When is esmolol (beta blocker) administered during Electroconvulsive Therapy (ECT)?

Timing of Esmolol Administration During ECT

Esmolol should be administered 1-2 minutes before induction of anesthesia (which occurs approximately 2 minutes before the electrical stimulus) to optimally attenuate the cardiovascular response to ECT. 1

Optimal Administration Protocol

The most effective timing is a bolus dose given 1 minute prior to anesthetic induction, which positions the drug to be active exactly when the electrical stimulus is delivered. 1

• Administer esmolol 100 mg IV bolus 1 minute before methohexital or other anesthetic induction 2, 1
• This timing ensures peak beta-blockade coincides with the electrical stimulus and subsequent cardiovascular surge 1
• The 100 mg dose is superior to 200 mg because it provides equivalent hemodynamic control while causing less reduction in seizure duration 2

Alternative Dosing Strategy

An infusion-based approach can be used for more sustained control:

• Give esmolol 80 mg bolus followed by 24 mg/min infusion starting 2 minutes prior to anesthetic induction 3
• Continue the infusion for 5 minutes after induction (total 7 minutes of infusion) 3
• This method reduces maximum heart rate by 26%, mean arterial pressure by 14%, and rate-pressure product by 37% 3

Critical Timing Considerations

Do not administer esmolol as part of the standard premedication regimen alongside anticholinergics, anesthetics, and muscle relaxants. 4, 5

• Standard ECT premedication consists only of anticholinergics (atropine/glycopyrrolate), anesthetic (methohexital), and muscle relaxant (succinylcholine) 4, 5
• Esmolol is reserved for patients with cardiovascular risk factors requiring additional hemodynamic control 6
• The drug should be given immediately before anesthetic induction, not during the earlier premedication phase 1

Hemodynamic Benefits vs. Seizure Duration Trade-off

While esmolol effectively blunts cardiovascular responses, it may reduce seizure duration, which is a critical consideration for ECT efficacy. 2, 7

• The 100 mg bolus dose minimally affects seizure duration compared to higher doses 2
• Esmolol 200 mg significantly shortens seizure duration and should be avoided 2
• Even the 80 mg dose reduces seizure duration by approximately 6 seconds clinically and 10 seconds on EEG 7
• Despite this reduction, esmolol does not significantly affect the frequency of requiring a second electrical stimulus, unlike labetalol, fentanyl, or lidocaine 1

Patient Selection for Esmolol Use

Esmolol should be reserved for high-risk patients with cardiovascular disease, not administered routinely to all ECT patients. 7, 6

• Target patients aged 53-90 years with at least one cardiovascular risk factor 6
• Use in patients where the cardiovascular risks of uncontrolled hypertension and tachycardia outweigh the potential reduction in seizure efficacy 7
• Avoid in patients with absolute contraindications: bradycardia (<60 bpm), decompensated heart failure, second/third-degree heart block, active asthma, cardiogenic shock, or pre-excited atrial fibrillation 8

Comparative Effectiveness

Esmolol demonstrates superior characteristics compared to alternative agents:

• Esmolol (1 mg/kg) and labetalol (0.3 mg/kg) both significantly reduce hemodynamic responses, but esmolol attenuates blood pressure more effectively 1
• Unlike labetalol, fentanyl, or lidocaine, esmolol does not significantly increase the frequency of requiring a second electrical stimulus 1
• Esmolol's 9-minute half-life provides rapid reversibility if adverse effects occur 8

Monitoring Requirements

Continuous cardiac monitoring is mandatory throughout esmolol administration during ECT. 8

• Monitor heart rate for excessive bradycardia 8
• Track blood pressure for hypotension 8
• Observe ECG for conduction abnormalities 8
• Assess clinically for signs of bronchospasm or heart failure decompensation 8