Comparison of Recovery Time and Complications During the Use of Etomidate and Thiopental Sodium in Anesthesia in Children for Electroconvulsive Therapy; A Double Blind Randomized Clinical Trial
AbstractBackground: Electroconvulsive therapy (ECT) is usually given to people with severe depression which has not responded to other forms of treatment such as anti-depressants. ECT may be accompanied by potentially significant medical complications including prolonged seizures, prolonged apnea, or cardiac or pulmonary complications. Modification of ECT with brief anesthesia and muscle relaxants should be accomplished. Present prospective randomized study is designed to compare Thiopental Sodium and Etomidate for their effect on hemodynamics, seizure duration, respiratory arrest, and recovery after electroconvulsive therapy and various adverse effects on Sick children in ECT.Methods: A total of 64 patients with psychiatric disorder were examined in a prospective randomized double-blind study. The patients were randomly divided into two groups as group T (n= 32, Thiopental sodium 2 mg kg-1), and group E (n = 32, Etomidate 0.1 mgkg-1).effects of etomidate versus thiopental in electroconvulsive therapy on cardiovascular system parameters (heart rate, blood pressure, and blood oxygenation), seizure variables, adverse effects and recovery variables were recorded at every session, on prespecified time points, and the findings were used in this evaluation.The methods used were descriptive study, cross tabs, Chi-square test, independent sample t-test, paired sample t-test, Fisher and repeated measure analysis of variance (ANOVA). It should be noted, the results are statistically significant at 95% has been mentioned.Results: Both groups were comparable in sex, weight and ASA physical status, with no statistically significant differences (p > 0.05). There was no difference in the Systolic blood pressure (DBP) between the two groups.Patients in etomidate group showed little change in mean Diastolic blood pressure 5th minutes after ETC (DBP5) and mean arterial pressure 5th minutes after ETC (MAP5), and heart rate 1th minutes after ETC (HR1), arterial blood oxygen saturation 1 and 5 minutes after ETC, compared to thiopental (p> 0.05).Based on statistical analysis, the relative superiority of etomidate compared to thiopental the anesthetic induction in the treatment of ECT, was seen in Four variables, duration of seizures, Recovery time, Reach verbal response after seizure and apnea durations (Back spontaneous breathing after a seizure).In addition, Pain on injection, nausea and vomiting and Myoclonus was more in etomidate group while Muscular pain activity was higher in thiopental group (p> 0.05).Conclusion: It seems that etomidate compared with thiopental has no conflict with ECT therapeutic effects in psychiatric patients. In addition, it probably can be used as a safe and effective drug for controlling ECT-induced hemodynamic changes and seizure variables. Drawback etomidate Compared with thiopental had a high incidence of myoclonus, Pain at injection site and nausea and vomiting.
Petrides G, Fink M, Husain MM, Knapp RG, Rush AJ, Mueller M, et al. ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. J ECT. 2001; 17(4):244-53.
Spellman T, Peterchev AV, Lisanby SH. Focal electrically administered seizure therapy: a novel form of ECT illustrates the roles of current directionality, polarity, and electrode configuration in seizure induction. Neuropsychopharmacology. 2009; 34(8):2002-10.
Azuma H. Electroencephalogram monitoring and implications. In: Swartz C, Ed. Electroconvulsive and Neuromodulation Therapies. Cambridge University Press, New York, 2009:468-476.
Habibi MR, Baradari AG, Soleimani A, Emami Zeydi A, Nia HS, Habibi A, et al. Hemodynamic responses to Etomidate versus ketamine-Thiopental sodium combination for anesthetic induction in coronary artery bypass graft surgery patients with low ejection fraction: a double-blind, randomized, clinical trial. J Clin Diagn Res. 2014; 8(10):GC01–5. [In Persian].
Forbes AM, Dally FG. Acute hypertension during induction of an aesthesia and endotracheal intubation in normotensive man. Br J Anaesth. 1970; 42(7):618-24.
Dashti M, Amini S, Azarfarin R, Totonchi Z, Hatami M. Hemodynamic changes following endotracheal intubation with glidescop® video-laryngoscope in patients with untreated hypertension. Res Cardiovasc Med. 2014; 3(2):e17598. [In Persian].
Abrams R. Electroconvulsive therapy. 4th ed. New York (NY): Oxford University Press; 2002.
American Psychiatric Association Committee on Electroconvulsive Therapy. The practice of electroconvulsive therapy: recommendations for treatment, training, and privileging. 2nd ed. Washington (DC): American Psychiatric Association; 2001.
Kramer BA. The use of ECT in California revisited 1984–1994. J ECT. 1999; 15(4):245-51.
Shiwach RS, Reid WH, Carmody TJ. An analysis of reported deaths following electroconvulsive therapy in Texas, 1993-1998. Psychiatr Serv. 2001; 52(8):1095-7.
Lihua P, Su M, Ke W, Ziemann-Gimmel P. Different regimens of intravenous sedatives or hypnotics for electroconvulsive therapy (ECT) in adult patients with depression. Cochrane Database Syst Rev. 2014; (4):CD009763.
Khajavi M, Emami A, Etezadi F, Safari S, Sharifi A, Shariat Moharari R. Conscious Sedation and Analgesia in Colonoscopy: Ketamine/ Propofol Combination has Superior Patient Satisfaction Versus Fentanyl/Propofol. Anesth Pain Med. 2013; 3(1): 208-13. [In Persian]
Ge R, Pejo E, Cotten JF, Raines DE. Adrenocortical suppression and recovery after continuous hypnotic infusion: Etomidate versus its soft analogue cyclopropyl-methoxycarbonyl mEtomidate. Crit Care. 2013; 17(1):R20.
Eray O. Comments on Etomidate Usage in the Emergency Department. Eurasian J Emerg Med. 2016; 15: 114-6.
Jarineshin H, Kashani S, Fekrat F, Vatankhah M, Golmirzaei J, Alimolaee E, et al. Seizure Duration and Hemodynamic State During Electroconvulsive Therapy: Sodium Thiopental Versus Propofol. Glob J Health Sci. 2015; 8(2):126-31.
Caro D, Walls RM, Grayzel J. Induction agents for rapid sequence intubation in adults. 2016, Wolters Kluwer. Available at: [URL:http://www.uptodate.com/contents/induction-agents-for-rapid-sequence-intubation-in-adult/. Aug 23, 2016].
Russo H, Bressolle F. Pharmacodynamics and pharmacokinetics of Thiopental. Clin Pharmacokinet. 1998; 35(2):95-134.
Reich DL, Hossain S, Krol M, Baez B, Patel P, Bernstein A, et al. Predictors of hypotension after induction of general anesthesia. Anesth Analg. 2005; 101(3):622-8.
Hirota K, Ohtomo N, Hashimoto Y, Kudo T, Kudo M, Ishihara H, et al. Effects of Thiopental on airway calibre in dogs: direct visualization method using a superfine fibreoptic bronchoscope. Br J Anaesth. 1998; 81(2):203-7.
Keel M, Mica L, Stover J, Stocker R, Trentz O, Härter L. Thiopental-induced apoptosis in lymphocytes is independent of CD95 activation. Anesthesiology. 2005; 103(3):576-84.
Ploppa A, Kiefer RT, Nohé B, Haeberle HA, Dieterich HJ, Unertl KE, et al. Dose-dependent influence of barbiturates but not of propofol on human leukocyte phagocytosis of viable Staphylococcus aureus. Crit Care Med. 2006; 34(2):478-83.
Sato M, Tanaka S, Suzuki K, Kohama A, Fujii C. Complications associated with barbiturate therapy. Resuscitation. 1989; 17(3):233-41.
Stover JF, Stocker R. Barbiturate coma may promote reversible bone marrow suppression in patients with severe isolated traumatic brain injury. Eur J Clin Pharmacol. 1998; 54(7), 529-34.
Loop T, Humar M, Pischke S, Hoetzel A, Schmidt R, Pahl HL, et al. Thiopental inhibits tumor necrosis factor alpha-induced activation of nuclear factor kappaB through suppression of kappaB kinase activity. Anesthesiology. 2003; 99(2):360-7.
Aono H, Hirakawa M, Unruh GK, Kindscher JD, Goto H. Anesthetic inductionagents, sympathetic nerve activity and baroreflex sensitivity: a study in rabbits comparing thiopental, propofol and etomidate. Acta Med Okayama. 2001; 55(4):197-203.
Mayer M, Doenicke A, Nebauer AE, Hepting L. Propofol andEtomidate-Lipuro for induction of general anesthesia. Hemo-dynamics, vascular compatibility, subjective findings andpostoperative nausea. Anaesthesist. 1996; 45(11):1082-4.
Wu J, Yao S, Wu Z, Wu Z, Chu S, Xia G, et al. A comparison of anesthetic reg-imens using etomidate and propofol in patient’s undergoingfirst-trimester abortions: Double blind randomized clinical trialof safety and efficacy. Contraception. 2013; 87(1):55-62.
Abbott C, Jones T, Lemke N, Gallegos P, McClintock S, Mayer A, et al. Hippocampal structural and functional changes associated with electroconvulsive therapy response. Transl Psychiatry. 2014; 4:e483.
Shah AJ, Wadoo O, Latoo J. Electroconvulsive Therapy (ECT): Important parameters which influence its effectiveness, BJMP [Internet]. 2013; 6(4):a634.
Canbek O, Ipekcıoglu D, Menges OO, Atagun MI, Karamustafalıoglu N, Cetinkaya OZ, et al. Comparison of Propofol, Etomidate, and Thiopental in Anesthesia for Electroconvulsive Therapy: A Randomized, Double-blind Clinical Trial. J ECT. 2015; 31(2):91-7.
Saffer S, Berk M. Anesthetic induction for ECT with Etomidate is associated with longer seizure duration than thiopentone. J ECT. 1998; 14(2):89-93.
Conca A1, Germann R, König P. Etomidate vs thiopentone in electroconvulsive therapy. An interdisciplinary challenge for anesthesiology and psychiatry. Pharmacopsychiatry. 2003; 36(3):94-7.
Kewalramani A, Choudhary S, Kushwaha R, Sharma NP, Bhateja S. Comparison of Butorphanol with Fentanyl for reducing Etomidate-induced myoclonus: A Prospective, Randomised Clinical Trial. Indian Journal of Clinical Anaesthesia. 2016; 3(3):324-8.
Reves JG, Glass PSA, Lubarsky DA, McEvoy MD. Intravenous non opioid anesthetics. In : Miller RD, editor. Miller’s anesthesia, 6th ed. Elsevier churchill livingstone. Chapter 10; 2006. p. 317-26.
Zahavi GS, Pinhas D. Comparison of anesthetics in electroconvulsive therapy: an effective treatment with the use of propofol, Etomidate, and Thiopental. Neuropsychiatr Dis Treat. 2014; 10: 383-9.