Propofol versus propofol-remifentanil combination anaesthesia in electroconvulsive therapy: Effects on seizure duration and hemodynamics

Objective: Electroconvulsive therapy (ECT) is an effective treatment of severe psychiatric disorders and has a favorable side effect profile. The efficacy of ECT is related to seizure duration and to the relative stimulus dosage above seizure threshold. Seizure duration of 25 seconds is considered to be the norm in modern ECT, although a definite correlation between seizure duration and clinical outcome remains to be demonstrated. Short seizures are considered negative predictors of outcome. The ideal hypnotic agent for ECT anesthesia should have a short half-life, not interfere with seizure duration and quality,and guarantee the patient's hemodynamic stability. We aimed to investigate the effects of propofol and propofol remifentanil combination to seizure duration and hemodynamic outcomes in ECT treatment. Material and Method:Twenty patients diagnosed with treatment resistant major depressive disorder and schizophrenia were included in this study. Heart rate (HR), systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), peripheral oxygen saturation (SpO2), and bispectral index (BIS) were measured and electroencephalograph was monitored in all patients. Patients were randomized into two groups as propofol remifentanil group (PR, n=10) and propofol group (P n=10) in a double-blind design. Fifty ECT for each group and a total of 100 ECT were evaluated. 1 mcg/kg remifentanil infused in 30-60 second in group FIR and same dose isotonic solution infused to group P. Propofol infusion applied to all patients subsequently up to BIS rate becoming 60. Succinylcholine (1 mg/kg) infusion used for muscular relaxation. All referred values (HR, SAP, DAP, MAP and SpO2) were recorded before anaesthesia and during 1, 3,5,7, 10th. Minutes of anesthesia. Seizure duration was measured by contraction time (i.e., duration of motor seizure) at isolated arm and seizure activity was recorded by EEG (i.e., duration of EEG seizure). Anaesthesia duration was defined as the time between BIS rate becoming 60 and reaction to verbal stimulation. Results: There was no significant difference between two groups in age, height, and weight (p>0.05). The differences in SAP, DAP, MAP, HR, and SpO2 measures before anaesthesia, before ECT, and after ECT were not significant between two groups (P>0.05). Seizure durations in isolated arms and EEG records were longer in FIR group (p<0.001 for both). Mean anaesthesia period was longer in group FIR (p<0.001) than grup P. Propofol doses were remarkably lower in all 5 ECT sessions in group FIR (p<0.001). Conclusion: Lower doses of propofol usage during anaesthesia in ECT applications may moderate the shortening effect of propofol of seizure duration. Remifentanil did not cause a clear hemodynamic change even with lower doses of propofol. Thus remifentanil may be an augmentation choice in ECT for patients with short seizure duration.