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Correspondence  |   November 2007
Electroconvulsive Therapy: Compassion in Care and Risk–Benefits of Discomfort
Author Notes
  • University of Pittsburgh, Presbyterian University Hospital, Pittsburgh, Pennsylvania.
Article Information
Correspondence
Correspondence   |   November 2007
Electroconvulsive Therapy: Compassion in Care and Risk–Benefits of Discomfort
Anesthesiology 11 2007, Vol.107, 857. doi:10.1097/01.anes.0000287343.24019.f4
Anesthesiology 11 2007, Vol.107, 857. doi:10.1097/01.anes.0000287343.24019.f4
To the Editor:—
The recent case report by Litt and Li raises several unmentioned issues.1 Anesthesia for electroconvulsive therapy (ECT) typically involves the administration of the lowest effective dose of induction agent (affording amnesia and minimizing drug-induced seizure inhibition) and liberal administration of muscle relaxant to prevent injury, especially in patients with severe osteoporosis (demographically, elderly women predominate). It is not uncommon for the relaxant to outlast the amnestic agent (in which case, liberal use of postseizure amnestic agents is recommended to prevent awake paralysis). ECT is frankly a situation inviting awareness and requiring close clinical observation and communication via  isolated limb responses to ensure amnesia in patients able to communicate (many cannot because of psychiatric illness). Repeated ECT raises seizure thresholds, reducing duration and effectiveness, often requiring changes from methohexital to induction agents less inhibitory, including etomidate to ketamine. Meticulous vigilance to ensure effective amnesia is important, because anesthetic dosage varies widely and changes in injection technique and cardiac output can influence induction characteristics of minimally effective, empiric doses.
Awareness is to be regarded as a frequent risk of ECT, mitigated only by close, continual observation. Specifically regarding the case report, I found it unusual that these authors chose to allow the patient to remain conscious after determining awake paralysis and before ECT was delivered, because the judicious injection of additional induction agent rapidly terminates this unpleasant situation. They instead allowed conscious paralysis to persist for several minutes until neuromuscular recovery was complete, determined then that the patient “described being awake and paralyzed and not liking it,”1 only to start again shortly thereafter. I would suggest, contrary to the title provided, that this indicates recall was present, but retrograde amnesia occurred with the successful subsequent ECT treatment, something quite unpredictable.
The authors asked the important ethical question: “To what extent should a physician allow discomfort if it is known that there will be no explicit memory of it?” In regard to ECT, a frank informed consent requires discussion of awareness with consideration of the risks and benefits of the anesthetic technique as well as ECT itself. This is no different than for the multiple surgical and diagnostic procedures during minimum alveolar concentration or regional anesthesia (i.e  ., cesarean delivery during spinal, awake fiberoptic intubations, intensive care unit sedation, surgical procedures or endoscopies during minimum alveolar concentration or no anesthesia), where discomfort is a daily and apparently accepted risk–benefit consideration. We must prevent discomfort as is reasonable and possible, but we cannot ensure complete lack of perioperative discomfort, remembered or forgotten. We would need to abandon regional and sedation techniques (with the inherent pain involved), as well as abandon the use of propofol, methohexital, and especially etomidate via  peripheral intravenous injection, because of the commonplace extreme, remembered and clearly expressed pain on injection. This is especially true (yet completely impossible) in ECT therapy, where preemptive intravenous lidocaine’s membrane stabilization (seizure inhibition) is specifically avoided.
University of Pittsburgh, Presbyterian University Hospital, Pittsburgh, Pennsylvania.
Reference
Reference
Litt L, Li D: Awareness without recall during anesthesia for electroconvulsive therapy. Anesthesiology 2007; 106:871–2Litt, L Li, D