Comparative study of propofol and thiopentone for modified electroconvulsive therapy at a tertiary hospital

 

 

Abstract              Background: Electro Convulsive Therapy (ECT) is widely practiced as cheapest, safest and most effective therapeutic technique in medical sciences, despite of having medical and legal opposition. The anesthetic requirements are amnesia, airway management, prevention of bodily injuries, attaining hemodynamic stability, smooth and rapid emergence. Present study was aimed to compare sodium thiopentone and propofol as an ideal anesthetic agent for modified ECT at our tertiary hospital. Material and Methods: Present study was hospital based, prospective, comparative study, conducted patients 18-60 years age, either gender, with ASAI/II, normal cardio respiratory status posted for modified ECT. Sixty scheduled for ECT were randomly assigned to two groups of 30 patients each. as Group P (propofol 1.5mg/kg body weight) and Group T (Thiopentone sodium 2 mg/ kg body weight) received. Results: In this study, modified ECT was given to 60 patients who received alternately either propofol or thiopentone and the results evaluated. The mean weight of the patients was 57.79 kg and the mean age 32.35 years, difference was highly significant. Gender and body weight were comparable in both groups. In present study majority of patients were of Schizophrenia, mania depressive psychosis, paranoid schizophrenia and bipolar mood disorder. A statistically significant change (p<0.05) in heart rate post ECT at 1 min to 5min. between the two groups. A statistically significant change (p<0.05) in the systolic blood pressure post ECT at 3 minutes, 4 minutes and 5 minutes between the two groups. Conclusion: When propofol is used for anesthetic induction and also shorter duration of motor seizure, significantly faster psychomotor recovery and faster Emergence from anesthesia was noted with propofol as compared with thiopentone sodium for anesthetic induction for modified ECT.

Keywords: modified ECT, propofol, thiopentone sodium, anaesthetic induction, psychomotor recovery.

 

INTRODUCTION

Electro Convulsive Therapy (ECT) has a central place in the treatment of psychiatric patients in spite of advances in psycho-pharmacotherapy. It is widely practiced as cheapest, safest and most effective therapeutic technique in medical sciences, despite of having medical and legal opposition.¹ Grand mal seizures are produced by ECT which are responsible for the therapeutic effect. Electro-convulsive therapy produces severe transient disturbances which can lead to dangerous sequel in patients who have cardiac and cerebrovascular diseases and undiagnosed illnesses in elderly.² Parasympathetic and sympathetic stimulation with adrenomedullary catecholamine release is responsible for hemodynamic changes. The Anesthetic requirements are Amnesia, Airway Management, Prevention of bodily injuries, attaining hemodynamic stability, Smooth and rapid emergence.^3,4 Detail understanding of the changes affecting cardio vascular system, respiratory system and central nervous system with violent muscular contractions and pharmacological measures to decrease them are major roles of anesthetics. Different strategies were studied for modification of cardiovascular changes with beta blockers, calcium channel blockers, Lignocaine, dexmedetomidine and fentanyl.⁵ An ideal Anesthetic agent for ECT should provide a smooth, rapid induction, a rapid recovery and no physiological effects of seizure activity.^5,6 Present study was aimed to compare. Sod. Thiopentone and Propofol as an Ideal anesthetic agent for modified ECT at our tertiary hospital.

              

MATERIAL AND METHODS

Present study was hospital based, prospective, comparative study, conducted in Department of Anaesthesiology, Vilasrao Deshmukh Government Medical College, Latur, India. Study duration was of 2 years (July 2018 to June 2020). Study was approved by institutional ethical committee.

Inclusion criteria: Patient 18-60 years age, either gender, with ASAI/II, normal cardio respiratory status posted for modified ECT.

Exclusion criteria: Patients with history of recent myocardial infarction (<3months). Recent cerebrovascular accident, angina pectoris, congestive heart failure, major bone fractures, pregnancy, postnatal patients. Aneurysms of major vessels, porphyria. Patients with shock and hypovolemia.

Those who were able to give written consent for ECT and anesthesia, written consent was obtained, and for those patients who were deemed unfit to give consent by the treating psychiatrist, consent was got from their relatives.

Sixty scheduled for ECT were randomly assigned to two groups of 30 patients each. Randomization was done using a stratified design, according to whether they were diagnosed to have depression or mania. Outcome assessment was done by trained raters who were blind to the drug used. Each patient’s pre-treatment and post-treatment psychiatric ratings were done by the same rater. ECT was given thrice weekly thrice, Monday, Wednesday, Friday.

Group P: Received propofol 1.5mg/kg body weight as the anesthetic agent.

Group T: Patients received Inj. Thiopentone sodium 2 mg/ kg body weight.

In all patients a detailed history, physical examination and relevant investigations were done and medication noted. Patients who were on benzodiazepines had the drug discontinued 12 hours prior to ECT. All patients were fasted overnight and received. Resuscitative equipment’s and emergency drugs were kept ready before administering ECT to treat the complications if any that might occur. Intravenous access secured pre oxygenation was done. Pulse rate and oxygen saturation was monitored continuously using a pulse oximeter. Preoperative B.P, HR and SPO2 were monitored and recorded. Intravenous Glycopyrrolate 0.2 mg was given. In both the groups muscle relaxation was achieved with intravenous administration of 0.5 mg/kg/bd wt. of succinyl-choline. After establishing an I.V. line on the left forearm the calculated dose of propofol or thiopentone was given over a period of 20 seconds. The induction dose was considered adequate if the eyelash reflex was lost after 30 seconds; otherwise additional agents were injected (with increments of 0.2 mg / kg body weight of propofol or 0.5 mg/kg body weight of thiopentone sodium) Suxamethonium 0.5 mg/kg was given after the cuffed forearm was isolated. Patients were ventilated normally at the rate of 8-10 breaths/min with 100% O2. Once the fasciculation due to suxamethonium subsided a soft mouth prop was inserted, bitemporal electrodes were placed for ECT and bilateral ECT was administered using brief pulse bidirectional constant current stimuli above seizure threshold (sine wave type) was used to administer electric shock. The duration of motor seizure was recorded by a stopwatch as well as stimulus intensity and the number of re-stimulation required to achieve a motor seizure of at least 15 seconds. Any patient who did not develop a bilateral tonic clonic motor seizure of at least 15 seconds were re-stimulated with higher stimulus doses by increasing the duration of pulses until on adequate seizure was achieved and maximum of 3 rest imulations were permitted at each session. Oxygenation was performed between re-stimulations. Once the motor seizure subsided patient’s ventilation was assisted with a facemask with 100% oxygen until the patient resumed spontaneous respiration. Any side effects like pain on injection, abnormal movement, and prolonged seizure defined as seizure duration >120sec, vomiting, bronchospasm or laryngospasm was noted. During recovery, patient was called by his/her name without other sensory stimuli and eye opening was noted. The presence of prolonged post-ictal restlessness or confusion was also noted in some patients. Data was collected by using a structure proforma. Data entered in MS excel sheet and analysed by using SPSS 24.0 version IBM USA. Qualitative data was expressed in terms of proportions. Quantitative data was expressed in terms of Mean and Standard deviation. Comparison of mean and SD between two groups was done by using unpaired t test to assess whether the mean difference between groups is significant or not. A ‘p’ value of <0.05 was considered as statistically significant where as a p value <0.001 was considered as highly significant.

 

RESULTS

In this study, modified ECT was given to 60 patients who received alternately either propofol or thiopentone and the results evaluated. The dose of the drugs was titrated according to requirements. The mean dose of thiopentone (Group–t) used was 2.2mg/kg and that for propofol (Group–p) was 1.44 mg/kg. The mean dose of succinylcholine given 0.52 mg/kg ECT was given to patients with different age groups, weight and different psychiatric illness. The mean weight of the patients was 57.79 kg and the mean age 32.35 years, difference was highly significant. Gender and body weight were comparable in both groups.

 

 

 

 

 

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