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BRIEF CLINICAL REPORT LETTER

Methohexital and Succinylcholine Dosing


for Electroconvulsive Therapy (ECT)
Actual Versus Ideal
Ethan O. Bryson, MD,*Þ Amy S. Aloysi, MD,Þ Dennis M. Popeo, MD,Þ Carol A. Bodian, DrPH,*
Rosa M. Pasculli, BA,Þ Mimi C. Briggs, BA,Þ and Charles H. Kellner, MDÞ

this period. The doses of each agent administered to these patients


Abstract: This report compares the actual doses of methohexital and during their first 4 treatments were obtained by dividing the
succinylcholine used for optimal anesthesia and muscle relaxation in administered dose by weight in kilograms and rounded to one
electroconvulsive therapy with written guidelines for dosing. The initial decimal. Changes in dose per kilogram were obtained for all
doses of methohexital and succinylcholine in milligrams per kilogram consecutive treatments in which the drug was administered.
were reviewed and compared with subsequent doses of each agent after Six patients received no methohexital and instead received
adjustments were made for individual patient responses during treatment. propofol or ketamine. The initial dose administered to the re-
The dose of methohexital required to induce general anesthesia for maining patients ranged from a minimum of 0.6 mg/kg to a
most patients is 1.0 mg/kg. The dose of succinylcholine required to pro- maximum of 2.0 mg/kg, with most of the patients receiving
vide adequate muscle relaxation during electroconvulsive therapy is 0.9 close to the mean dose of 1.0 mg/kg. The initial dose of 7
mg/kg, although there is considerable variability in patient response to patients was changed at the second treatment (3 increased
this drug. and 4 decreased). Another 7 patients had an initial dose change
Key Words: methohexital, succinylcholine, anesthesia, at the third treatment (5 increased and 2 decreased), and 2 more
electroconvulsive therapy, ECT patients (1 increased and another 1 decreased) at the fourth
treatment. Three of these patients had their methohexital dose
(J ECT 2012;28: e29Ye30)
changed twice. The dose was unchanged over the course of
4 treatments for 54 patients (77%). The dose of methohexital
Dear Editor: administered on the fourth treatment, after all required adjust-
The current practice is to estimate the dose of methohexital ments had been made, ranged from a minimum of 0.6 mg/kg to
and succinylcholine required to achieve adequate anesthesia and a maximum of 1.5 mg/kg, with most of the patients receiving
muscle relaxation for electroconvulsive therapy (ECT) based on close to the mean dose of 1.0 mg/kg.
patient’s weight using the standard of 1 mg/kg weight. Some- Of these patients, one received no succinylcholine but re-
times, this dose of each medication is not ideal and must be ceived rocuronium1 instead. The initial dose of succinylcholine
adjusted on subsequent treatments. In the case of methohexital, administered to the other patients ranged from a minimum of
too great a dose can result in increased seizure threshold and 0.6 mg/kg to a maximum of 1.4 mg/kg, with most of the patients
delayed awakening; too small a dose increases the risk for receiving close to the mean dose of 0.9 mg/kg. The dose was
awareness. For succinylcholine, too small a dose increases the changed at the second treatment for 19 patients (12 decreased and
risk for physical injury during the motor seizure, and too great a 7 increased). Another 4 patients had an increase in dose at the
dose increases the risk for postprocedure weakness, which can third treatment, and 2 more patients had an initial increase at the
result in awareness while the patient is still paralyzed. If the fourth treatment. Four of these patients had 2 adjustments to their
methohexital should wear off first, there is a risk of atelectasis succinylcholine dose, and one had 3 adjustments. The dose was
and/or hypoventilation, with increased shunting and decreased unchanged over the course of 4 treatments for 50 patients (67%).
oxygen saturation, and increased risk for aspiration. All of these The initial dose of methohexital was estimated by the ECT
events can increase the catecholamine surge, which accom- treatment team before the first treatment. Medical conditions such
panies the induced seizure and can further exacerbate hyper- as cardiac or liver disease, which may increase or decrease the
tension and tachycardia in at-risk patients. response to a drug, were considered when estimating the initial
After obtaining institutional review board approval from dose. As such, the dose of methohexital ranged from a minimum
the Mount Sinai Hospital Program for the Protection of Human of 0.6 mg/kg to a maximum of 2.0 mg/kg, but most of the
Subjects, a retrospective chart review was conducted involving all patients received a dose within 0.1 of the mean dose of 1.0 mg/kg.
patients who received ECT at the Mount Sinai Medical Center from We chose to examine the dose of methohexital administered on
January 1 through December 31 of 2010. A total of 88 patients the fourth treatment, after any required adjustments had been
were identified as having received their initial treatment during made, to see if there was a change in either the range or the
mean dose administered. After adjustments had been made by the
treatment team based on the patient’s clinical response to the drug,
From the Departments of *Anesthesiology and †Psychiatry, Mount Sinai the range was somewhat narrowed, with a minimum of 0.6 mg/kg
School of Medicine, New York, NY.
Received for publication October 6, 2011; accepted October 7, 2011.
and a maximum of 1.5 mg/kg. Still, most of the patients received
Reprints: Ethan O. Bryson, MD, Department of Anesthesiology, Mount Sinai close to the mean dose of 1.0 mg/kg, so it seems that the published
Hospital, One Gustave L Levy Place, New York, NY 10029 (e-mail: guidelines for methohexital dosing remain a good starting point
ethan.bryson@mountsinai.org). for most patients.
The authors have no conflict of interest to declare.
Support was provided solely from institutional and departmental sources.
The initial dose of succinylcholine was estimated by the ECT
Copyright * 2012 by Lippincott Williams & Wilkins treatment team before the first treatment based on the patient’s
DOI: 10.1097/YCT.0b013e3182503bc9 weight, and the perceived risk for injury should muscle relaxation

Journal of ECT & Volume 28, Number 3, September 2012 www.ectjournal.com e29

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Bryson et al Journal of ECT & Volume 28, Number 3, September 2012

proved to be inadequate. As such, the initial dose administered for ECT, most patients will likely require a dose close to the
ranged from a minimum of 0.6 mg/kg to a maximum of 1.4 established mean. The dose of methohexital required to induce a
mg/kg, but once again, most of the patients received within 0.1 of level of anesthesia appropriate for ECT for most patients is
the mean dose of 0.9 mg/kg. We chose to examine the dose of 1.0 mg/kg, although some patients may require more or less,
succinylcholine administered on the fourth treatment to see if depending on comorbidities. The dose of succinylcholine re-
there was a change in the range or mean dose. After adjustments quired to provide muscle relaxation sufficient to prevent injury
had been made by the treatment team based on the patient’s during ECT is 0.9 mg/kg, although there is considerable vari-
clinical response to the drug, the range was somewhat greater, as ability in patient response to this drug.
the minimum had been decreased to 0.4 mg/kg. Our study sug-
gests that the optimal dosage for ECT is, in fact, close to the
published standard of 1 mg/kg. REFERENCES
Although a significant number of patients will require an 1. Bryson EO, Aloysi AS, Katz M, et al. Rocuronium as muscle relaxant
adjustment in the dose of both methohexital and succinylcholine for electroconvulsive therapy (ECT) in a patient with adult onset
required to produce adequate anesthesia and muscle relaxation muscular dystrophy. J ECT. 2011;27:e63Ye64.

e30 www.ectjournal.com * 2012 Lippincott Williams & Wilkins

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.