Comparison of etomidate and methohexital as anesthetic agents for continuation and maintenance electroconvulsive therapy: A retrospective analysis of seizure quality and safety.

BACKGROUND: The ideal hypnotic agent for electroconvulsive therapy (ECT) is still under debate and previous studies comparing etomidate and methohexital have produced conflicting results. This retrospective study compares etomidate and methohexital as anesthetic agents in continuation and maintenance (m)ECT with regard to seizure quality and anesthetic outcomes. METHODS: All subjects undergoing mECT at our department between October 1st, 2014 and February 28th, 2022 were included in this retrospective analysis. Data for each ECT session were obtained from the electronic health records. Anesthesia was performed with either methohexital/succinylcholine or etomidate/succinylcholine. Standard seizure quality parameters, anesthesiological monitoring data, pharmacological interventions and side-effects were recorded. RESULTS: 573 mECT treatments in 88 patients were included (methohexital n = 458, etomidate n = 115). Seizures lasted significantly longer after using etomidate (electroencephalography: +12.80 s [95 %-CI:8.64-16.95]; electromyogram +6.59 s [95 %-CI:4.14-9.04]). Time to maximum coherence was significantly longer with etomidate (+7.34 s [95 %-CI:3.97-10.71]. Use of etomidate was associated with longer procedure duration (+6.51 min [95 %-CI:4.84-8.17]) and higher maximum postictal systolic blood pressure (+13.64 mmHg [95 %-CI:9.33-17.94]). Postictal systolic blood pressure > 180 mmHg, the use of antihypertensives, benzodiazepines and clonidine (for postictal agitation), as well as the occurrence of myoclonus was significantly more common under etomidate. CONCLUSIONS: Due to longer procedure duration and an unfavorable side effect profile, etomidate appears inferior to methohexital as an anesthetic agent in mECT despite longer seizure durations.

The influence of anaesthetic choice on seizure duration of electroconvulsive therapy; etomidate versus methohexital.

BACKGROUND: Many of the anaesthetic drugs used for electroconvulsive therapy have anticonvulsant properties and may influence efficacy of electroconvulsive therapy. With this study we aim to provide more information on the effect of etomidate and methohexital on seizure duration. We explore the relationship between induction drug, motor and electroencephalography seizure duration. Moreover, we study the relationship of seizure duration and number of therapies. METHODS: In this retrospective study we collected data from patient records from 2005 until 2016. Inclusion criteria were the use of etomidate and/or methohexital and documentation of dosage, electroconvulsive therapy dosage and seizure duration. Exclusion criteria were missing data on either induction drug, dosage or seizure duration. RESULTS: Thirty seven patients were analysed. The mean age was 52 years and seventy six percent were female. Most patients were suffering from affective disorders (81%). Motor and electroencephalography seizure duration were analysed in 679 and 551 electroconvulsive therapies, respectively. Compared to methohexital, motor and electroencephalography seizures under etomidate were 7 and 13 s longer, respectively. Furthermore, there was a negative association between seizure duration and number of treatment and a negative association between seizure duration and electroconvulsive therapy dosage. CONCLUSIONS: This study demonstrates significant longer motor and electroencephalography seizure duration using etomidate compared to methohexital. Etomidate might therefore increase the effectiveness of electroconvulsive therapy. Moreover, we observed a negative association between seizure duration, number of treatment and electroconvulsive therapy dosage. With this study we contribute to the available literature comparing methohexital and etomidate as induction agents for electroconvulsive therapy.

Superselective methohexital challenge prior to intracranial endovascular embolization.

Pharmacologic provocative testing (PT) and intraoperative neurophysiologic monitoring (IONM) both mitigate and predict risks associated with endovascular embolization procedures. We present a series of patients undergoing endovascular intracranial embolization predominantly for AVMs both under general anesthesia and awake with the use of IONM. We reviewed our database to identify all patients undergoing endovascular procedures between January 1, 2014 and January 1, 2016. Awake patients were tested with SSEP, EEG and real time neurologic examination while TcMEPs were performed in all anesthetized patients. BAEPs were performed in anesthetized patients if indicated. Methohexital was administered as an injection at a dose of 5 mg or 10 mg and repeat testing was performed if needed.Sixty-three endovascular procedures that met criteria were performed in 32 patients. 54 procedures in 28 patients were performed under general anesthesia, 9 procedures in 4 patients were performed in wakefulness. PT was negative in 61 procedures and subsequently completed embolizations without neurological sequelae. In two cases, the testing was positive and the procedure was terminated without embolization in one patient. The other patient underwent embolization at an alternative site without repeat PT. There were no new postoperative neurologic deficits after any of these procedures. Specificity of PT was 100% as none of the patients with a negative provocative test developed a new postoperative neurologic deficit after embolization. To our knowledge, this is the first review of PT with the use of neurophysiologic IONM techniques under general anesthesia. These data suggest a high specificity comparable to awake testing.

A randomized controlled trial comparing methohexital and propofol for induction in patients receiving angiotensin axis blockade.

BACKGROUND: Pharmacologic angiotensin axis blockade (AAB) has been associated with profound hypotension following anesthetic induction with propofol. To combat this problem, investigators have attempted to withhold angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) preoperatively, or evaluated the effects of different induction agents in conferring greater hemodynamic stability. To date, methohexital has not been compared with the most commonly used induction agent, propofol. Hence, the primary objective was to study the hypothesis that methohexital confers a better hemodynamic profile than propofol for anesthetic induction, in patients receiving AAB. The secondary objective was to investigate the postinduction levels of serum neurohormones in an attempt to explain the mechanisms involved. METHODS: Forty-five adult, hypertensive patients taking ACEi or ARB and scheduled for elective, noncardiac surgery completed the study. Patients were randomized to receive equi-anesthetic doses of either propofol or methohexital for anesthetic induction. Hemodynamic variables were measured and blood samples were drawn before induction and for 15 minutes afterwards. RESULTS: Methohexital resulted in less hypotension compared with propofol (P = .01), although the degree of refractory hypotension was similar (P = .37). The postinduction systolic blood pressure (P = .03), diastolic blood pressure (P < .001) and heart rate (P = .03) were significantly higher in the methohexital group. A nonsignificant elevation of serum norepinephrine and epinephrine levels was observed in the methohexital group, while serum arginine vasopressin and angiotensin II levels did not differ between groups. CONCLUSION: While methohexital was shown to confer greater hemodynamic stability in patients taking ACEi/ARB, the measured hormone levels could not explain the mechanism for this effect.

Systematic Review: Rectal Administration of Medications for Pediatric Procedural Sedation.

BACKGROUND: Per rectum (PR) medication delivery is an alternative to traditional oral (PO), intravenous (IV), or intramuscular (IM) administration of medication for procedural sedation of pediatric emergency department patients. However, many emergency physicians are unfamiliar with its use, and there are no widely adopted guidelines or reviews dedicated to this topic. OBJECTIVE: Our aim was to provide emergency physicians with an overview of PR procedural sedation medications in pediatric patients. METHODS: We performed a PubMed literature search of relevant keywords limited to studies of human subjects published in English between January 1, 1990 and December 31, 2017. We excluded case reports, general review articles, editorial/opinion pieces, correspondence, and abstracts. Two of the authors then conducted a structured review of the selected studies. RESULTS: A total of 315 PubMed citations meeting the search criteria were found. Twenty-eight articles were included for final detailed review. Only 4 of the 28 included studies were conducted in the emergency department setting. A total of 9 different medications have been studied for PR procedural sedation. Sedation effectiveness ranged from 40% to 98%. No life-threatening complications were reported in any of the included clinical trials. Hypoxia was found to occur in up to 10% of those receiving PR sedation. CONCLUSIONS: Pediatric procedural sedation with PR medications appears to be feasible, moderately effective, and safe based on our review of the current literature. However, further studies on its applicability in the emergency department setting are needed.

A Bayesian framework systematic review and meta-analysis of anesthetic agents effectiveness/tolerability profile in electroconvulsive therapy for major depression.

The aim of this study was to assess the efficacy and tolerability/acceptability of 6 anesthetic agents in ECT for depressive disorders. We systematically reviewed 14 double-blind randomized controlled trials (610 participants). Efficacy was measured by the mean scores on validated depression scales at 6 ECT (or the nearest score if not available), number of responders at the end of treatment and seizure duration. The acceptability was measured by the proportion of patients who dropped out of the allocated treatment, and the tolerability by the number of serious adverse events and post-treatment cognition assessment. After excluding the trials responsible for heterogeneity, depression scores of patients who were administered methohexital were found to be significantly more improved than those who received propofol (p = 0.001). On the contrary, those who were administered propofol had lower depression scores than those with thiopental at the end of treatment (p = 0.002). Compared to propofol, methohexital was found to be significantly associated with higher seizure duration (p = 0.018). No difference was found for the acceptability profile (all p > 0.05). In summary, ketamine and methohexital may be preferred to propofol or thiopental in regard of effectiveness in depression scores and increased seizure duration. Further studies are warranted to compare ketamine and methohexital.

[Methohexital for analgosedation of ventilated intensive care patients : prospective nonrandomized single center observational study on incidence of delirium]. / Methohexital zur Analgosedierung bei beatmeten Intensivpatienten : Prospektive nichtrandomisierte "Single-center"-Observationsstudie zur Delirinzidenz.

BACKGROUND: Delirium is defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) as a potentially reversible disturbance of consciousness and a change of cognition caused by a medical condition, drug intoxication, or medication side effect. Delirium affects up to 80 % of intensive care unit (ICU) patients and is associated with increased morbidity and mortality. One risk factor for development of delirium in ventilated intensive care unit patients is sedation. The German S3 guidelines on "Analgesie, Sedierung und Delirmanagement in der Intensivmedizin" (analgesia, sedation and delirium management in intensive care medicine) of the DGAI (German Society for Anesthesiology and Intensive Care Medicine) and the DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine) recommend midazolam and propofol for sedation, although both drugs are associated with a high incidence of delirium. AIM: Within the framework of this study the question arose whether the barbiturate methohexital could be associated with a lower incidence of delirium in comparison to midazolam or propofol in analgosedated and ventilated ICU patients. MATERIAL AND METHODS: This was a prospective nonrandomized observational cohort study in a mixed medical surgical intensive care unit. Patients ventilated within 72 h after admittance were consecutively allocated to either propofol/remifentanil versus methohexital/remifentanil (expected ventilation duration ≤ 7 days) or midazolam/fentanyl versus methohexital/fentanyl (expected ventilation duration > 7 days) by the attending senior consultant anesthetist at the time of admission and/or intubation. Primary endpoint was delirium at any time during the ICU stay. Delirium was checked every 8 h by ICU nurses using the intensive care delirium screening checklist (ICDSC), with delirium defined as ICDSC ≥ 4 points. Before evaluation of the ICDSC the Richmond agitation sedation scale (RASS) score and the visual analogue scale for pain (VAS target ≤ 4) were measured. To assure reliable evaluation of the ICDSC, the RASS score of the patient at the time of evaluation had to be ≥ - 2. Assuming an incidence of delirium in the midazolam group of 70 % and in the methohexital group of 35 %, 16 patients were needed each in the midazolam/fentanyl and the methohexital/fentanyl cohorts (p = 0.05, ß = 0.1). Assuming an incidence of delirium in the propofol group of 50 % and in the methohexital group again of 35 %, 94 patients were needed in the propofol/remifentanil and methohexital/remifentanil groups, respectively (p = 0.05, ß = 0.1). RESULTS: A total of 222 patients were evaluated, 34 in the methohexital vs. midazolam group and 188 in the methohexital vs. propofol group. Out of 16 patients sedated with midazolam, 15 developed delirium (94 %) in contrast to only 5 out of 18 patients sedated with methohexital (28 %). Thus compared to midazolam the sedation with methohexital reduced the incidence of delirium by 66 % (p < 0.001) corresponding to a number needed to treat (NNT) of 1.5. Out of 94 patients in the propofol/remifentanil group, 64 developed delirium (68 %) in contrast to only 23 out of 94 in the methohexital/remifentanil group (24 %). Thus compared to propofol the sedation with methohexital reduced the incidence of delirium by 44 % (p < 0.001), corresponding to an NNT of 2.5. CONCLUSION: Sedation with methohexital compared to midazolam or propofol reduced the incidence of delirium by more than 50 % in ventilated ICU patients.

A randomized comparison of ketamine versus methohexital anesthesia in electroconvulsive therapy.

To assess the clinical utility of ketamine as an anesthetic agent for electroconvulsive therapy (ECT), based upon recent findings that ketamine may have antidepressant properties. Depressed ECT patients were randomly assigned to receive anesthesia with either ketamine or methohexital. Outcome measures included assessments of depressive severity, cognition, post-anesthesia side effects, and hemodynamics. Twenty one patients were treated with ketamine and 17 with methohexital. There were no significant differences in depression or cognitive outcomes between the two drugs. Additionally, there were no measures of post-anesthesia tolerability or hemodynamics which favored ketamine. Ketamine anesthesia does not accelerate the antidepressant effect of ECT or diminish the cognitive side effects, at least as measured in this study. Furthermore, there is no apparent benefit of ketamine for speed or quality of post-ECT recovery, and it is associated with higher systolic blood pressures after the treatments. Ketamine is associated with longer motor seizure duration than methohexital.

Methohexital in total intravenous anesthesia during intraoperative neurophysiological monitoring.

Total intravenous anesthesia (TIVA) is usually recommended during spinal surgery when transcranial motor evoked potentials (tcMEPs) are used to monitor. A shortage of propofol has prompted a search for an alternative sedative-hypnotic agent. We explored the use of methohexital as an alternative. TIVA was provided for two adult patients having spinal surgery using an infusion of methohexital. TcMEPs and somatosensory evoked potentials were acquired to monitor neurological function and electroencephalogram was used to titrate the methohexital dose. Two cases are presented in which the anesthesia and monitoring that was provided were successful. These cases indicate that methohexital can be a suitable alternative to propofol in some patients.

Comparison of methohexital and etomidate as anesthetic agents for electroconvulsive therapy in affective and psychotic disorders.

BACKGROUND: ECT is a well-established treatment for severe depression. The available data on psychosis are limited, but reliable. Its therapeutic potential relies on the induction of a generalized seizure. Besides other narcotics, methohexital and etomidate are used for general anesthesia in ECT. Since prolonged seizures have been reported following the use of etomidate, it can be deduced that the substances might differ in their anticonvulsant properties, resulting in a lower increase in stimulus intensity during the course of treatment under etomidate. Besides this hypothesis, we aimed to investigate the differential effects of etomidate and methohexital on clinical features, ECT parameters and side effects of the treatment. METHODS: We performed a retrospective analysis of treatment data of patients with affective and psychotic diagnosis who received general anesthesia for ECT either with etomidate or with methohexital. RESULTS: ECT with etomidate and methohexital was equally effective. During the course of therapies the administered electric charge increased significantly and equally in both treatment groups. In the methohexital group, but not in the etomidate group, electroencephalographic seizure duration had a declining trend during the course of therapies. We observed more side effects during and immediately after ECT in the methohexital group than in the etomidate group. LIMITATIONS: The limitations of this study are that the patients received various psychotropic co-medications, which influence ictal parameters differently, and, secondly, the study is based on a retrospective analysis. CONCLUSION: The results of our analysis suggest that etomidate and methohexital affect ictal parameters to different extents. Longer seizure duration and fewer side effects are in favor of etomidate.

[Methohexital for treatment of intracranial hypertension]. / Methohexital zur Therapie des erhöhten intrakraniellen Drucks.

BACKGROUND: Barbiturate coma therapy is a useful method to control increased intracranial pressure (ICP) in patients with severe brain damage if standard measures have failed to lower ICP. Pentobarbital (not available in Germany) and thiopental (in Germany only approved for induction of anesthesia) have frequently been used in patients with intracranial hypertension and the effects and side-effects are well-described. However, little is known about the effect of methohexital (the only barbiturate in Germany approved for maintaining anesthesia) in lowering increased ICP. Therefore, the effect of methohexital on ICP was studied in patients where standard measures had failed to control intracranial hypertension. METHOD: A retrospective observational study was carried out with the inclusion criteria of patient age ≥18 years and methohexital therapy for 12 h or more with ICP monitoring in place. Methohexital was administered following a standardized algorithm to patients for whom standard measures, such as deep anesthesia, normoventilation, cerebral perfusion pressure (CPP) >65 mmHg, osmotherapy, neurosurgical evacuation of mass lesions, had failed to lower ICP. Methohexital was used if the ICP had risen above 20-25 mmHg for more the 20-30 min and otherwise manageable causes for the ICP increase had been ruled out. Methohexital was given continuously in addition to standard analgesia and sedation in doses of 2-4-6 mg/kg body weight (BW), depending on the ICP lowering effect. The records of the patient data management system from the years 2008/2009 were used to compare the ICP and CPP before and during methohexital administration. For statistical analyses Student's t-test was applied for measured values and the χ(2)-test was applied for percentage values whereby p<0.05 was defined as being statistically significant. RESULTS: During the study period 36 patients required methohexital therapy and 30 fulfilled the inclusion criteria. In 26 out of 30 patients the data were complete and these 26 patients were included in the data analyses. Of the patients 6 (23%) died due to elevated intracranial hypertension and 20 patients (77%) survived. In all patients methohexital lowered the ICP from 25.2 mmHg (standard deviation, SD ±4.3 mmHg) to 19.8 mmHg (SD ±12.5 mmHg) within the first 24 h, this result closely failed to reach a level of significance. In the 20 survivors methohexital lowered the ICP from 25.88 mmHg (SD ±4.8 mmHg) to 14.25 mmHg (SD ±6.9 mmHg) within the first 24 h, which is statistically highly significant. In non-survivors the ICP had risen from 24 mmHg (SD ±2.6 mmHg) to 32 mmHg (SD ±16.3 mmHg) within the first 24 h despite all efforts. Due to the CPP driven volume and vasopressor therapy no significant changes in the CPP during methohexital administration were observed. No significant changes in brain temperature (as possible cause for the decrease of the ICP) were observed. Non-survivors received significantly more methohexital due to increased ICP and required significantly more vasopressor therapy to maintain a sufficient CPP. CONCLUSIONS: Methohexital showed a clear trend for decreasing ICP in patients with intracranial hypertension refractory to standard therapeutic measures. In survivors the effect was highly significant. Patients not responding to methohexital therapy seemed to have an unfavorable outcome.

Crying with left temporal lobe seizures and Wada testing.

Dacrystic seizures are characterized by crying and are rare in patients with epilepsy. The crying that occurs during complex partial seizures is expressed as an unconscious behavior unassociated with sadness or depressive quality. It has been reported to occur with focal seizures that are localized to the frontotemporal regions and is frequently lateralized to the nondominant hemisphere. We describe a woman with left temporal lobe epilepsy and recurrent complex partial seizures with crying behavior that was reproduced during left carotid methohexital anesthesia, suggesting functional inactivation by two different mechanisms. Following left amygdalohippocampectomy she became seizure free for >2years without perioperative mood destabilization. Localized functional networks that involve limbic structures may be involved in patients with dacrystic seizures with a favorable outcome following epilepsy surgery.

The influence of anaesthetic medication on safety, tolerability and clinical effectiveness of electroconvulsive therapy.

BACKGROUND: Electroconvulsive therapy (ECT) is still considered the most effective biological treatment strategy in psychiatric disorders. However, the clinical efficacy of ECT may be affected by stimulus variables and the concomitant use of psychopharmacological medication. Furthermore, most anaesthetics have anticonvulsant properties and therefore might additionally influence the efficacy of ECT. METHOD: In order to explore whether different anaesthetics might alter the effectiveness or safety of ECT we retrospectively analyzed 5482 ECT treatments in 455 patients. Anaesthetics were chosen according to clinical reasons and comprised thiopental, methohexital, propofol and etomidate. RESULTS: Seizure duration was significantly affected by the anaesthetic medication with longest seizure activity during thiopental anaesthesia. In addition, postictal suppression, a further prospective parameter of ECT effectiveness, was significantly higher during propofol and thiopental anaesthesia. The clinical effectiveness was significantly better during propofol and thiopental anaesthesia. In contrast, the overall safety did not differ between the anaesthetic groups. CONCLUSION: Our study supports the hypothesis that inducting anaesthetic agents have a different impact on seizure duration, ictal and postictal electrophysiological indices and clinical efficacy of ECT. Compared to thiopental, which has been established as a standard anaesthetic during ECT, also the modern anaesthetic propofol is a suitable inducting agent.

A retrospective comparison of anesthetic agents in electroconvulsive therapy.

A recent lack of availability of the anesthetic agent methohexital in the United States allowed for a naturalistic study of the efficacy and the adverse effects of alternatives. Methohexital, propofol, and thiopental were compared as anesthetic agents for electroconvulsive therapy in 95 patients treated during a 23-month period in a general public hospital. Missed seizures and arrhythmias were infrequently observed (<4% for any agent). Methohexital was found significantly related to longer seizure durations in comparison with both other agents (P < 0.01). The use of propofol was associated with increased risk of missed seizure (8.9%) compared with methohexital (3.9%) and thiopental (3.2%). Propofol was also associated with higher doses of administered energy, with a statistically significant difference (P = 0.018) observed between propofol and thiopental. Although propofol required the greatest energy delivery, it was associated with the shortest seizure durations. Methohexital resulted in the longest seizure duration, and thiopental was associated with the least amount of energy delivery with an intermediate seizure length.

Procedural sedation and analgesia: a review and new concepts.

Procedural sedation and analgesia has become a commonplace procedure in the ED, certainly falling under the domain of the EP. Every EP should approach PSA as a complex procedure requiring high-level skills and knowledge. Initially, understand that PSA represents a spectrum of goals, from anxiolysis and pain relief to deep sedation. Assess the needs of the patient and the concomitant procedure and set goals accordingly. There is a pharmacopia of drugs that provide sedation and analgesia. Become familiar with their pharmacology, advantages and disadvantages, and indications. This will allow for appropriate usage and achievement of sedation goals. Several drugs that are commonly used for general anesthesia are proving themselves to be safe and efficacious for PSA. Both etomidate and propofol have emerged as useful drugs for PSA. Continued research and practice with these agents will add to our understanding and help define their use for PSA. Performing PSA as a procedure itself requires preparedness, diligent monitoring, and risk awareness. Knowing the patient's comorbid state and choosing agents that will not exacerbate their baseline status minimize risk. Following fasting guidelines is appropriate in certain clinical situations, and is prudent when time permits. However, these guidelines are a benchmark for minimizing risk and are not supported by evidence-based medicine. It is important to be cognizant of the guidelines but also to identify the emergency scenario where action must be taken despite the fasting guidelines. Controlling sedation depth also minimizes the risk of aspiration and other complications. The ETCO2 monitor and Bispectral Index may prove to be useful adjuncts for monitoring sedation depth. However, there is nothing yet that measures sedation depth quantitatively that can replace the qualitative assessment of the EP. More and more PSA is falling under the domain of the EP. It is important for the EP to be involved in hospital policy and guidelines associated with this procedure, and to remain aware of new research in this field. EPs can thereby contribute to quality assurance throughout the medical community by setting a standard in the practice of PSA, as they are not the only practitioners using this procedure. With continued practice and research, expertise in this field will grow measurably.

The comparative hemodynamic effects of methohexital and remifentanil in electroconvulsive therapy.

Remifentanil is a short acting opioid frequently used to supplement general anesthesia for brief procedures. Narcotic agents are known for their ability to blunt autonomic responses to stimuli such as laryngoscopy and intubation and do not alter seizure threshold. We hypothesized that the combination of remifentanil and methohexital for induction would produce favorable suppression of sympathetic response during electroconvulsive therapy (ECT). With Institutional Review Board approval and informed consent, patients were enrolled in a prospective, randomized, double-blind, crossover study of methohexital alone versus remifentanil with an adjuvant of low-dose methohexital. One hundred ten ECT treatments were evaluated and subjects were treated in an alternating fashion with one of two induction protocols: Methohexital alone in an 80-100 mg IV bolus or remifentanil 500 mcg IV bolus combined with methohexital 40 mg IV. Bilateral ECT was performed in standard fashion and systolic blood pressure and heart rate were recorded throughout the procedure. No significant differences were found in baseline hemodynamic values between the two groups. Heart rate was significantly lower in the remifentanil group versus methohexital group at one minute post-induction and just prior to ECT stimulus. Pre-ECT systolic blood pressure was not significantly different between the two groups. Heart rate remained lower in the remifentanil group at all measured timepoints during the treatment and continuously for five minutes after the seizure. Systolic blood pressure was significantly lower at one minute following the end of seizure and five minutes after end of seizure. Remifentanil's short duration of action, favorable side effect profile, potential proconvulsant activity and ability to suppress hemodynamic response make it a potential novel drug for ECT induction.

Seizure length and clinical outcome in electroconvulsive therapy using methohexital or thiopental.

Seizure duration is an extensively studied and controversial indicator of treatment quality in electroconvulsive therapy. Previous research comparing the effect of the barbiturate anesthetics methohexital and thiopental on seizure duration has yielded conflicting results. A recent period of unavailability of methohexital in the United States allowed for retrospective comparison of seizure length as well as clinical improvement in treatment using each agent. Retrospective review was made of 837 treatments administered to 97 patients between January 2, 2002, and May 31, 2003, examining anesthetic, seizure duration, and Global Assessment of Functioning (GAF) scores of inpatients at hospital admission and discharge. Analysis of variance of treatments 2-5 showed no significant effect for anesthetic on seizure duration. Analysis on a treatment-by-treatment basis revealed a marginally significant trend toward shorter EEG seizures in the thiopental group at the second treatment (50.5 +/- 23.6 s vs. 61.1 +/- 27.9 s; P = 0.07) and fifth treatment (41.7 +/- 16.9 s vs. 51.8 +/- 24.0 s; P = 0.07). A difference approaching statistical significance revealed shorter convulsion length in the thiopental group at treatment 5 (29.0 +/- 12.3 s vs. 34.8 +/- 12.3 s; P = 0.07). Comparison of GAF score improvement at hospital discharge revealed no significant difference (GAF increase 26.4 +/- 9.4 for methohexital-treated patients vs. 24.8 +/- 12.0 for thiopental-treated patients; t = 1.00, df = 82, P > 0.1). Trends approaching significance in treatments 2 and 5 revealed shorter seizures in the thiopental group. However, data on clinical recovery reveals no greater improvement in the methohexital group. Thus, this study calls further into question the premise that choice of barbiturate anesthetic may affect clinical efficacy.