Challenges and pitfalls in anesthesia for electroconvulsive therapy.

Electroconvulsive therapy (ECT) refers to the application of electricity to the patients' scalp to treat psychiatric disorders, most notably, treatment-resistant depression. It is a safe, effective, and evidence-based therapy that is performed with general anesthesia. Muscle relaxation is used to prevent injuries related to the tonic-clonic seizure caused by ECT. Hypnotics are administered to induce amnesia and unconsciousness, so that, patients do not experience the period of muscle relaxation, while the generalized seizure is left unnoticed. For the anesthesiologist, ECT is associated with the challenges and pitfalls that are related to informed consent, social acceptance of ECT, airway management (especially in COVID-19 patients), and the interaction between ventilation and anesthetics from one viewpoint, and seizure induction and maintenance from another. The exact mode of action of the therapy is as unknown as the optimal choice or combination of anesthetics used.

Anesthesia for electroconvulsive therapy.

PURPOSE OF REVIEW: Electroconvulsive therapy (ECT) is a well established and effective therapy in treatment-resistant depression. It is performed under general anesthesia, but no consensus exists regarding the optimal anesthetic drugs. A growing interest in optimizing adjunctive medication regimes in ECT anesthesia has emerged in recent years. Moreover different methods of seizure induction have been evaluated. RECENT FINDINGS: Pretreatment with dexmedetomidine eased the propofol injection pain and reduced the hyperdynamic response to ECT, but prolonged recovery. Remifentanil exhibited no proconvulsive effect and had no effect on seizure quality. Ketamine showed an antidepressive effect but was associated with cardiovascular side effects and an increased recovery time. A bispectral index-guided anesthesia or a time delay between anesthesia and seizure induction resulted in a better seizure quality presumably by avoiding high concentrations of (anticonvulsive) hypnotics. Seizure induction by magnetism seems to be an alternative to ECT, as the former is associated with less cognitive side effects but comparable antidepressive efficacy. SUMMARY: The current practice of anesthesia for ECT should not be modified, as the evidence of studies is either too low or the results are inconsistent. Some approaches are promising but require validation in further studies with a higher number of participants.