A 55-year-old woman with severe treatment-resistant MDD (failed 4 antidepressant trials) is referred for ECT. She has no prior seizure disorder. Her baseline ECG shows a QTc of 445 ms and she takes atenolol. What anesthetic consideration is critical for ECT?

• A Use succinylcholine for muscle relaxation; its duration of action must match seizure length to prevent patient injury ✓
• B Avoid methohexital as it lowers seizure threshold more than propofol
• C Continue atenolol on the day of ECT to prevent tachycardia-related seizure prolongation
• D Thiopentone is the preferred agent as it provides longest therapeutic seizure duration

Explanation

In ECT, succinylcholine is the depolarizing muscle relaxant of choice because of its rapid onset and short duration, allowing safe motor isolation of the seizure without prolonged paralysis. Methohexital (barbiturate) is the preferred induction agent for ECT as it has a shorter duration and minimally elevates seizure threshold compared to propofol or thiopentone, which are more anticonvulsant. Beta-blockers (atenolol) are often held before ECT as they can attenuate the post-ictal cardiovascular response that helps confirm adequate seizure generalization, but practice varies. Thiopentone raises seizure threshold more and is not preferred.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.