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ARTICLE
Year : 2008  |  Volume : 30  |  Issue : 1  |  Page : 48-51 Table of Contents   

Comparision of thiopentone sodium and propofol in ECT anaesthesia


1 Anaesthesiologist, Dy.Civil Surgeon R.M.O, Institute of Mental Health, Hyderabad, India
2 Post graduate in Psychiatry, Institute of Mental Health, Hyderabad, India
3 Proffessor of Psychiatry Dy.Superintendent, Institute of Mental Health, Hyderabad, India
4 Superintendent, Institute of Mental Health, Hyderabad, India
5 Proffessor of Anaesthesia, Gandhi Medical College, Hyderabad, India

Correspondence Address:
T M Omprakash
Anaesthesiologist, Dy.Civil Surgeon R.M.O, Institute of Mental Health, Hyderabad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7176.43134

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How to cite this article:
Omprakash T M, Ali MI, Anand B, Devi M G, Surender P. Comparision of thiopentone sodium and propofol in ECT anaesthesia. Indian J Psychol Med 2008;30:48-51

How to cite this URL:
Omprakash T M, Ali MI, Anand B, Devi M G, Surender P. Comparision of thiopentone sodium and propofol in ECT anaesthesia. Indian J Psychol Med [serial online] 2008 [cited 2019 Sep 22];30:48-51. Available from: http://www.ijpm.info/text.asp?2008/30/1/48/43134

This Study is conducted to compare Thiopentone sodium with Propofol as induction agents for modified ECT in hundred patients of ASA Grl & ASA Gll in a randomized fashion divided into two groups of fifty each. The patients selected for both groups wherein PR>80/mt. & B.P>90/60 mmHg. Group 'T' (n=50) received injection Thiopentone sodium 3 to 5 mg/Kg body weight and Group 'P' (n=50) received Propofol 1.5 to 2 mg/Kg body weight.

Anticholinergic agents were used depending on the pulse rate. Patients with pulse rate <100/mt. were used Atropine sulphate 0.6 mg. and patients with pulse rate >100/mt. were used Glycopyrrolate 0.2 mg, Scoline is given in the dose of 0.5mg/Kg body weight.

The Seizure duration is observed following application of stimulus, after normal latent period of 2 to 3 seconds tonic - clonic movements were observed in the both groups of the drugs normal Seizure is observed.

When there is no Seizure following optimal stimuli only the " Masseter Spasm " is observed which is correlated with other parameters like decreased oxygen saturation , initial bradycardia followed by tachycardia, Conjunctival congestion, pupillary dilation and EEG changes signifies that patient has attained a normal Seizure.

The recovery pattern is observed by the following parameters

  1. Establishment of spontaneous ventilation
  2. Pulse rate
  3. Blood pressure ( Systolic and diastolic)
  4. Tone of the muscles
  5. Orientation to time and space.


ECT has been widely recognized and accepted treatment modality for various Psychiatric Ailments. With the use of Succinyl Choline by Wanderdel in 1951 modified ECTs came into existence. Use of General Anaesthesia led to the reduced incidence of Physical & Psychological trauma. The Ideal IV agent used for Modified ECT should provide 1. Rapid onset, 2. Short duration of action, 3. Attenuation of adverse Physiological effects of ECT, 4. Rapid recovery and 5. No adverse shortening of seizure duration [8] ; Methohexitone offers rapid induction and recovery from anaesthesia along with cardiovascular stability and has advantage over Thiopentone regarding seizure duration. Due to non availability of methohexitone Thiopentone was being used till date for all MECTs despite of its side effects like prolonged wakening time, arrhythmias & laryngeal spasm. Recent introduction of Propofol seems to be promising, as it has rapid onset of action and better quality of recovery compared with Thiopentone. Propofol although is known to cause pain on injection and decrease seizure duration, it does not have any adverse effects on therapeutic outcome [4] . Considering all these aspects present study was designated to evaluate Propofol as an induction agent for MECT and compare it with equivalent dose of Thiopentone.


   Material & Methods Top


After careful pre-anaesthetic evaluation 100 patients in the age group of 15 to 50 years of either sex, ASA grade I or II who requires MECTs were included in the study. Informed consent was obtained from the patients and care takers in the prescribed form. Patients by simple random sampling were divided into 2 groups of 50 each.

After the intial ECT patients who were on thiopentone were crossed over to Propofol for the next ECT administration. Thus after the cross over a total 50 patients in two groups completed the study. Group T received Thiopentone Sodium in the dose of 3-5 mg/Kg body weight and Group P received Propofol 1.5 - 2 mg/Kg body weight [9] . Monitoring of Systolic BP, Diastolic BP, Heart rate and Hb Oxygen saturation (SPO2) was done. After starting IV line patients with PR<100/mt were given Atropine 0.6 mg and patients with PR>100/mt were given Glycopyrollate 0.2 mg admixed with either Thiopentone or Propofol. Irrespective of the medication that the patient is taking. Induction of anaesthesia was done by titration method till patient goes into sleep. Succynylcholine was administered in the dose of 0.5 mg/kg body weight [9] and patients were ventilated with 100% Oxygen with face mask using Magill's circuit till scoline fasciculation subsided.

Later a rubber mouth gag was inserted into the oral cavity separating tongue and buccal mucosa and supporting chin MECT applied bitemporally after applying ECT Gel on to the electrodes. MECT was given using a constant current BPE-791 for 1 Sec, if there were no signs of seizures out of the stimulus. Then ECT is administered at 1.2 Sec and 1.4 Sec successively till the required seizure is obtained. When patient does not show seizure activity even after 3 stimuli, procedure was stopped and patients were recovered. In the next sitting the time set is increased so as to get an adequate seizure; patients were given 100% Oxygen till regaining spontaneous respiration; PR/SBP/DBP/SPO2/ were recorded before induction (T0), after the cessation of Seizure (T1), after Recovery (T2). Duration of Seizure was recorded in seconds by clinical method from start of electrical impulse to the end of the clonic contraction using a hand held stop watch or using an inbuilt stop watch in the machines. Normally seizure induced by ECT produces a grandmal type of seizure, a latent period of 2-3 seconds is followed first by a tonic phase of 10-12 Seconds then by a clonic phase lasting 30-50 Secs [1] .

When there was no Seizure following optimal stimuli only the 'Masseter Spasm' was observed [1] , wherein the patient bites the rubber gag tightly causing opening of mouth difficult, it is associated with other parameters like decreased Oxygen saturation, initial bradycardia followed by tachycardia, conjunctival congestion, pupillary dilation and EEG changes shows build up of Alpha and Beta rhythmic activity during the tonic phase, which is followed by repetitive polyphasic spikes and wave complexes in the clonic Phase, synchronous with clonic movements, which signifies that the patient attained a "Definitive Seizure".

The recovery pattern is observed by the following parameters

  1. Establishment of spontaneous ventilation
  2. Pulse rate
  3. Blood pressure ( Systolic and diastolic)
  4. Tone of the muscles
  5. Orientation to time and space.



   Results Top


The two groups were compared as regards the mean seizure duration was significantly shorter with Propofol group than Thiopentone. Automatic Limb Movements, able to sit and stand, shake hand to test grip were quicker in Propofol group than Thiopentone (Tale-2).

[Table 1],[Table 2]

PR/SBP/DBP in both groups were compared there was transient increase in PR after induction in both groups. Systolic BP was increased in both the groups after Seizure. There is a minimal increase in the Diastolic BP in both groups. After recovery they came to more or less pre ECT levels.

Pain on injection observed in 15 patients in Propofol group as compared to none with Thiopentone Group. Ectopic beats were observed in Thiopentone subsided with spontaneous ventilation. Massator Spasm is observed in prolonged seizure and when there is no perceptible seizure.


   Discussion Top


The duration of Seizure Activity lasting for > 25 Seconds in single session or a maximum of 210 seconds of cumulative duration leads to good therapeutic outcome [2],[3] . In the present study the mean Seizure duration was sufficiently shorter in Propofol group compared Thiopentone Group. Elevation of Seizure threshold after Propofol administration may explain the lower duration of Seizure [6] .

When Seizure activity is not observed in spite of optimal stimuli conventionally, all anti-convulsant drugs were stopped prior to ECT sessions and Inj Deriphylline IV was given before induction to accentuate the Seizure response. Interestingly patients not eliciting Seizure with Pentothal have shown good response to Propofol in 2 cases.

The early recovery helps in early discharge from recovery room to the wards or to their homes. There was faster and smoother recovery with Propofol compared to Thiopentone [5],[7] .

Thus Propofol seems superior to Thiopentone in attenuating the physiological response to ECT with minimal haemodynamic changes [5],[7],[8] .

Arrhythmias occurred in 6% patients who received Thiopentone, but were transient and resolved spontaneously. Arrhythmias were observed by Rampton in 19% of their patients, but no premedication was used [8] . They advocated the use of Atropine or Glycopyrollate along with beta blocker or lignocaine to prevent these arrhythmias may be due to the use of Atropine or Glycopyrollate.

About 15% patients complained of pain with Propofol, none with Thiopentone. Propofol is known to cause pain on injection, which can be attenuated by using 1% or 2% xylocard. Thrombophelebitis is more common with Thiopentone.

Nausea and vomiting are more with Pentothal when compared to Propofol. The antiemetic property of Propofol can be beneficial while applying ECT as a day care procedure [9] .

"Cross over Study" from Thiopentone to Propofol and Propofol to Thiopentone makes our minds open to choose the correct drug in a given patient.

Cost effectiveness of drug and availability in the remote places make us to use Thiopentone as most widely used anaesthetic despite its side effects, which can be ameliorated with the use of anticholinegics compared with Propofol, which is costly and has its limitations in the use as induction agent. Patients with altered lipid profile is a risk factor for use of Propofol.

To conclude Propofol in the dosage of 1.5 mg - 2 mg per Kg body weight intravenously can be safely used for modified ECT in ASA Gr I & II patients with better haemodynamic results and the recovery characteristics without compromising therapeutic outcome. Antiemetic property makes drug of choice for day care procedure. However, its role in very sick and haemodynamically compromised patients needs further evaluation.

 
   References Top

1.Secrets of Anaesthesia - Anaesthesia for ECT - Steven J. Stein, MD, Kevin Fitz Patrick MD.  Back to cited text no. 1    
2.Ottoson JO. Experimental studies of memory impairment AFTER ELECTRO CONVULISVE THERAPY; The Role of the electrical stimulation and of the seizure studied by variation of stimulus intensity and modification by lidocaine of seizure discharge. Acta Psychiatry Scand 1960, 145 (Suppl): 103-32  Back to cited text no. 2    
3.Weiner RD. The Psychiatric use of electrically induced seizures. Psychiatry 1979; 136 (12); 1507-17.  Back to cited text no. 3    
4.Mitchel P, Torda T, Hickie I, Burke C. Propofol as an anaesthetic agent for ECT. Effect on outcome and length of course. Aust NZJ Psychiatry 1991; 25: 255-61.  Back to cited text no. 4    
5.Boey WK, Lai FO, comparison of Propofol and Thiopentone as anaesthetic agents for electro convulsive therapy. Anaesthesia 1990; 45: 623-8  Back to cited text no. 5    
6.Yanny HF, Christmas D. Propofol infusion for status epilepticus, Anaesthesia 1988; 43:514  Back to cited text no. 6    
7.Rouse EC, Propofol for electroconvulsive therapy. Anaesthesia 1988; 43 (Suppl): 61-4.  Back to cited text no. 7    
8.Rampton AJ, Griffin RM, Stuart CS, Durcan JJ, Huddy NC, Abbott MA. Comparison of Methohexital and Propofol for electroconvulsive therapy. Effects on haemodynamic responses and seizure duration. Anaesthesiology 1989; 70:412-17.  Back to cited text no. 8    
9.Mackenzie RA, Southhorn PA, Stensned PE, Anaesthesia at remote locations. In: Millar RD, editor. Anaesthesia. 5th ed. Churchill Livingstone Philadelphia 2000; 2263-65.  Back to cited text no. 9    



 
 
    Tables

  [Table 1], [Table 2]



 

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