Recommended Dosages for ECT Medications
Primary Anesthetic Agent
Methohexital is the preferred anesthetic agent at a dose of 1.0 mg/kg IV 1, 2. This provides optimal anesthesia induction with adequate seizure duration for therapeutic efficacy 1, 2.
Alternative Anesthetic Agents
If methohexital is contraindicated, acceptable alternatives include 1:
- Etomidate: Produces longer seizure durations than methohexital, though specific dosing ranges from 0.15-0.3 mg/kg IV 3
- Propofol: 0.75-1.0 mg/kg IV, though this agent produces dose-dependent decreases in seizure duration and may require more treatments, particularly with right unilateral electrode placement 4, 3
- Thiopental sodium: Acceptable alternative per guidelines 1
- Ketamine: Acceptable alternative per guidelines 1
Important caveat: Propofol at 1.5 mg/kg significantly shortens seizure duration (motor: 20±6 s, EEG: 33±12 s) compared to lower doses, and should be avoided at higher dosing 3. Etomidate demonstrates no dose-dependent reduction in seizure duration across the 0.15-0.3 mg/kg range 3.
Muscle Relaxant
Succinylcholine at 0.9 mg/kg IV is the standard muscle relaxant 1, 2. This dose provides adequate muscle relaxation during ECT, though considerable individual variability exists 2.
Alternative Muscle Relaxants
If succinylcholine is contraindicated 1:
- Atracurium: Acceptable alternative, though specific ECT dosing not provided in guidelines 1
- Mivacurium: Acceptable alternative 1
- Rocuronium: 0.3 mg/kg IV followed by sugammadex 1.5 mg/kg IV for reversal produces comparable seizure durations to succinylcholine 5
The rocuronium-sugammadex combination is a viable alternative when succinylcholine is contraindicated, producing similar EEG seizure durations (55.09±36.11 s vs 47.00±26.33 s) and clinical outcomes 5.
Anticholinergic Premedication
Atropine or glycopyrrolate must be administered immediately before ECT 1, 6. Specific dosing is not provided in guidelines, though standard practice uses glycopyrrolate 0.2 mg IV 3, 7.
Mandatory Administration Scenarios
Anticholinergic premedication is required in these situations 6:
- Before seizure threshold determination by dose titration method
- Before the first treatment with right unilateral electrode placement
- To prevent bradycardia, arrhythmia, or cardiac asystole
Critical pitfall: Withholding anticholinergic medication during these scenarios leaves patients vulnerable to vagally-induced cardiac complications including asystole 6.
Ventilation Protocol
Patients must be ventilated with 100% oxygen before administration of the electrical stimulus 1, 6. This is a mandatory component of the ECT procedure 1.
Summary Dosing Table
| Medication Class | First-Line Agent | Dose | Alternatives |
|---|---|---|---|
| Anesthetic | Methohexital | 1.0 mg/kg IV | Etomidate (0.15-0.3 mg/kg), Propofol (0.75-1.0 mg/kg), Thiopental, Ketamine |
| Muscle Relaxant | Succinylcholine | 0.9 mg/kg IV | Rocuronium (0.3 mg/kg) + Sugammadex (1.5 mg/kg), Atracurium, Mivacurium |
| Anticholinergic | Atropine or Glycopyrrolate | 0.2 mg IV (glycopyrrolate) | Either agent acceptable |
| Ventilation | 100% Oxygen | Before stimulus | Mandatory |