Optimal Dose of Succinylcholine and Rocuronium for Electroconvulsive Therapy (ECT)
Condition: Neuromuscular Blockade; ECT
Study type: Interventional

Summary: 
      Electroconvulsive therapy (ECT) is the transcutaneous application of small electrical stimuli
      to the brain to produce generalized seizures for the treatment of selected psychiatric
      disorders such as severe depression. The aim of ECT is to induce a therapeutic tonic seizure
      where the person loses consciousness and has convulsions. Patients need general anesthesia
      and neuromuscular blockade to treat pain and avoid excessive tonic clonic motor contraction
      that might be associated with compression fractures. Neuromuscular blocking drugs (NMBD) are,
      therefore, administered after induction of general anesthesia to induce neuromuscular
      blockade. Despite the importance of NMBDs to provide optimal conditions for ECT treatment,
      the optimal NMBD dose to achieve acceptable neuromuscular blockade without excessive or
      untoward effects has not previously been identified in any study and in a prospective
      randomized fashion. The aim of this study is, therefore, to identify the optimal NMBD dose of
      two commonly used neuromuscular blocking agents (succinylcholine and rocuronium) in order to
      optimize the muscle strength modulation during ECT that facilitates ECT with the minimal side
      effects.
    

Detailed description: 
      Patients, who consent to participate in the study, will randomly receive either
      succinylcholine or rocuronium by utilizing the Dixon's up and down technique. For patient
      safety, the first dose of either agent will be defined by the anesthesiologist providing
      care, and subsequent doses will be incrementally increased or decreased by 10% based on the
      assessment of a psychiatrist blinded to dose, who uses a dichotomous scale to assess the
      quality of the ECT (acceptable and not acceptable). The investigators will switch to the
      second compound as soon as the patient has received one neuromuscular blocking agent dose
      that resulted in 'acceptable muscle relaxation', and another dose that resulted in
      'unacceptable' conditions'.

      Acceleromyography will be used for monitoring neuromuscular transmission. Following induction
      of general anesthesia, the TOF-Watch SX will be calibrated (mode 1, 50 mA), and train-of-four
      (TOF) stimulation (every 15 seconds) will be initiated and maintained until recovery of the
      T1 to 100% baseline. Non-invasive blood pressure, heart rate, peripheral oxygen saturation
      (SpO2), and time to recovery of spontaneous breathing will be measured during the procedure.
      In addition the investigators will measure stimulation parameters used to initiate ECT, as
      well as the duration of seizure as well as the entire procedure time.
    

Intervention name(s): Succinylcholine; Rocuronium
Intervention type(s): Drug; Drug
Intervention description(s): Succinylcholine will be given during the series of ECT treatments. The initial dose will be defined by the anesthesiologist in charge for clinical care. The Dixon's up and down method will be used in consecutive treatments. The investigators will switch to the second compound as soon as the patient has received one neuromuscular blocking agent dose that resulted in 'acceptable muscle relaxation', and another dose that resulted in 'unacceptable' conditions'.; Rocuronium will be given during the series of ECT treatments. The initial dose will be defined by the anesthesiologist in charge for clinical care. The Dixon's up and down method will be used in consecutive treatments.
Other intervention name(s): Suxamethonium
Intervention MeSH terms: Rocuronium; Succinylcholine
Allocation: Randomized
Intervention model: Crossover Assignment
Masking: Double (Care Provider, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Succinylcholine; Rocuronium; ECT