Management of 2 Cases of Prolonged Seizure: Report From Singapore
Out on PubMed, from investigators in Singapore, is this report:
Selecting right unilateral placement to facilitate continuation of electroconvulsive therapy following prolonged seizures.
Asian J Psychiatr. 2021 Sep 29;66:102874. doi: 10.1016/j.ajp.2021.102874. Online ahead of print.PMID: 34624745
The abstract is copied below:
Available literature remains limited in the identification of risk factors for prolonged seizures in electroconvulsive therapy and much less is reported about the continuation of electroconvulsive therapy after prolonged seizures. We describe two cases with prolonged seizures early in their course of electroconvulsive therapy and the subsequent adjustment made that allowed for safe and effective continuation of electroconvulsive therapy. In both cases, right unilateral electroconvulsive therapy was continued at a suprathreshold stimulus dose of six times relative to seizure threshold. Both patients continued their course of electroconvulsive therapy with no further episodes of prolonged seizures. They did not experience significant cognitive side effects and were discharged after showing marked improvement in their clinical symptoms. Prolonged seizures do not preclude the use of electroconvulsive therapy. The selection of ultrabrief right unilateral electroconvulsive therapy allows for a higher suprathreshold dose with less cognitive side effects compared to bilateral placements. This mitigates the risk of prolonged seizures, allowing for safe and effective continuation of electroconvulsive therapy.
Keywords: Dosage relative to seizure threshold; Electroconvulsive therapy (ECT); Prolonged seizure; Risk factor.
Also, the top 2 panels of EEG display are unconvincing; only the bottom panel shows clearly what is described.
Finally, who knows if this would have happened with bilateral electrode placement at higher stimulus doses; the elevation of RUL to primacy in all situations may have its downsides...
Disagreements aside, I thank the authors and give them kudos for this helpful contribution to the ECT literature.
Unfortunately, in the upper image of figure 1a, only the first 18 seconds of the seizure are visible. Whether the seizure terminates in the next seconds therefore remains unclear. The lower image of figure 1a clearly shows a post-ictal shivering, a typical side effect of anesthesia, for example under propofol. A seizure is no longer clearly recognizable here, since the shivering is completely predominant. In my opinion, therefore, Figure 1B shows another seizure, which is shorter than the first one due to the higher stimulation dose.
ReplyDeleteClose cooperation between psychiatrist and anesthesiologist is also very important in this example to be able to distinguish between shivering and seizure.