What is the role of anesthesia in electroconvulsive therapy (ECT)?

Updated: Sep 24, 2019
  • Author: Mehul V Mankad, MD; Chief Editor: Dennis M Popeo, MD  more...
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In the first several years of use, ECT was performed without anesthesia. Since the late 1950s, however, ECT has been performed under general anesthesia. [18] The goal is to produce a brief period of general anesthesia accompanied by muscle relaxation. The level of desired sedation exceeds so-called conscious sedation. Inadequate anesthesia may lead to problems such as incomplete unconsciousness and autonomic arousal.

Induction anesthetic agents used in ECT include the following: [1, 44]

  • Methohexital (barbiturate)

  • Thiopental (barbiturate)

  • Etomidate (nonbarbiturate)

  • Ketamine (nonbarbiturate)

  • Fentanyl and analogues (opioid)

  • Propofol (nonbarbiturate)

Methohexital is most commonly used and is the preferred anesthetic for ECT because of its established safety record, effectiveness, and low cost. Propofol, while an effective induction anesthetic, has the greatest anticonvulsant properties of commonly used agents for ECT. Ketamine and etomidate have the least negative impact on seizure duration [1, 44] Inhalational anesthesia with medications such as sevoflurane may also be an option, but such approaches are uncommon. [45]

The cognitive outcome after ECT may be affected by the choice of the anesthetic medication. [46] No matter which anesthetic medication is used, the appropriate dose should be established at each treatment session, and adjustments should be made at subsequent treatment sessions. [1]  As seizure quality is directly affected by the choice of induction anesthetic agent, the ECT treatment team and the anesthesia team should discuss choice of induction agent and should consider seizure efficacy when considering changes to the anesthesia care plan. [47]

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