Commentary on Sevoflurane Review From Dr. Andrade

Here is Dr. Andrade's  most recent online commentary in J Clin Psych:

The link is here:

https://doi.org/10.4088/JCP.21f14173
https://www.psychiatrist.com/jcp/depression/anesthesia-electroconvulsive-therapy-niche-role-for-sevoflurane/

The abstract is copied below:

Anesthesia for electroconvulsive therapy (ECT) usually involves the intravenous (IV) administration of drugs such as methohexital, thiopental, propofol, etomidate, or ketamine. Sevoflurane is an inhalational anesthetic agent that has been available for the past 3 decades. Although many studies have examined sevoflurane in the context of ECT, treatment guidelines make either no mention or only passing mention of its potential use in the ECT procedure. A recent systematic review and meta-analysis identified 12 randomized clinical trials (pooled N = 377) of sevoflurane vs IV anesthetics in patients receiving ECT. The meta-analysis found that sevoflurane was associated with shorter EEG seizure duration than barbiturate, ketamine, or propofol anesthesia; that the postictal suppression index did not differ significantly between sevoflurane and propofol; that sevoflurane increased heart rate more than did the IV anesthetics; that sevoflurane increased mean arterial pressure more than did barbiturates and propofol but less than did ketamine; and that, overall, adverse events did not differ significantly between sevoflurane and IV anesthetics. Other known disadvantages of sevoflurane include the need for additional anesthesia instrumentation, the potentiation of action of nondepolarizing muscle relaxants, and the increased complexity of the ECT procedure. These findings and considerations do not encourage the use of sevoflurane for ECT anesthesia. However, there may be a niche role for sevoflurane in patients who are afraid of needlesticks or who are too agitated for an IV line to be set up while they are conscious and in patients who characteristically experience prolonged ECT seizures. Sevoflurane could also be useful in the final trimester of pregnancy because it may inhibit ECT-induced uterine contractions. Importantly, undesired effects of sevoflurane on seizure duration and the hemodynamic response to ECT can be attenuated by discontinuing its administration after induction.

And from the text;

The concerns expressed in the previous section discourage the routine use of sevoflurane as anesthesia for ECT, especially because administering inhalational anesthesia increases infrastructural requirements and the complexity of the ECT procedure. So, in what contexts may sevoflurane be administered?

Sevoflurane could be useful for patients who are too agitated or too afraid of needle sticks for anesthesia to be administered intravenously; the muscle relaxant for ECT can be administered once the sevoflurane anesthesia takes effect. Next, sevoflurane has been suggested to reduce uterine contractions after ECT; it could therefore be useful when ECT requires to be administered during pregnancy, especially during the third trimester. Finally, some patients tend to have problematically prolonged seizures with ECT; sevoflurane anesthesia can be useful in such patients. Sevoflurane-related amplification of the hemodynamic response to ECT or its attenuation of seizure duration can be addressed by decreasing or stopping its administration after induction.

Readers may note that a risk with sevoflurane is that it may increase the effect of nondepolarizing muscle relaxants16–18; the interaction between sevoflurane and succinylcholine is less clear. On a parting note, there have been many case reports of seizure-like activity provoked by sevoflurane; these are incongruent with the seizure-abbreviating action of sevoflurane that was identified in the meta-analysis. Perhaps the EEG effects of sevoflurane in the context of ECT merit careful further exploration.

Dr. Andrade uses the recent systematic review and meta-analysis of sevoflurane (see blog post of July 17th) as a jumping off place to write a brief review of ECT technique and a more detailed review of ECT anesthesia induction agents. He also critiques the meta-analytic methods of the review.
He is correct in saying that sevoflurane has a "niche role," a very small niche, I might add.
Dr. Andrade's commentaries are always worth reading, and I commend this one to all students of ECT anesthesia, ~10 minutes.