The Trend of Adding Remifentanil in ECT Anesthesia: What Are We Doing?

To the Editor: T he use of remifentanil in electroconvulsive therapy (ECT) has been supported in the literature for more than 10 years. It is used as part of anesthesia for the procedure. It is considered beneficial because it has been shown to prolong seizure duration, improve recovery time, and better modulate blood pressure. Remifentanil has also been shown to attenuate the acute hemodynamic response to ECT. This has been demonstrated with electroencephalographic (EEG) readings and blood pressure responses at the time of the ECT procedure. Thus, immediate benefits of remifentanil are well supported. Remifentanil augmentation is thought to enable a smaller dose of anesthetic agent to be used, thus increasing the chance of a successful seizure. Despite no known direct proconvulsant effects, the addition of remifentanil allows a reduced dose of other anesthetic agents, particularly those that are anticonvulsant. Common anesthetic agents used in ECT, such as propofol and thiopentone, potentially raise seizure thresholds, potentially creating an antiseizure effect. This has implications for reducing the effectiveness of ECT. Benefits have been shown whether remifentanil has been used to augment the other agents or as a sole induction agent. When remifentanil-supplemented anesthesia is reserved for patients with refractory depression, that is, after they do not respond to standard treatment, it may be assumed that these patients will require more ECT treatments to achieve a therapeutic response to ECT. Remifentanil is typically used for cases of high seizure threshold resulting in too short or missed seizures. Remifentanil is also given routinely to all ECT patients in many institutions.Whether remifentanil-supplemented anesthesia affects the number of treatments needed, if given routinely, is not known. Although no actual adverse effect from the use of remifentanil for ECT has been reported to date, the risk profile associated with remifentanil use suggests that caution should be exercised. Both profound respiratory depression and severe cardiovascular depression have been described.