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Anesthetic Management During Electroconvulsive Therapy in Children: A Systematic Review of the Available Literature

Stein, Alecia L. S. MD*; Sacks, Stuart M. MD; Roth, Joeli R. BS*; Habis, Mohammed MD*; Saltz, Samantha B. MD; Chen, Catherine MD*

Author Information
doi: 10.1213/ANE.0000000000004337
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Abstract

Electroconvulsive therapy (ECT) has proven to be a safe and therapeutic treatment for a multitude of psychiatric conditions in adults.1–3 However, existing literature on its use in children is more limited. After robust use during the mid-20th century, persistent negative perception4–6 stymied research in children for decades. ECT utilization suffered after the development of newer psychotropic medications,7 in combination with a fear of unknown neurocognitive effects8 and the influence from negative popular culture depictions.4 Despite the existence of favorable outcome data, which supports ECT as a low-risk, effective option in early9 and late-stage7,10–12 psychiatric disease, this modality is still underutilized in children.10,11

Throughout the early decades, ECT was administered without general anesthesia (GA) and caused significant morbidity and emotional trauma, and, as such, exacerbated the associated stigma.2 Eventually, ECT practice evolved to the modern method where implementation of GA and muscle paralysis led to diminished morbidity and improved tolerability.

The implications of the corresponding anesthesia management for ECT have been well described in the adult literature,13–15 whereas there is a dearth of corresponding pediatric anesthesia literature.16,17 From the earliest published reports of ECT in children, reference to use of anesthesia, or lack thereof, is minimal.18–20 As ECT use in children is increasingly accepted as an effective treatment modality, definition of its key clinical features, patient and safety profile, and corresponding best anesthesia practices are necessary to facilitate safe periprocedural care. Therefore, our primary objective was to review and synthesize the current, available literature on optimal anesthesia care for children undergoing ECT, and, in doing so, to identify gaps ripe for future investigation.

METHODS

Data Source and Search

PubMed, Cochrane Database of Systematic Review, and Embase queries were performed in November 2018. The keywords used in all searches were valid MeSH (NLM/NIH) terms. PubMed search terms were “adolescents” or “children” or “preschooler” AND “electroshock” or “electroconvulsive” or “electric stimulation”; Cochrane database search terms were “child” or “children” or “adolescent” or “youth” or “preschool” AND “electroconvulsive” or “ECT” or “electroshock”; and Embase search terms were “child” or “children” or “adolescent” or “youth” or “preschool” AND “electroconvulsive” or “ECT” or “electroshock”.

Eligibility Criteria

Eligibility criteria were as follows: (1) manuscript written in English; (2) persons under 18 years of age; and (3) use of ECT intervention. Reasons for article exclusion included no use of ECT intervention, no full-text article published, non-English language, or inadequate demographic information with regard to age.

Study Selection

Figure 1.
Figure 1.:
Prism flow diagram. The initial search results; the number of records identified, included, and excluded; and the reasons for exclusions (see below). aArticles screened and excluded based on title/abstract being unrelated to the topic. bFull-text articles omitted based on exclusion criteria: patients ≥18 y of age, no use of ECT, no full-text article published, non-English language, and cases without adequate demographic information with regard to age.21

Two senior reviewers independently screened articles identified by the search strategy (Figure 1).21 Title and abstract review were performed to remove duplicates and to assess for eligibility. Included studies underwent full-text review. Studies not meeting inclusion criteria were excluded. A cited reference search of included articles was performed to identify additional citations not captured in the database search.

Data Extraction

Data extract included patient information including age, sex, comorbidities, psychiatric diagnoses, medication regimen, and indication for ECT. Other data extracted included anesthesia medications (induction and paralytic agents and premedication), details of airway management (type of ventilation and method of securing airway), details of ECT (total number of treatments, seizure duration, and laterality), and reported adverse events.

Risk of Bias Assessment

Studies were assessed by 2 authors utilizing tools specific to each study design. The Critical Appraisal Skills Program (CASP) checklist was used to critically appraise the quality of cohort and case–control studies; the National Heart, Lung, and Blood Institute (NHLBI) Study Quality Assessment Tool for Case Series from the National Institute of Health was used for descriptive observational studies.

Analysis

Analysis of categorical variables was presented as a numerical value and percentage of total cases. The methods described above are consistent with the Preferred Reporting Items for Systematic Reviews (PRISMA) protocol for systematic reviews.

RESULTS

A total of 2453 titles were identified by the search strategy, of which 317 were deemed potentially relevant and included by initial abstract and title screening. Of these articles, 243 were excluded after full-text review, and 67 were included. Eight additional articles were identified on citation review, for a final total of 75. This process is depicted in the PRISMA diagram (Figure 1).

Study Characteristics

Table 1.
Table 1.:
Summary of Pediatric ECT Literature
Figure 2.
Figure 2.:
Number of articles on pediatric ECT published by year. ECT indicates electroconvulsive therapy.

The 75 included studies22–96 (Table 1) consisted of observational descriptive studies (case reports [n = 48], case series [n = 21], retrospective chart review [n = 1]) and observational analytical studies (cohort [n = 4] and case–control [n = 1] studies). Publication years ranged from 1990 to 2018 (Figure 2). Additional articles, including 1 randomized case–control study with 74 patients9 and 2 larger retrospective chart reviews,10,97 were excluded due to inclusion of adult data in their results. With the exception of a few case reports,23,45 the search query originated from psychiatric journals. No observational or interventional trials focusing on anesthesia management during pediatric ECT were identified.

Demographics

Clinical data were summarized for a combined 592 patients (Table 2). The median age was 15 years (range, 6–17 years), and weighted mean age was 15 years. Of the 114 patients with a known age during their treatment course(s), more than 90% were reported to be between 12 and 17 years of age; with the remaining individuals reportedly being between 6 and 11 years of age. No recent reports of ECT administered to children <6 years of age were identified. The total cohort included 310 males (M) and 282 females (F) (M:F, 52.4%:47.6%).

Table 2.
Table 2.:
Demographics and Clinical Characteristics of Children <18 Years of Age Undergoing ECT

The primary psychiatric diagnoses most commonly represented were major depressive disorder (n = 185), schizophrenia/schizoaffective disorders (n = 187), bipolar disorder/mania (n = 106), and isolated catatonia (n = 44). A multitude of neurological disorders were also treated with ECT in this cohort: neuroleptic malignant syndrome (NMS)23,34,87,92 (n = 8), refractory status epilepticus29,36,58,61 (n = 5), anti-N-methyl-d-aspartate (NMDA) receptor encephalitis66,70,74,82 (n = 4), lupus cerebritis67,76,78 (n = 4), and intractable tics26,74 (n = 2).

Medical comorbidities were reported in approximately 16% of all cases. The most common coexisting conditions were developmental delay (n = 21) and autism (n = 18). Other coexisting conditions include those from the cerebral nervous system (CNS; n = 7) including cerebral palsy and structural abnormalities and hematologic (n = 4) and endocrine systems (n = 5). Other coexisting conditions of note included pregnancy50,80 and Down syndrome (n = 7).62,84,88,91

Common primary indications for ECT treatments included severe psychosis (n = 190), symptoms refractory to pharmacotherapy (n = 154), suicidality (n = 153), catatonic symptoms (n = 90), and aggressive/self-injurious behavior (n = 10), and frequently, multiple behavioral indications for ECT were present in individual patients.

Medications

All of the cases were reported to have underwent and subsequently failed at first- and second-line medical treatments before referral to ECT and, in some cases, proceeded to fourth- and fifth-line treatments before ECT.93 Psychotropic drug classes included benzodiazepines, antipsychotics, and selective serotonin reuptake inhibitors. In several reports, the current medication regimen was stopped immediately before ECT initiation, but this was not universally described. Chronic benzodiazepine use was either held for 12 hours68 or antagonized with flumazenil (0.4–0.5 mg) immediately before ECT.,55,61,77,82,92 In others, midazolam was administered immediately postprocedure for prevention of postictal delirium.60,77

Anesthetic Approach

Limited detail of the anesthetic technique was identified in 36 of the eligible articles. No technique other than GA was described, and only the occasional mention of supplemental oxygen was noted.23 Induction agents were reported as follows: 73% of treatment courses utilized propofol (n = 422 patients); a percentage skewed due to the article detailing ECT in 406 children under propofol-induced GA88; 8% utilized methohexital (n = 45); 3% utilized thiopental (n = 18); and <1% utilized ketamine (n = 1),85 etomidate (n = 1),67 or inhalational volatile agent alone (n = 1).37 Other variations described included combinations of the above induction agents (Figure 3A).23,69,91,93 In terms of paralytic agents, less than half (n = 31; 41.3%) of the reviewed articles reported the use of a neuromuscular-blocking agent, and, of those, the majority reported use of succinylcholine (n = 490; 82.8%). Other reported paralytics agents consisted of rocuronium, atracurium, and mivacurium (Figure 3B).

Figure 3.
Figure 3.:
Comparison of reported anesthetic agents. A, Percentage distribution of reported anesthetic induction agents administered before initiation of ECT in children. B, Percentage distribution of reported muscle paralytic agents administered before initiation of ECT in children. ECT indicates electroconvulsive therapy.

We did not identify any reported instances of anesthetic emergencies or complications. Further specific detail regarding the periprocedural anesthesia care, including the methods of airway management, intraprocedural hemodynamic monitoring, emergence, recovery locations, and staffing and time for anesthesia recovery, were lacking in the articles reviewed.

ECT Characteristics

Table 3.
Table 3.:
ECT Characteristics

If a patient ultimately underwent >1 ECT treatment course, the details of each course were tabulated individually. The average number of ECT treatments per patient was 18.9 ± 21.9 (range, 2–156; Table 3), with 7 patients ultimately required ongoing maintenance ECT,46,52,55,57,65,83,92 most commonly due to malignant catatonia. Seizure length duration, as objectively measured by electroencephalogram (EEG), was calculated. The weighted average for induced seizure duration was 91.89 ± 144.3 seconds (range, 4–867 seconds; n = 63 cases), with the majority reporting durations between 20 and 120 seconds. ECT laterality was reported in 153 cases, 108 were (70.59%) bilateral, 21 (13.73%) unilateral, and 24 cases (15.69%) utilized a combination of the 2. Data from articles in which laterality was reported as an average over the entire cohort were not analyzed.31

Adverse Events

The most common events to occur were minor: headache, nausea/vomiting, sedation, and short-term amnesia. More severe events, such as benign cardiac arrhythmias, symptomatic bradycardia, or prolonged seizure time, were identified as occurring less frequently. Two deaths in children with treatment-resistant refractory status epilepticus were reported subsequent to salvage ECT.36,61

DISCUSSION

ECT is among the most frequently performed medical procedures in adults, with major depression as the most common indication.98 In contrast, ECT is used far less frequently in minors. Current epidemiological data suggest that, in the United States, only approximately 1% of all ECT treatments are performed on patients <19 years of age,10 and in regions with more restrictive laws, this age discrepancy widens.99 Acceptance of ECT as a beneficial treatment modality is increasing,88 as is research interest on the subject. While the positive change in publication frequency over the past 2 decades (Table 2) may suggest as much, recent large-scale epidemiological surveys of pediatric ECT have not yet been completed.

We performed what is, to our knowledge, the first systematic survey of the literature specifically focusing on anesthetic practice for ECT in children. We were able to identify 70 articles that met our inclusion criteria (Table 1). Our analysis shows that ECT has been used in a wide range of ages for a variety of indications (Table 2). Consistent with current psychiatric literature,11,12 the majority of reported treatments were administered to adolescents. The youngest patient in this cohort was 6 years of age, with approximately 10% under 11 years of age.

Preprocedural Considerations

The children in this review were referred most commonly for severe psychosis or symptoms refractory to oral medical regimens with primary diagnoses of major depression, schizophrenia, or bipolar disorder/mania (Table 2). ECT is indicated in children when psychiatric illness becomes life threatening (ie, suicidality or self-injurious behavior, malignant catatonia, or malnourishment) or for that which has proved refractory to treatment. The American Academy of Child and Adolescent Psychiatry (AACAP) guidelines suggest the following criteria for ECT based off of (1) diagnosis; (2) severity of symptoms that are persistent and significantly disabling; and (3) lack of response to appropriate trials of pharmacotherapy. In addition, per the guidelines, every child should receive evaluation from an independent, nontreating psychiatrist before initiation of ECT course.100

Children receiving referral for ECT differ in many ways from their adult counterparts. Psychiatric literature demonstrates that these children present with extremely advanced psychiatric disease complicated by symptoms of severe dehydration, malnourishment, and diminished functional capacity10,79 due to significant delays in treatment and diminished access to care.55,57 State age regulations101 and perception problems among health care professionals result in referrals for ECT only after all other treatment options have been exhausted.97 In addition, these children, while likely to be free from chronic cardiopulmonary disease, may be complicated by coexisting disease,10 multiple psychiatric diagnoses, or other significant medical conditions. The common conditions described to coexist in this cohort include developmental delay, autism spectrum disorder, and Down syndrome (Table 2). A triad of catatonia, autism, and psychosis/self-injurious behavior has been observed frequently and in fact is theorized to be a distinct subpopulation of autism.44,48,52,55,58,60,73

Although ECT is considered low risk with no absolute contraindications, preprocedural anesthesia evaluation and medical optimization should be completed while considering particular comorbidities. For instance, endotracheal intubation should be planned in children at risk of aspiration or upper airway obstruction during sedation (ie, Down syndrome, syndromes that impact the airway, or severe obesity). Children with intracranial implants or masses require specific planning with regard to electrode placement,45,70 and children with refractory status epilepticus are likely to be intubated, sedated, and undergoing treatment in intensive care settings.29,36,58,61

Typically, preprocedural testing is not required unless indicated due to preexisting comorbidities, such as cardiovascular disease, or when medication regimens warrant as much. However, baseline basic metabolic values will often have been obtained to rule out reversible medical causes of psychiatric symptomatology.102 Menstruating girls should undergo urine pregnancy testing before the procedure. While ECT is not specifically contraindicated in pregnancy, fetal anesthetic exposure should be minimized.103 In fact, ECT is the choice treatment for bipolar disorder and major depression during pregnancy. While the fetal impact from ECT exposure is unknown, it is considered safe.104 Two cases of successful ECT administration in pregnant adolescents have been identified in the literature.50,80

Regarding historical periprocedural imaging, physicians would order pre- and post-ECT vertebral radiographic screening when ECT was administered without anesthesia. Later, subsequent to modern ECT practice, analysis of pre- and post-ECT films, demonstrated no resulting musculoskeletal injury. Accordingly, the American Psychiatric Association (APA) does not recommend routine radiographic imaging.105

Treatment of procedural anxiety without intravenous (IV) access is a known challenge to the pediatric anesthesiologist. Younger patients and those with developmental delay, needle phobia, or severe agitation or aggression have obvious difficulty with repeated IV sticks. This presents an additional challenge for GA inductions for a procedure that, in our analysis, averaged 16 treatments, ranged as high as 150, and was administered as often as 3 times per week. In the case of the highly anxious child, inhalational induction, followed by IV access and intra- or supraglottic airway management, may be considered.

Premedication with a benzodiazepine such as midazolam before an inhalational induction is difficult, for use of this drug class risks decreasing seizure duration and therapeutic response,106 although to what extent this effect may differ in children versus adults is not yet known. In addition, children suffering from catatonia or anxiety are typically on chronic benzodiazepine treatment and typically require flumazenil, a benzodiazepine competitive antagonist, reversal before treatment. Dosages of 0.4–0.5 mg provide antagonism with preservation of seizure quality. Withdrawal symptoms are minimized as long as benzodiazepines are readministered immediately postprocedure.107 Therefore, benzodiazepine anxiolysis is not ideal. However, dexmedetomidine may prove a better option for periprocedural sedation for not only does it attenuate the catecholamine surge after ECT, it also reduces agitation without impacting seizure quality or duration.108,109 Intranasal administration is an option in children without venous access; however, the extended time (approximately 45 minutes) to effect must be considered.110 Alternative to inhalational inductions, when a long treatment course is anticipated in children with significant needle phobia, placement of a peripherally inserted central catheter or port may be prudent.16

The overall anesthetic plan should attend to 3 main goals: (1) ensure adequate depths of anesthesia; (2) provide complete muscle relaxation to blunt convulsions; and (3) utilize medications that minimize impact on seizure quality yet facilitate a rapid recovery. Seizure quality may benefit from increased time interval between administration of induction agent and initiation of the electrical stimulus.111

Features of ECT

Details of ECT, including length of treatment course, electrode placement, and seizure duration, were collected (Table 3). The average treatments per course in our tabulated data are consistent with those noted in the psychiatric literature.112 Data suggest that improvement of clinical status in adolescents may not be expected until ≥6 rounds have been completed. Only when the treatment course reached 12 rounds did they become statistically predictive for improvement.112 Disease type, severity, and treatment delays translate to longer ECT courses97 and additional anesthetic exposures.

In this cohort, bilateral electrodes were most commonly used. The AACAP guidelines recommend unilateral treatment first followed by bilateral treatment in refractory or critically urgent cases.100 Electrode placement requires careful discussion between the proceduralist and anesthesiologist, for, in addition to its impact on therapeutic response,113 electrode placement can interfere with airway access. In adults, high-dose unilateral ECT is noninferior to bitemporal ECT and is associated with a better side effect profile.114 Contralateral unilateral electrode placement is helpful when motor seizure is measured17 or in the presence of implanted CNS devices (ie, deep brain stimulators or cochlear implants), where bilateral placement may cause electrical burn or device malfunction.45

EEG is the most objective measure of seizure duration. Alternatives to EEG include electromyography (EMG) or direct visualization of an extremity isolated from circulation via inflated noninvasive blood pressure cuff or tourniquet.16 Clinical evidence suggests that therapeutic response is positively associated with seizure duration115; however, little consensus exists regarding optimal seizure durations in the pediatric population. Children exhibit lower seizure thresholds and longer durations; thus, they require less electrical stimulus.58 Seizure lasting <15 or >120 seconds are considered suboptimal.16,116 Seizure adequacy has been defined as >25 seconds by some authors.88 EEG seizure activity ranging between 25 and 50 seconds in adults appears to produce the optimal response.

Variables Affecting ECT-Induced Seizure Quality

It is incumbent on the anesthesiologist to understand those variables that affect therapeutic seizure quality. Physiological changes, such as reductions in partial pressures of carbon dioxide (Paco2), have been shown to reduce the seizure threshold and prolong duration. Gómez-Arnau et al117 demonstrated reduced threshold stimulus requirements in adult patients who were hyperventilated before the application of electrical stimulus. This phenomenon has not yet been investigated with respect to the pediatric population.

Almost all hypnotic agents exhibit anticonvulsant properties mediated via gamma-aminobutyric acid-a (GABAa) receptor activation and release of its inhibitory neurotransmitter, GABA. The impact of these agents on therapeutic seizure parameters in children has not yet been studied. Even so, large, well-designed studies on clinical outcome and optimal dosages in adults are still needed.15 Methohexital, a short-acting barbiturate, is the gold standard for anesthesia induction for ECT. Although there is a dose-dependent decrease in seizure duration, its effect is less than that of other barbiturates or propofol, especially at increasing doses.118 Recovery in children is rapid (5–15 minutes), and its hemodynamic profile is favorable.17 Of note, paradoxical tonic–clonic seizures have been described after methohexital administration.72 Consider methohexital the first-line agent of choice when available and in the case of suboptimal seizure duration with the use of propofol.15

Propofol-based induction is increasingly common. A majority of cases in this review utilized this agent with good clinical outcome.88 Low-dose propofol (0.75 mg/kg) results in similar seizure durations as methohexital, but the seizure threshold increases significantly at higher doses (1.5–2.5 mg/kg).118 Advantages include reduced fluctuations in hemodynamics after ECT,119 faster recoveries,15 and overall preserved seizure quality in randomized, double-blinded controlled trials.118,120 Administration of propofol in combination with agents such as dexmedetomidine109 or remifentanil121 demonstrates synergism and reduces the required induction dose. Considering its ready availability, proven efficacy, and increased seizure duration in the presence of adjunctive administration, propofol may be a good option for children.

Ketamine, a selective NMDA receptor antagonist, lowers seizure threshold and increases its duration and amplitude when compared to methohexital.122 Despite this favorable profile, only 1 case reviewed reports its use.85 It may be an appropriate substitute after suboptimal seizure response.123 ECT with ketamine elicits a better clinical response over other agents specifically for depression, but it is associated with a higher side effect profile.124 Drawbacks include dysmorphic hallucinations that are difficult to mask without benzodiazepine anterograde amnesia, accentuated fluctuations of hemodynamics from catecholamine release, and excessive salivation.

Etomidate has actually been shown to increase seizure length when compared to propofol and thiopental125; however, it is not frequently used in children. Its side effect profile includes nausea and vomiting, adrenal suppression, and increased risk of hemodynamic instability.118

Volatile inhalational agents, namely sevoflurane, may be indicated when inhalational induction is required to place an IV, in late-stage pregnancy to reduce post-ECT uterine contractions,13 or in the event of planned controlled mechanical ventilation. The impact of lower concentrations (1.7%) of sevoflurane with nitrous oxide 50% on seizure duration and attenuation of hemodynamic response are equal to thiopental, whereas the impact of higher sevoflurane concentrations (3.4%) exceeds that of thiopental.13 Disadvantages of these agents include increased time to achieve requisite anesthesia depth and recovery.

Muscle Relaxation

Muscle relaxation is a key component of modern ECT. Adequate paralysis should be confirmed with the use of nerve stimulation126 to minimize injury and postprocedural complications. Historically, succinylcholine is the agent of choice due to its rapid onset and recovery, and the agent was used in the majority of cases reviewed. Certain clinical scenarios, however, will warrant the use of alternative agents.

Succinylcholine given in the presence of catatonia has been described to cause brief destabilizing hyperkalemia127,128 with a rapid return to baseline.128 This fluctuation is likely due to an up-regulation of muscle nicotinic acetylcholine receptors (AChRs) after catatonia-associated disuse limb atrophy129 and has also been described after extremity immobilization disuse from a casted limb.130 Children with prolonged refractory catatonia are likely to have upregulated AchRs, and short-acting alternatives to succinylcholine should be considered.

The agent should also be avoided in patients with susceptibility to NMS,131 a rare, potentially fatal complication of atypical antipsychotic medications. NMS is characterized by muscle rigidity and hyperthermia,119 and, in some cases, it may be treated with ECT.23 The syndrome shares biochemical similarities to malignant hyperthermia (MH),119 has been triggered by depolarizing and some nondepolarizing agents,23 and in some cases has responded to dantrolene treatment. Literature is conflicting in regard to the susceptibility of NMS patients to MH and corresponding triggering agents, but feasible alternatives should be considered nonetheless.132

The use of longer-acting agents has been proposed as an alternative to succinylcholine when dantrolene is unavailable. Rocuronium used with sugammadex reversal may be the viable alternative to succinylcholine. This combination results in shorter recovery times and fewer side effects.133 Reports of sugammadex use in children are in the literature, and research is ongoing.134 Rocuronium without sugammadex reversal will require extended controlled ventilation with a secured airway, and the time under GA will be significantly prolonged.135

Autonomic Considerations

ECT induces a rapid vagal stimulation followed by a longer-lasting sympathetic surge, which lasts for 5–10 minutes. This hyperdynamic response is characterized by hypertension, tachycardia, and increased cerebral blood flow. Antimuscarinic premedication will reduce upper airway secretions and suppress vagally induced bradyarrhythmias. Glycopyrrolate is typically preferred over atropine; because it does not cross the blood–brain barrier, deleterious cognitive effects may be avoided.136 Most anesthetic agents, particularly propofol,121 blunt this sympathetic response. While most children are free from cardiopulmonary and CNS disease, consideration should be made to choose specific agents that minimize the hemodynamic fluctuations in children with particular risk.

Psychotropic Medications

Children presenting for ECT will typically be on ≥1 psychotropic agent.10,59 Many of these medications have the potential to interact with anesthetic agents.

Antidepressants.

Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressants in this population.137 They exhibit minimal effect on seizure threshold or cardiac conduction pathways. In addition, they have relatively minimal anticholinergic properties, sedative effects, and less orthostatic hypotension when compared to other antidepressants.138 Discontinuation before ECT is not warranted. Tricyclic antidepressants are still used in the pediatric population to treat obsessive-compulsive and attention-deficit hyperactive disorders. They induce both anticholinergic and myocardial depressant effects and should be tapered slowly before the procedure. Abrupt discontinuation may precipitate cholinergic symptoms.139

Mood Stabilizers.

Lithium is a mood stabilizer prescribed for the treatment of bipolar disorder. The agent prolongs both seizure duration and muscle relaxation and may contribute to the incidence of postictal delirium. Lithium should be discontinued before ECT with the supervision of the prescribing psychiatrist. If unable to be discontinued, hold for 24 hours or proceed with the lowest therapeutic blood level. Nondepolarizing neuromuscular blockers should be administered in incremental and reduced doses and titrated to the desired degree of blockade.136

Second-Generation Antipsychotics.

Clozapine, risperidone, and olanzapine have replaced first-generation antipsychotics as the primary treatment for schizophrenia due to deleterious side effects: extrapyramidal side effects, tardive dyskinesia, and prolactin elevations.140 Both first- and second-generation antipsychotics can lower seizure threshold, but no recommendations are currently available regarding their periprocedural continuation.

Anticonvulsants.

Anticonvulsants, such as phenytoin and carbamazepine, should be discontinued before ECT, or the choice of anesthetic should be altered to decrease seizure threshold. In addition, succinylcholine should be avoided with these medications due to the risk of hyperkalemia and prolonged blockade.136

Postprocedural Considerations

After treatment, the patient should be brought to an area equipped for postanesthesia recovery. These procedures are typically completed as an outpatient with same-day discharge or a return to inpatient psychiatric care. In addition to meeting the standard criteria for discharge, special attention should be given to neurological status and its return to baseline. Postictal delirium may arise after ECT, with its incidence estimated to be as high as 7.8%.97 Prophylactic midazolam administered immediately postprocedure may prevent its onset. The agent given with droperidol141 or low-dose propofol142 may also be effective in severe cases. Low-dose (0.5 μg/kg) dexmedetomidine is another option that reduces agitation and facilitates recovery with minimal impact on ECT seizure quality.108,109

ECT Response.

Early intervention with ECT in combination with antipsychotic medical regimen is demonstrably effective.9 The average response rates for the spectrum of advanced psychiatric disease are also impressive.12 ECT reduces hospital stays and suicidal and self-injurious behavior in adolescents.143 However, close psychiatric monitoring is required, as suicide attempts after ECT are more medically serious and more often complete.143,144

Adverse Events.

ECT is considered to be as safe, if not more so, for children as it is for adults. Our review of the literature supports this assertion, because the majority of adverse events identified in this cohort were typically minor and transient in nature. In the pediatric ECT literature, observed treatment courses were generally well tolerated.9,10 Common complaints are typically transient and include headache, subjective memory loss, nausea, and prolonged and tardive seizures.11,97 The randomized case–control study of 112 adolescents by Zhang et al9 was the only study to measure outcomes of an ECT group compared to a control. Of the 74 in the ECT treatment arm, none terminated treatment due to intolerable adverse effects. Furthermore, there was no difference in the overall rate of reported adverse events (5%) in both groups. The only adverse effects reported more frequently in the ECT group were transient headaches (P < .001) and dizziness (P = .046).9 Adverse effects after pediatric ECT have been described to occur at some point in 65% of full treatment courses; however, their incidence in individual ECT exposures has been reported as 18%.10

No major morbidity events were captured in our review; however, 2 deaths were reported and attributed to refractory status epilepticus unresponsive to ECT. Large adult epidemiological estimates suggest that overall ECT mortality rates are low. Examination of the Texas mandatory database revealed only 25 deaths after a reported >40,000 ECT sessions were administered to approximately 5000 individuals >/- 16 years of age.145 These rates include all deaths regardless of causal relation to the procedure, with the most common cause being suicide. No mortality occurred in the immediate periprocedural period, 6 were attributed to cardiopulmonary causes, 1 following aspiration pneumonitis, and 8 were completed suicides.145 In the recent query of the same database query by Dennis et al144 then containing >160,000 ECT procedures, the all-mortality rate was 2.4/100,000 treatments on day 1, and 18.0/100,000 at 14 days post-ECT. Death rates increased with age, and no deaths were reported in those <18 years of age.144 Watts et al126 analyzed death events involving ECT captured from root cause analysis reports within the Veterans Affair (VA) Health System. Their estimated mortality rate was <1 death per 73,440 treatments during the years between 1998 and 2009. These results represent an improvement on earlier reported mortality rates of 1/10,000 patients,146 as Watts et al126 hypothesizes, perhaps due to advances in anesthesia and overall hospital care.

No reports of major anesthesia-related events were identified in the cases reviewed. While Scarano et al145 reports a single death from aspiration pneumonitis, these events are rare. The lack of anesthesia-associated events in our query is encouraging; however, the small sample size of approximately 600 patients limits analysis of the actual incidence of major morbidity and mortality in children undergoing ECT. Further detailed study with a specific focus on anesthesia features and outcome is warranted for this population.

Some incidences of anesthesia-related adverse events are found in the adult literature.126,145 Reported events from the VA data involved errors related to inadvertent delays in the onset of neuromuscular blockade and ECT being initiated in the setting of incomplete paralysis. In one case, sequestered muscle relaxant infused into the patient after the treatment leading to postprocedural paralysis, apnea with desaturation, and intubation with intensive care unit admission. Tubocurarine was mistakenly administered instead of succinylcholine in another case, causing delayed onset and recovery from paralysis with apnea and desaturation. Other cases of inadequate or improperly administered paralysis led to instances of fractured extremities and episodes of prolonged apnea and desaturation. The most common ECT-related adverse event in this report involved injuries to the mouth (dentition, lips, or tongue) from improper bite block use or lack thereof (n = 12).126

Existing hesitation to implement ECT stems from concern regarding potential negative neurocognitive effects in the developing brain.147 There seems to be some impact on the brain, because deficits in short-term memory do occur,10,11,143 especially with bilateral electrode placement and increased treatment frequency.114 However, memory assessments tended to be subjective, and formalized neurocognitive testing is rarely completed. The AACAP guidelines recommend that children should undergo memory assessment before and after their treatment course; however, little consensus exists on type of testing and its corresponding validity in this population.100 Prospective studies have made use of formalized neurocognitive testing to assess for the long-term impact of ECT. Literature collectively suggests that ECT only minimally affects brain structure,148 and evidence suggests that ECT may even exert neurotrophic and neuroprotective effects.149 Formalized neurocognitive testing in children in the months and years following their ECT treatment courses failed to demonstrate any persistent significant cognitive impairment.25,150,151 Patient surveys are consistent with these findings. Respondents who received ECT before 18 years of age reported low levels of anxiety and depression and adequate academic performance, but overall depressed global functioning, likely a component of their underlying psychiatric condition overall.143

Limitations

There are several important limitations to our study. We extracted all details relevant to the anesthetic management of children undergoing ECT from a very limited literature pool. The cutoff of <18 years of age excluded a few additional articles of better quality, especially those that consolidated the data from the adolescent patients with that of their adult cohorts. The quality of evidence is low. Articles were typically descriptive in nature, almost universally from the psychiatric literature, at risk of reporting and selection bias, and lacking in consistent details of the anesthetic management. The data analysis contained herein is mostly descriptive in nature and will serve to assist in generating a hypothesis for future research.

CONCLUSIONS

We completed the first known systematic review of the anesthetic considerations of pediatric ECT. This review is, to date, the largest consolidation of data from 592 children and adolescents, providing details relevant to the field in the face of significant gaps in the literature. Consistent implementation of ECT in children still faces many obstacles, despite demonstrated favorable clinical response, low-reported adverse events, and minimal long-term neurocognitive effects. Consequently, children requiring ECT suffer from unnecessary treatment delays and diminished access to care. They present in extreme psychiatric and medical decompensation, ultimately complicating anesthetic management. Data on the impact of anesthetic agents on seizure quality in children are lacking and are extrapolated from adult literature. Future study should focus on the impact of anesthetic techniques on efficacy and safety profile in children, starting with epidemiological, population-based research using existing ECT registries or database analysis of the anesthesia electronic record.

DISCLOSURES

Name: Alecia L. S. Stein, MD.

Contribution: This author helped design and conduct the study, tabulate and analyze the data, and primarily write and edit the manuscript.

Name: Stuart M. Sacks, MD.

Contribution: This author helped conduct the study, tabulate and analyze the data, and write the manuscript.

Name: Joeli R. Roth, BS.

Contribution: This author helped design and conduct the study and tabulate the data.

Name: Mohammed Habis, MD.

Contribution: This author helped conduct the study and contribute content to the manuscript.

Name: Samantha B. Saltz, MD.

Contribution: This author helped review and consolidate the data.

Name: Catherine Chen, MD.

Contribution: This author helped design and conduct the study and tabulate and analyze the data.

This manuscript was handled by: James A. DiNardo, MD, FAAP.

FOOTNOTES

GLOSSARY

AACAP = = American Academy of Child and Adolescent Psychiatry

AChRs = = acetylcholine receptors

APA = = American Psychiatric Association

CASP = = Critical Appraisal Skills Program

CNS = = cerebral nervous system

ECT = = electroconvulsive therapy

EEG = = electroencephalogram

EMG = = electromyography

GA = = general anesthesia

GABAa = = gamma-aminobutyric acid-a

IV = = intravenous

MH = = malignant hyperthermia

NHLBI = = National Heart, Lung, and Blood Institute

NMDA = = N-methyl-d-aspartate

NMS = = neuroleptic malignant syndrome

Paco2 = = partial pressures of carbon dioxide

PRISMA = = Preferred Reporting Items for Systematic Reviews

SSRI = = selective serotonin reuptake inhibitors

VA = = Veterans Affair

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