Anesthesia for Electroconvulsive Therapy: A Niche Role for Sevoflurane

Abstract

Anesthesia for electroconvulsive therapy (ECT) usually involves the intravenous (IV) administration of drugs such as methohexital, thiopental, propofol, etomidate, or ketamine. Sevoflurane is an inhalational anesthetic agent that has been available for the past 3 decades. Although many studies have examined sevoflurane in the context of ECT, treatment guidelines make either no mention or only passing mention of its potential use in the ECT procedure. A recent systematic review and meta-analysis identified 12 randomized clinical trials (pooled N = 377) of sevoflurane vs IV anesthetics in patients receiving ECT. The meta-analysis found that sevoflurane was associated with shorter EEG seizure duration than barbiturate, ketamine, or propofol anesthesia; that the postictal suppression index did not differ significantly between sevoflurane and propofol; that sevoflurane increased heart rate more than did the IV anesthetics; that sevoflurane increased mean arterial pressure more than did barbiturates and propofol but less than did ketamine; and that, overall, adverse events did not differ significantly between sevoflurane and IV anesthetics. Other known disadvantages of sevoflurane include the need for additional anesthesia instrumentation, the potentiation of action of nondepolarizing muscle relaxants, and the increased complexity of the ECT procedure. These findings and considerations do not encourage the use of sevoflurane for ECT anesthesia. However, there may be a niche role for sevoflurane in patients who are afraid of needlesticks or who are too agitated for an IV line to be set up while they are conscious and in patients who characteristically experience prolonged ECT seizures. Sevoflurane could also be useful in the final trimester of pregnancy because it may inhibit ECT-induced uterine contractions. Importantly, undesired effects of sevoflurane on seizure duration and the hemodynamic response to ECT can be attenuated by discontinuing its administration after induction.