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A novel use of remifentanil for electroconvulsive therapy in a third trimester parturient
Abstract Number: T-02
Abstract Type: Case Report/Case Series
Introduction: Psychiatric disorders in pregnancy can affect the safety of both mother and fetus(1). Their pharmacologic management can be challenging and requires weighing potential teratogenic risks to the fetus against possible benefits to the mother. Electroconvulsive therapy (ECT) has been found to be effective in the treatment of psychiatric disorders in pregnancy(2). Special considerations, however, must be taken in order to provide a safe anesthetic to a parturient for a procedure with potential wide hemodynamic changes. The use of remifentanil as part of the anesthetic management of ECT in the parturient has not been previously reported. We report the use of remifentanil for ECT in a third trimester parturient with prior significant hemodynamic responses to ECT.
Case: A 40 year-old G3P1 with history of bipolar disorder and diabetes mellitus was admitted at 30 weeks gestation for a manic episode. She was initially treated with antipsychotics, however did not improve. At 32 weeks gestation, she began a series of nine ECT treatments. For each treatment, the patient was given antacid prophylaxis prior to anesthesia induction with 30mg of sodium citrate PO as well as 20mg famotidine IV. She was positioned supine with left uterine displacement and her trachea was intubated using a video laryngoscope following a rapid sequence intubation technique with cricoid pressure. Anesthesia was induced for her first ECT treatment with 1mg/kg methohexital and 1mg/kg succinylcholine. This treatment was complicated by severe hypertension (BP 216/109) following the ECT stimulus, which was treated with IV labetalol. On subsequent ECT treatments, the patient received a bolus of 3mcg/kg remifentanil in addition to 0.9mg/kg methohexital and 0.9mg/kg succinylcholine for induction. The remifentanil successfully blunted the hyperdynamic response to the subsequent ECT treatments. No fetal or maternal complications were seen with the addition of remifentanil. Fetal heart rate was monitored with non-stress testing prior to and following each ECT treatment with no fetal heart rate decelerations seen. At 36 weeks gestation, the patient developed pre-eclampsia and underwent a cesarean section under spinal anesthesia. During placement of the spinal anesthetic the patient was anxious and exhibited signs of mania. Dexmedetomidine was given in 4mcg boluses for a total of 8mcg to achieve anxiolysis and sedation with good response. A live baby was born weighing 2210g with APGARS of 8 at 1 minute and 9 at 5 minutes.
Discussion: We report the anesthetic management of a series of ECT treatments and cesarean delivery in a manic parturient. Remifentanil successfully attenuated the hyperdynamic response following the ECT treatments. Dexmedetomidine also provided adequate sedation during cesarean delivery under spinal anesthesia in a manic parturient.
1. The journal of ECT. Dec 2011;27(4):328-330.
2. General hospital psychiatry. Nov-Dec 2013;35(6):636-639.