Matthew F. Majeske

Dosing and effectiveness of ketamine anesthesia for electroconvulsive therapy (ECT): a case series

Objective: To provide additional data about the clinical efficacy and dosing range for ketamine used as the induction agent in electroconvulsive therapy (ECT). Method: We reviewed the clinical data in our academic hospital ECT service over the last four years for patients who had received ketamine as the sole, or adjunctive, anesthesia induction agent. We extracted clinical data about antidepressant response as well as absolute and weight-based dosing for ketamine. Results: We found nine patients who were treated with ketamine as the anesthetic at some point during the course of their treatment (eight as the sole agent, one as adjunctive). The median induction dose for ketamine was 1.1 mg/kg. For most patients, there was demonstrable clinical benefit. Conclusions: Ketamine has a role as an alternative induction anesthetic agent in ECT. Our case series adds to the literature on the concomitant use of ECT and ketamine.

Case Report: Transient Left Bundle Branch Block Associated with Ect

We present the first reported case of transient left bundle branch block (LBBB) occurring during electroconvulsive therapy (ECT). LBBB is an important clinical finding, as it is associated with a significant increase in mortality. Physicians providing ECT should be aware of the significance of new-onset LBBB; it may occur during treatment.

Transient febrile reaction after electroconvulsive therapy (ECT) in a young adult with intellectual disability and bipolar disorder.

Abstract We report the case of a 27-year-old man with mild-moderate intellectual disability (ID) and bipolar disorder treated with electroconvulsive therapy (ECT). He was psychiatrically hospitalized for agitation, aggression, and manic symptoms including insomnia, rapid and pressured speech, and hyperactivity. After multiple medication trials, ECT was recommended. The treatment was delayed owing to the need to obtain evaluation for incapacity and then substituted consent from the patient’s mother. He received 2 ECT treatments with marked improvement but complicated by transient fevers, which resolved without treatment. Fever workup was unremarkable. The patient became calm and cooperative and was discharged home. He was readmitted 3 weeks later, again in an agitated manic state. He received 5 additional ECT treatments, but this time with no post-ECT fevers. Once again, his manic symptoms resolved, and he was safely discharged. Whereas patients with ID pose special challenges, our case is in keeping with the previous literature, which supports the use of ECT in patients with ID and comorbid psychiatric disorders.

Resolution of Acute Suicidality After a Single Right Unilateral Electroconvulsive Therapy.

patients. This finding made me reconsider the results of a study we conducted in 1989. We too, found that an individual electroconvulsive treatment given to depressed patients improved problem solving. We discounted the finding at the time and did not mention it in the abstract of the paper. The finding was described as surprising in the body of the paper and attributed to a practice effect. Our study was primarily of the timecourse of magnetic resonance changes over the 24 hours after an individual electroconvulsive treatment. We intended to compare any changes with the cognitive effects of an individual treatment and needed measures of cognition that could be easily repeated several times for a period of 6 hours. We chose to assess orientation because repeated testing of orientation was practicable and clinically relevant. We also chose to assess problem solving because we had access to a reliable test of verbal reasoning that was brief and available in 5 parallel versions on a microcomputer. The patient had to study a screen on which the letters AB or BA appeared. A statement appeared below (for example, “A follows B”), and the patient was asked to decide if the statement was true or false; the answer was to be typed on the keyboard: T for true and so on. All 18 included patients who satisfied research diagnostic criteria for major depressive disorder. The mean age of the sample was 51 years, and 13 patients were women. The index treatment was the fifth (median) treatment in a course of electroconvulsive therapy. Methohexitone was used to induce anesthesia, and suxamethonium was used to induce muscle relaxation. Brief pulse (1.5 milliseconds) stimulation was used in all patients. Bilateral stimulation was used in 10 patients and unilateral stimulation in 8 patients. Problem solving was assessed on the morning before treatment and repeatedly throughout the rest of the day (approximately 40 minutes, 2 hours, 4 hours, and 6 hours after treatment). Problem solving 40 minutes after treatment was better than before treatment. Problem solving also improved steadily throughout the day. There was a suggestion that problem solving improved more in patients treated with unilateral electroconvulsive therapy, but this difference was not statistically significant. Unfortunately, the raw data and statistical analysis are no longer available. We were aware of the practice effect, and for this reason had arranged for the patients to rehearse with the microcomputer both the afternoon before treatment and again early on the morning of treatment. Nevertheless, the finding was so counterintuitive to us that we still attributed it to a practice effect.

Hemifacial Erythema in Right Unilateral Electroconvulsive Therapy.

We present a case of transient right hemifacial rash after right unilateral electroconvulsive therapy. This phenomenon may have similarities with the cranial dysautonomia, Harlequin syndrome.

Extreme variability in succinylcholine dose for muscle relaxation in electroconvulsive therapy

Objectives: To determine what dose of succinylcholine falls outside the range of 2 SD above or below the mean optimal dose of 0.9 mg/kg used for electroconvulsive therapy (ECT). Methods: In this retrospective chart review, for all patients who received ECT at our institution within the 5-year study period, the initial dose of succinylcholine in milligrams per kilogram was compared with subsequent doses after adjustments were made for individual patient responses. Mean and SD were calculated using the dose of succinylcholine, once the optimal dose for each patient had been determined, based on clinical response. Results: Five hundred patients treated during the 5-year period met inclusion criteria, 180 (36%) of whom required an adjustment of the succinylcholine dosing either above (119 patients) or below (61 patients) the 0.9 mg/kg standard after their first treatment. Conclusions: In those patients who required an adjustment of 2 SD either above or below the mean dose of succinylcholine (29 patients, 5.8%), adequate neuromuscular blockade was only achieved with either an increased dose of up to 2.10 mg/kg or a decreased dose as low as 0.29 mg/kg.