Electroconvulsive therapy in a catatonia patient: succinylcholine or no succinylcholine?

by Joung et al. [1] published in Anesthesia & Pain Medicine. We wish to describe our experience with different anesthetic drugs and techniques in a patient with catatonia undergoing multiple electroconvulsive therapy (ECT) sessions. Catatonia is characterized by a constellation of psychomotor disturbances associated with immobility, mutism, and rigidity [2]. ECT is the preferred treatment modality [2]. As patients with catatonia are prone to muscle rigidity, hyperkalemia, and deteriorating Glasgow coma scale (GCS) score, anesthesia is challenging for ECT procedures [3]. A 48-year-old female patient weighing 35 kg presented with hallucinations, dementia, and increased muscle rigidity in all four limbs for the past 6 months and was diagnosed with catatonia (secondary to Lewy bodies in the substantia nigra). As the patient was resistant to pharmacological therapy (lorazepam, escitalopram, and syndopa), ECT was finally planned. Her GCS score was E4V1M5. As routine blood investigations were normal, our main concern was serum potassium (4.45 mEq/L), which was expected to rise further with succinylcholine, a commonly used neuromuscular blocking drug (NMBD) in ECT procedures [2]. In her first ECT session, succinylcholine was avoided because of the reported risk of life-threatening hyperkalemia as a result of upregulation of nicotinic cholinergic receptors secondary to long-term immobilization (as the patient was immobilized for the past 6 months). Glycopyrrolate (0.2 mg), propofol (80 mg), and atracurium (15 mg) were administered to the patient. I-gel insertion and propofol infusion were started for maintenance until recovery from neuromuscular blockade. After the procedure, the patient recovered to her preoperative GCS score. In the second ECT session, the same anesthesia technique was used. There was no improvement in the GCS score after two ECT sessions although an improvement in muscle rigidity was observed. In the third ECT session, it was decided to use succinylcholine instead of atracurium with complete preparation for monitoring, diagnosis, and management of hyperkalemia, in case Letter to the Editor Anesth Pain Med 2022;17:454-455 https://doi.org/10.17085/apm.22202 pISSN 1975-5171 • eISSN 2383-7977