Acute and Prophylactic Management of Postictal Agitation in Electroconvulsive Therapy

Abstract

Postictal agitation (PIA) is a common adverse effect of electroconvulsive therapy (ECT), a treatment used for a variety of psychiatric disorders. Because of risk of harm to patients and health providers when patients develop PIA, its acute management and prophylaxis are of vital importance for ECT practitioners. This article describes PIA risk factors, as well as practical steps to manage this ECT complication. Nonpharmacologic patient safety interventions are critical components of PIA management. Benzodiazepines, antipsychotics, and additional anesthetic doses are discussed as acute treatment interventions. Prophylactic pharmacologic choices described include antipsychotics, postseizure anesthetics, and dexmedetomidine. Exploratory choices such as melatonin and intranasal formulations of sedatives are also discussed. This review suggests that common medication like olanzapine and propofol are cost-effective considerations to decrease PIA incidence and/or severity after ECT. In addition, dexmedetomidine presents a management alternative for treatment-resistant PIA. This literature review outlines treatment choices while suggesting future directions for considering effective treatments of postictal agitation in clinical settings.

Pharmacological prevention of postictal agitation after electroconvulsive therapy—A systematic review and meta-analysis

“…The use of dexmedetomidine to prevent PIA after ECT was the most recently described in two reviews that summarized the evidence thus far ( 12 , 36 ). In contrast to our results, Li et al ( 12 ) performed a meta-analysis on two studies ( 17 , 26 ) to investigate the effect of dexmedetomidine on PIA and found no statistically significant preventative effect.…”

“…Therefore, the effect of dexmedetomidine (to reduce the mean EAS score as opposed to placebo) in this meta-analysis was mostly measured on “relaxed and awake” patients. In addition, Sterina et al ( 36 ) recently published a narrative review on the acute and prophylactic interventions for PIA after ECT. They described various (non-) pharmacological interventions that could be attempted to prevent or treat PIA, including dexmedetomidine.…”

“…As seen in Supplementary Table 2 , none of the included studies clearly defined the psychiatric indication for ECT, management of agitation prior to ECT or in between sessions, the ECT procedure, or any other possible risk factors for PIA that could confound the results. These risk factors include gender ( 6 , 35 ), concomitant lithium or SSRI use ( 6 , 36 ), and substance use disorder ( 35 ). The generalizability of the results is questionable as most studies were performed in Asia [except for one Egyptian study ( 29 )], and mostly young healthy patients or patients with mild systemic disease (ASA II) were included.…”