Use of Intravenous Anesthetic Combinations for Electroconvulsive Therapy Under General Anesthesia and Muscle Relaxation in Patients With Mental Illness: A Scoping Review.

Abstract

Background: Modified electroconvulsive therapy (mECT) requires general anesthesia, and induction-agent selection influences seizure quality, hemodynamic stability, recovery, and adverse events. Evidence regarding induction-agent combinations remains fragmented.

Objective: To map the clinical evidence on combinations of intravenous induction agents used during mECT, summarize reported outcomes, and identify knowledge gaps.

Methods: A PRISMA-ScR-compliant scoping review was conducted using PubMed, Embase, ScienceDirect, and LILACS (2004 to 2024). Eligible studies included adults undergoing mECT receiving combinations of at least 2 intravenous induction agents in comparative clinical studies. Systematic reviews were excluded from the primary synthesis but screened through citation tracking. Two reviewers independently performed study selection, data extraction, and risk-of-bias assessment (Cochrane RoB 2). Findings were synthesized narratively.

Results: Twenty-nine studies met the eligibility criteria, all randomized controlled trials. The most common combinations were propofol-ketamine (ketofol), propofol-dexmedetomidine, and propofol-remifentanil. Compared with propofol alone, ketamine-containing regimens were generally associated with longer seizure durations. Compared with ketamine-containing regimens, propofol-based regimens provided greater hemodynamic stability and faster recovery but shorter seizure durations. Adding remifentanil to propofol tended to prolong seizure duration while maintaining rapid recovery. Adding dexmedetomidine to propofol-, ketofol-, or thiopental-based regimens reduced agitation and sympathetic responses but was occasionally associated with bradycardia and hypotension. Heterogeneity in interventions, comparators, and outcome measures precluded conclusions regarding the superiority of any anesthetic combination.

Conclusions: Intravenous induction-agent combinations in mECT seem to offer complementary pharmacologic advantages depending on the desired clinical outcome. However, current evidence does not support the superiority of any single regimen. Future comparative trials using standardized outcome measures are needed to better inform anesthetic selection.