Seizure Duration: Increased Charge=Shorter Seizures
Out on PubMed, from the well-known Harvard group, is this study:
Changes in seizure duration during acute course electroconvulsive therapy.
Brain Stimul. 2021 Jun 10:S1935-861X(21)00117-0. doi: 10.1016/j.brs.2021.05.016. Online ahead of print.PMID: 34119670
The abstract is copied below:
Background: Seizure duration has long been measured as a potential marker of ECT treatment efficacy, with concern that short seizures may be clinically ineffective. Relatively small studies have documented a trend towards shorter seizures during acute course ECT, but data from large cohorts would help provide normative data on seizure duration changes during treatment.
Objective: This study analyzes the effects of age, sex, ECT dose, and treatment number on the duration of electrographic seizures during acute course ECT in a large single-center cohort.
Methods: A single-center retrospective chart review was conducted of adult patients receiving a first course of ECT from 2000 to 2017 at a large freestanding psychiatric hospital.
Results: 3648 patients met inclusion criteria, receiving 32,879 acute course ECT treatments. There was a shortening of mean ECT seizure duration over the acute course, with the greatest decrease in duration over the first 3 treatments but continuing decreases over the entire acute course. Older age, higher ECT dose, and increasing treatment number were all associated with shorter seizures, while sex was not significantly associated. Increasing treatment dose was associated with shorter seizures relative to no dose increase, with those patients receiving the highest cumulative doses also having the shortest cumulative seizure time.
Conclusions: Among patients undergoing acute-course ECT treatment, seizure duration decreased over the treatment course, and increases in applied electrical charge were associated with shorter seizures.
Keywords: Cohort studies; Electroconvulsive therapy;
This well-presented data set is most important for debunking the myth that the way to get a longer seizure is to raise the charge; in fact, the opposite is true. But raising the charge may still be the correct intervention for the next treatment.
Here are my opinions of the duration issue:
1) VERY short seizures may be less than optimally therapeutic.
2) at the long end, the intervention cut off should be 2 minutes, not 3. One hundred and twenty seconds is plenty long, and it may be more difficult to terminate seizures the longer they persist. You should be calling for the methohexital at around 100-110 seconds...
Dr. Luccarelli is to be commended for another yeoman's effort at data mining. The data themselves are compelling, but without clinical correlation, they are of limited significance.
Still, I recommend that all ECT clinicians read this report in full, ~20 minutes.
Thank you for your coverage of our article. We agree completely that the clinical importance of seizure duration remains unproven (with the possible exception of very short seizures), but hope that our article can put to rest the idea that a higher electrical dose will lengthen short seizures, as in our dataset the opposite was true. We agree that a 2 minute cutoff for seizures is sufficient, in our protocol we give low-dose propofol for any seizure continuing past that point (regardless of the initial anesthetic). We hope to better link this duration data to outcomes in a future publication.
ReplyDelete-James Luccarelli