adults is 1.1 per 10,000 treatments 1

Post-Procedure Recovery

Immediate Recovery

• Recover the patient in a specially designated area with expert nursing care 1
• Provide close monitoring until fully recovered from anesthesia 1
• Monitor for at least 24 hours for tardive seizures (late seizures occurring after the ECT session) 1

Management of Complications

Obtain neurology consultation if:

• Recurrent prolonged seizures occur 1
• Tardive seizures occur 1
• Difficulties are experienced in terminating a prolonged seizure 1
• Neurological or other physical sequelae appear present 1

Common minor side effects (headache, nausea, vomiting, muscle aches, confusion, agitation) usually do not persist beyond the day of treatment and should be managed conservatively. 1

Treatment Setting and Frequency

Administer ECT only on an inpatient basis to better monitor treatment response, seizure duration and intensity, and recovery after anesthesia. 1

• Most centers in the United States administer ECT three times weekly 1
• Treatment may begin at either two or three times weekly, with schedule changes if the patient experiences significant confusion 1

Critical Coordination Points

• Ensure communication between psychiatrist, anesthesiologist, and ECT team regarding all medications to prevent errors 3
• The ECT team can adjust anesthetic dosing if seizure induction becomes problematic 2
• Coordinate with the anesthesiologist regarding all concurrent medications 2