Electroconvulsive therapy (ECT) is a safe treatment process in which the risk entailed is said to be generally no greater than that associated with the use of short-acting barbiturates l-4 • Opinions differ as to the relative safety of electroconvulsive therapy in debilitated patients or in those with severe myocardial dysfunction. Gerring and Shields 5 identified a group of patients at high risk for the development of cardiovascular complications, namely myocardial ischaemia and/or arrhythmias following electroconvulsive therapy. In this group, which included patients with a history of angina, myocardial infarction, congestive heart failure, arrhythmias, rheumatic heart disease or an abnormal baseline electrocardiogram, the complication rate was 70%. However, Dec et al. 2 found electroconvulsive therapy to be safe, effective and well tolerated in a group of elderly debilitated patients, one-quarter of whom had severe cardiovascular disease including poor ejection fractions and recent myocardial infarctions.

Five patients known to be previously hypertensive but not currently receiving anti-hypertensive medications were studied for a total of twenty-six administrations of electroconvulsive therapy. Patients randomly received sublingual nifedipine 10 mg, 20 minutes prior to half of their treatments, and for the remaining treatments acted as their own controls. The use of nifedipine resulted in significant attenuation of the blood pressure response to therapy. Systolic pressure increase was 24 mmHg (SD 14) versus 62 mmHg (SD 24) (P < 0.01). There was no difference in heart rate between the two groups. It is concluded that nifedipine reduces the pressor response to electroconvulsive therapy in individuals with a history of hypertension.

We prospectively audited 150 patients undergoing dental procedures with Target Controlled Infusion (TCI) of propofol and remifentanil to evaluate patient safety, adverse effects and post-operative discharge time and patient feedback. This anaesthetic technique provides for early recovery after surgery and allows for a 92% rate of “fast track” discharge within 20 minutes (mins) of completion of surgery. The technique proved safe with 14 patients (9.3%) experiencing a total of 14 adverse events, none of which were serious and all of which were easily managed. The adverse events were 8 cases of hypoxaemia (5.3%), 3 cases of paradoxical agitation/anxiety (2.0%), 2 cases of nausea (0.01%), neither of which required treatment and 1 case of generalised body itching, again not requiring treatment. Patient feedback was unanimously positive. We compared our rate of adverse events using TCI propofol and TCI remifentanil with our previous publication of 350 patients in which we used bolus alfentanil and TCI propofol. Additionally, we compared the effect target (Cet) propofol infusion levels required between the two groups. We advocate the use of remifentanil in combination with propofol in particular for longer duration cases and for those patients at risk of developing or who manifest an intraoperative paradoxical agitation reaction.

Twenty patients with good ventricular function undergoing coronary artery bypass surgery were studied to determine whether the pre-bypass use of nitrous oxide resulted in any differences in cerebrospinal fluid markers indicative of cerebral ischaemia. All patients were anaesthetised with diazepam, fentanyl and pancuronium, after which ten patients received 50–60% nitrous oxide in oxygen until commencement of bypass, and the remaining patients 100% oxygen. Because of the known effect of nitrous oxide in expanding gaseous bubbles, any neurological dysfunction of gaseous microembolic origin may be worsened in the presence of nitrous oxide. Patients were lumbar punctured 24 hours after cardiopulmonary bypass and cerebrospinal fluid analysed for the following markers of central nervous system ischaemia: creatine kinase, lactate, total protein, noradrenaline, adrenaline and adenylate kinase. There was a statistically significant difference in cerebrospinal fluid lactate between the two groups. There were no statistically significant differences in the other cerebrospinal fluid markers of ischaemia.

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