moyenne de 14 pour cent et celle du rapport pouls-pression de. 37 pour cent. Ces effets dtaient statistiquement significatifs une, deux, trois et quatre minutes ...
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Esmolol bolus and infusion attenuates increases in blood pressure and heart rate during electroconvulsive therapy To determine whether a standardized dose of esmolol can effectively attenuate the cardiovascular response to electroconvulsive therapy (ECT), 17ASAphysicalstatusl-Hpatients were studied in a randomized within-patient, crossover design. Each patient received "no esmolol" during one ECT and three to five days later crossed over to the alternative treatment receiving an esmolol 80 mg bolus followed by 24 rag. min -j infusion two minutes prior to induction of anaesthesia and continued for five minutes after induction. Esmolol blunted the maximum increases in heart rate (HR) by 26 per cent, mean arterial pressure (MAP) by 14 per cent, and rate pressure product by 3 7 per cent with significant differences (P < 0.05) noted at one, two, three and four minutes after ECT (minutes five, six, seven, and eight of the esmolol infusion). There was no significant difference in seizure duration between the two groups and no adverse reactions occurred. Nous avons dvalud l'effet d' une dose standard d'esmolol sur la rdponse cardio-vasculaire aux ~lectrochocs. Dix-sept patients de classe ASA 1 ou H dtaient randomisds et recevaient en prdparation d' une premier ~lectrochoc soit de l'esmolol, soit rien du tout; les r~les #tant inverses trois gt cinq jours plus tard
Key words ANAESTHESIA:electroconvulsive therapy; COMPLICATIONS:hypertension, tachycardia; SYMPATHETIC NERVOUS SYSTEM: beta-adrenergic antagonists, esmolol. Departments of Anesthesiology and Psychiatry, University of Kansas Medical Center, Kansas City, Kansas 66103. Presented in part at the 1988 Annual Meeting of the American Society of Anesthesiologists, San Francisco, California. Address correspondence to: Dr. A.L. Kovac, Department of Anesthesiology, University of Kansas Medical Center, 39th and Rainbow Boulevard, Kansas City, Kansas 66103. C A N J A N A E S T H 1990 / 37: I ! p p 5 8 - 6 2
Anthony L. Kovac MD, Hiroshi Goto MD, Kasumi Arakawa MDPhD, Manuel P. Pardo MD
lors du deuxi~me traitement. Nous avons observd qu' un bolus de 80 mg d'esmolol suivi d'une perfusion d 24 mg. min -I d~butant deux minutes avant et se continuant cinq minutes apr~s l' induction de l' anesthdsie, attdnue l' acc~l~ration maximale du pouls de 26pour cent, l' augmentation de la pression artdrielle moyenne de 14 pour cent et celle du rapport pouls-pression de 37 pour cent. Ces effets dtaient statistiquement significatifs une, deux, trois et quatre minutes post-~lectrochoc (P < 0.05) soit cinq, six, sept et huit minutes apr~s le ddbut de l' infusion. La durde des convulsions ~tait semblable dans les deux groupes et il n' y eu aucune complication.
Electroconvulsive therapy (ECT) is the treatment of choice for patients with depression unresponsive to pharmacological therapy. It causes an intense stimulation of the sympathetic nervous system. Hypertension and tachycardia follow, which may be insignificant or may result in myocardial ischaemia and infarction or stroke, especially in patients with cardiovascular disease. 1'2 Esmolol, a new cardiac selective ultrashort-acting beta adrenergic blocking agent, has been approved in the U.S. for the treatment of supraventricular tachycardias. The objective of this study was to investigate whether a standardized dose of esmolol bolus and infusion can effectively attenuate the cardiovascular responses to ECT in patients receiving general mask anaesthesia.
Methods This study was approved by the Human Subjects Committee of our institution and written informed consent was obtained from each patient. Patients were ASA physical status I or II. Exclusion criteria are listed in the Table. All patients received premedication with glycopyrrolate 0.3 mg IM 30 to 60 minutes prior to ECT. Preoxygenation was started and each patient received both esmolol and "no esmolol" in a randomized, within patient
K o v a c etal.: ESMOLOL AND HAEMODYNAMICS IN ECT
crossover design. During the esmolol treatment an IV bolus of esmolol 80 rag, followed by a continuous infusion at a rate of 24 mg" min- i was started two minutes before induction of anaesthesia. Anaesthesia was induced with methohexitone 1.0 m g . k g -t IV followed by succinylcholine 0.75 m g . k g -I. The patient's lungs were ventilated via face mask with 100 per cent oxygen. Electroconvulsive therapy was performed after fasciculation had ceased. The esmolol infusion was continued until five minutes after induction of anaesthesia. Heart rate (HR) was monitored by ECG and blood pressure (BP) was measured by manual cuff. Seizure duration was measured by EEG. Baseline HR and BP measurements were taken during preoxygenation two to four minutes before the infusion of esmolol. Measurements were repeated every minute throughout the esmolol infusion and at 2, 5, 10, 15, and 30 minutes after the infusion was discontinued. Three to five days later the patients crossed over to the alternative treatment and the procedures outlined above were repeated. Patients received the same electrical shock current and received only one shock per treatment. Data was evaluated as per cent change from pre-ECT baseline values. Analysis of variance (in a crossover model) was used to analyze HR, mean arterial pressure (MAP), and rate pressure product to test for treatment differences and any carryover effect. A P < 0.05 level was used for statistical significance. All computations were performed with the aid of the Statistical Analysis System. 3
Results Of the 17 patients who completed the study, the mean ( - S D ) age was 49 - 17 (range 25-77) and weight was 64 -+ 17 kg (range 50-106). There were no significant differences in pre-study baseline vital signs between the esmolol and "no esmolol" groups. Esmolol was found to blunt significantly the increase in HR (Figure 1) and MAP (Figure 2). The HR and MAP declined after esmolol and increased after administration of ECT. Treatment with esmolol resulted in significantly lower maximum per cent changes in HR and MAP. In fact, esmolol kept the HR TABLE
Exclusion criteria
Pregnant women Less than 21 years of age AV conduction block greater than 1~ Systolic BP
