New IV Benzo For ECT Anesthesia: Study From Korea
Out on PubMed, from authors in Korea, in JECT, is this paper:
The Effect of Remimazolam on Seizure Profile, Hemodynamics, and Recovery in Patients With Electroconvulsive Therapy Comparison With Propofol and Etomidate: A Retrospective Study.
J ECT. 2024 Jun 10. doi: 10.1097/YCT.0000000000001025. Online ahead of print.PMID: 38857335
Objectives: To compare seizure-related, hemodynamic, and recovery outcomes when using remimazolam for ECT with those of other anesthetics, specifically propofol and etomidate.
Methods: A total of 49 patients who underwent 405 ECT treatment sessions under general anesthesia were retrospectively analyzed. Remimazolam, propofol, and etomidate were used for 93, 138, and 174 ECT sessions, respectively. The primary outcome was durations of motor and electroencephalogram (EEG) seizure activity, whereas secondary outcomes included hemodynamics (ie, mean arterial pressure [MAP] and heart rate [HR] at various time points from induction to postanesthesia care unit [PACU] discharge), antihypertensive drugs administration after electrical stimulus, and recovery profiles (ie, length of PACU stay and incidence of postictal confusion).
Results: Durations of motor and EEG seizures were shorter for remimazolam than etomidate (motor, P < 0.001; EEG, P = 0.003) but similar compared with propofol (motor, P = 0.191; EEG, P = 0.850). During seizure, remimazolam showed a comparable MAP and HR to etomidate (MAP: P = 0.806; HR: P = 0.116). The antihypertensive drug use was lowest for remimazolam (6.8%), followed by propofol (35.6%) and etomidate (65.6%), and the mean length of PACU stay was comparable for remimazolam (19.7 min), propofol (22.8 min), and etomidate (24.5 min). The occurrence of postictal confusion did not differ among the 3 agents (P > 0.050).
Conclusions: Remimazolam is a promising anesthetic option for ECT because of its comparable seizure profiles, stable hemodynamics, and comparable PACU stay when compared with propofol and etomidate without additional adverse events.
The article is here.
And from the text:
This is pretty interesting stuff in the world of ECT anesthesia. Benzos get a bad rap in ECT, other than for seizure termination and agitation treatment. This is a tantalizing, retrospective, pilot study, and the authors promise a prospective one, so kudos to them.
Too soon to know the exact recipe, but perhaps the ideal future ECT induction mix will include ketofol, dexmedetomidine and a whiff of remimazolam...
That is an extremely exciting story.
ReplyDeletePossibly one limitation will remain that, as reported in the paper, higher amounts of charge are necessary for remimazolam. These are known to lead to a higher rate of cognitive side effects, just like benzodiazepines per se, so both together could represent a real limitation.
Additionally, the EU has unfortunately followed the "UN Convention on the Rights of Torture" ("European Committee for the Prevention of Torture
(CPT) standards'") in Section 1.2.2 that unmodified ECT is to be regarded as torture. Since in Europe the new drug is not approved as a general anesthetic but only as a sedative (like other benzodiazepines), ECT is strictly speaking to be regarded as unmodified (as it does not involve anesthesia) and could therefore legally fall under torture. A huge problem. As a limittion, it could be mentioned that the EU also defines "unmodified" including the omission of a muscle relaxant, so ECT with benzodiazepine AND muscle relaxant may not be described as classically unmodified after all.
Very interesting !