Procedural and Perioperative Pain Management for Children
Mark V. Boswell, B. Eliot Cole in Weiner's Pain Management, 2005
Barbiturates are sedative–hypnotic agents devoid of analgesic properties. Their mechanism of action likely derives from stimulation of GABAergic inhibitory pathways in the central nervous system. Historically barbiturates have been thought to have hyperalgesic properties accentuating pain perception, but this is not now generally thought to be clinically relevant in humans at usual doses. The shortacting barbiturates methohexital and thiopental have been widely used for induction of general anesthesia; these agents produce dose-dependent respiratory and cardiovascular depression. Methohexital and thiopental may be administered rectally to provide sedation in children, but absorption and degree of sedation are variable. Both agents may rapidly induce deep sedation and general anesthesia.
The Technique of MMECT
Barry M. Maletzky, C. Conrad Carter, James L. Fling in Multiple-Monitored Electroconvulsive Therapy, 2019
The higher doses of methohexital are used at the first session when a longer postanesthetic set-up time can be expected, or when patient resistance to barbiturates is unknown. The lower dosage range is preferred at all other times. As with so many other medications, size and obesity cannot be used to accurately predict how much drug to administer. Once the patient is asleep, the electrodes are applied as outlined below, and the stimulus wires for the EKG are connected as well. The MMECTA test button is then depressed. If the light indicates “ready” (see Figure 2), the succinylcholine is then given. If, however, the light indicates “fail,” the stimulus cannot be given (even if the stimulus button is depressed) and the cause of the failure must be ascertained. Table 6 lists the typical causes for a failure of this type. All connections must be scrutinized to make sure they are properly made and tightly applied. The treatment settings must be examined and settings lowered, if necessary. If, however, all connections are secure, the first step is to remove the electrode band and rewash the patient’s forehead and all electrodes with acetone as the most common cause of failure is poor skin-electrode contact. Most often this procedure will result in a “ready” on retest and muscle paralysis can then proceed. To have rendered the patient paralyzed before testing might have prolonged the period of apnea, necessitating the use of more oxygen, and might even have required the use of more muscle paralyzing agent if over two to three minutes had elapsed while the cause of the failure was being investigated.
Anaesthesia for ECT
Alan Weiss in The Electroconvulsive Therapy Workbook, 2018
Methohexital (0.5-1.0 mg/kg) remains prominent in ECT and is considered the "gold standard" against which other anaesthetic agents are compared (Ding and White, 2002). Methohexital can be difficult to administer as it is associated with pain on injection and a higher incident of involuntary movements, coughing, hiccups and laryngo- spasm (MacPherson and Loo, 2008). In recent years the availability of methohexital has become difficult to source and ECT services have had to revert to using thiopentone or embrace other intravenous anaesthetic agents like propofol. The frequency of sinus bradycardia and premature ventricular contractions is greater for thiopentone compared to methohexital (Ding and White, 2002).
Delaying initiation of electroconvulsive treatment after administration of the anaesthetic agent and muscle relaxant reduces the necessity of re-stimulation
Published in Nordic Journal of Psychiatry, 2018
Márton Asztalos, Peter Matzen, Rasmus W. Licht, Kristian Bjørn Hessellund, Alexander Sartorius, René Ernst Nielsen
Originally, electroconvulsive therapy (ECT) was performed as a brief electrical pulse without concurrent anaesthesia and muscle relation, but it has since evolved with multiple types of anaesthetic and muscle relaxants being used [1]. Over time, various anaesthetic agents have been evaluated [2,3], originally focusing on barbiturates, their derivatives, e.g. methohexital, and propofol, but with a shifted focus to other agents in the last decade, e.g. ketamine [4]. The electrical stimulus dosages required to induce seizures (seizure threshold) is influenced by the ECT regimen employed, but also by age and gender [5–7]. Across treatment settings, the time from administration of anaesthetics and muscle relaxants to ECT initiation varies. It is generally assumed that increasing this time interval improves the seizure quality, but the evidence is limited [8]. The study by Galvez et al. [8] showed that prolonged time since administration of anaesthetics was associated to better seizure quality in patients treated with propofol and succinylcholine. In that study, the time from administration of anaesthetics and muscle relaxant to ECT was prolonged as long as possible, making it harder to interpret results and harder to make clinical guideline suggestions to be implemented clinically. Additionally, Sartorius et al. [9] have shown that a lighter thiopental anaesthesia leads to an earlier remission, but timing was not included in their study. No further studies have investigated the effects of prolonging time from administration of anaesthetics and muscle relaxant to ECT, as far as the authors are aware.
Anesthesia for electroconvulsive therapy during the COVID-19 pandemic
Published in Expert Review of Neurotherapeutics, 2021
Elaine Loureiro Pereira-Soares, Antonio Leandro Nascimento, Jorge Adelino da Silva, Antonio Egidio Nardi
ECT is performed under general anesthesia, using a traditional technique of intravenous injection of a hypnotic agent, succinylcholine, for muscle relaxation, and manual ventilation (MV) using a mask. Several hypnotics can be used in this procedure, and methohexital is considered the best option [5], followed by etomidate, propofol, and thiopental. In the case of contraindication to succinylcholine, muscle paralysis can be achieved using rocuronium with subsequent reversal with sugammadex [5]. Positive-pressure hyperventilation is generally used prior to ECT for improving seizure quality [6] although the evidence for this is weak [7]. However, MV is a potentially risky procedure for aerosol production and virus dispersion. The smaller particles produced by aerosols can be suspended in the air, pass through filter barriers, and inhaled [8]. Therefore, the anesthesia procedure prior to ECT had to be modified to continue using this treatment option along with ensuring the safety of patients and healthcare professionals.
Sedation in cardiac arrhythmias management
Published in Expert Review of Cardiovascular Therapy, 2018
Federico Guerra, Giulia Stronati, Alessandro Capucci
The subcutaneous ICD consists of a pulse generator that is usually implanted in the left anterior axillary line, and of a single, double-coil, extra-thoracic lead which is inserted subcutaneously [39]. As the lead deployment involves extensive tunneling and DFT testing, the whole procedure is currently supervised by an anesthesiologist for either GA or deep sedation. Despite the fact that two large clinical registries have already been published, anesthetic management was not taken into consideration neither in the EFFORTLESS nor in the IDE reports [40]. Therefore, available evidence is limited to small observational experiences. Essandoh and colleagues prospectively collected anesthetic management outcomes in 73 consecutive patients implanted with an S-ICD [41]. The first four patients were managed with deep sedation and without anesthesiologist support, using intermittent boluses of fentanyl (0.5–1.0 μg/kg) and midazolam (15–30 μg/kg), while DFT testing was managed with a single dose of methohexital (0.5–1.0 mg/kg). Investigators report patient discomfort during lead tunneling and DFT testing, leading the team to switch to GA for the subsequent procedures. The induction agents used included midazolam, propofol, fentanyl, and etomidate, and GA was maintained with volatile anesthetics. Lead tunneling was performed safely without the need for muscle relaxation. Lidocaine was injected subcutaneously at the end of the procedure in order to alleviate postoperative pain. Overall, reported intraprocedural complications were rare and mainly associated with severe pain (11%) and hypotension (53%), with the latter requiring inotropic or vasopressor support. They were however easily managed.
Related Knowledge Centers
- Anesthesia
- Biological Activity
- Electroconvulsive Therapy
- Inhibitory Postsynaptic Potential
- Ionophore
- Sodium Thiopental
- Urea
- Barbiturate
- Anesthetic
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