Flumazenil in ECT
Out on PubMed, from clinicians in Japan, is this case report and literature review:
Flumazenil for Successful Seizure Induction With Electroconvulsive Therapy: Case Report and Literature Review.
Clin Neuropharmacol. 2020 Dec 21;Publish Ahead of Print. doi: 10.1097/WNF.0000000000000429. Online ahead of print.PMID: 33351502
The abstract is copied below:
Objective: Electroconvulsive therapy (ECT) is indicated for various psychiatric situations that are difficult to manage otherwise and may be regarded as a last resort but seizure induction is sometimes difficult, resulting in inadequate trials and futile outcomes.Method: We report on a 72-year-old female patient with bipolar depression whose seizure induction with ECT was challenging but the use of flumazenil was deemed effective to obtain remission in the end. We also provide a literature review on this topic.
Results: Seizure induction was managed with the use of flumazenil, a selective GABA-A receptor antagonist to neutralize the effects of benzodiazepine hypnotics, together with decreasing the amount of anesthesia, increasing the pulse width, and adding chlorpromazine. A PubMed search with keywords of flumazenil and ECT yielded only 14 hits (December 2020) and found some indication that flumazenil might be of use for this purpose even in the absence of benzodiazepines, although evidence base has remained very limited.
Conclusions: Flumazenil, an antidote of benzodiazepines, may be effective regardless of whether benzodiazepines are in use. Because inefficient ECT is clinically problematic, more studies are necessary to investigate the effectiveness of flumazenil for successful seizure induction with ECT.
This case report and literature review is a useful reminder of concepts of seizure adequacy and the option to use flumazenil, when appropriate, for benzodiazepine (BZ) reversal.
I hesitate to be a "monday morning quarterback" in clinical situations, but the case report itself is unconvincing at best - way too many moving parts to have any idea if the flumazenil was helpful.
Flumazenil is a useful tool, but it is not a panacea, and does not replace good clinical practice in going through the steps to figure out why a patient's seizures may be inadequate. This starts with a review of concomitant medications, anesthesia drugs and doses, stimulus dosing parameters, and good hyperventilation.
I have always been a fan of keeping ECT anesthesia as uncomplicated as possible. Many patients (most?) will have perfectly fine ECT seizures even with a small amount of BZ on board- routine use of flumazenil in such patients (even at the first treatment) will persuade the practitioner that it was the flumazenil that allowed for a good seizure, when it may have been totally unnecessary.
Some would argue on the other hand, that since flumazenil is very safe, why not use it liberally?
It does complicate the treatment slightly, since "covering" with additional benzodiazepine before anesthesia emergence to prevent withdrawal symptoms is thought to be prudent, when flumazenil has been given.
The rationale, and need, for using flumazenil, in catatonic patients who have recently been on or remain on, high doses of BZ, is a different situation-that is a very convincing scenario for its use.
And the idea that flumazenil has intrinsic benefit, even if no exogenous BZ has been taken by the patient, while intriguing, needs more investigation.
I agree with the authors' surprise that the available literature on the use of flumazenil in ECT is still so limited.
A table from the report:
This case report and literature review is a useful reminder of concepts of seizure adequacy and the option to use flumazenil, when appropriate, for benzodiazepine (BZ) reversal.
I hesitate to be a "monday morning quarterback" in clinical situations, but the case report itself is unconvincing at best - way too many moving parts to have any idea if the flumazenil was helpful.
Flumazenil is a useful tool, but it is not a panacea, and does not replace good clinical practice in going through the steps to figure out why a patient's seizures may be inadequate. This starts with a review of concomitant medications, anesthesia drugs and doses, stimulus dosing parameters, and good hyperventilation.
I have always been a fan of keeping ECT anesthesia as uncomplicated as possible. Many patients (most?) will have perfectly fine ECT seizures even with a small amount of BZ on board- routine use of flumazenil in such patients (even at the first treatment) will persuade the practitioner that it was the flumazenil that allowed for a good seizure, when it may have been totally unnecessary.
Some would argue on the other hand, that since flumazenil is very safe, why not use it liberally?
It does complicate the treatment slightly, since "covering" with additional benzodiazepine before anesthesia emergence to prevent withdrawal symptoms is thought to be prudent, when flumazenil has been given.
The rationale, and need, for using flumazenil, in catatonic patients who have recently been on or remain on, high doses of BZ, is a different situation-that is a very convincing scenario for its use.
And the idea that flumazenil has intrinsic benefit, even if no exogenous BZ has been taken by the patient, while intriguing, needs more investigation.
I agree with the authors' surprise that the available literature on the use of flumazenil in ECT is still so limited.
The below comment is from Dr. Max Fink:
ReplyDeleteFlumazenil ECT 01-06-21
My associates and I were developing a catatonia rating scale and treatment protocols for BZD and ECT at University Hospital in Stony Brook in 1990s. Some seizures were inadequate.
I received a call from Sam Bailine, relating his experience with flumazenil, in 1994. We followed his advice and established flumazenil during induction for ECT for every catatonia patient. The results, published in the Acta Scand Psychiatrica in 1996 established treatment protocols for catatonia well accepted today.
We are very grateful for Sam's pioneering studies and advice.
Max Fink
I treated an elderly patient with a clear past history of ECT responsivity in past episodes years ago who was admitted for severe depression and had now developed cryptogenic cirrhosis with a history of hepatic encephalopathy (HE) (on lactulose). During the current episode he had undergone two prior courses without response. Given his compelling history of prior response and relatively short seizure durations in his two most recent courses, we opted for a RE-trial of ECT.
ReplyDeleteGiven the finding of increased GABA-ergic tone with HE, we pretreated with flumazenil despite not being on benzodiazepines. With thins strategy and the addition of Wellbutrin, his condition improved substantially.