Anesth Analg 2001;92:1171-1172
© 2001 International Anesthesia Research Society
AMBULATORY ANESTHESIA
Rapacuronium: An Alternative To Succinylcholine For Electroconvulsive Therapy
Andrew G. Kadar, MD*,
Barry A. Kramer, MD
,
Maury C. Barth, MD*, and
Paul F. White, PhD, MD
Departments of *Anesthesiology and Psychiatry, Cedars Sinai Medical Center, Los Angeles, California, and the Department of Anesthesiology and Pain Management University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
Address correspondence to P. F. White, MD, Department of Anesthesiology & Pain Management, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390–9068. Address e-mail to paul.white{at}utsouthwestern.edu
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Introduction
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Electroconvulsive therapy (ECT) is a brief procedure that is increasing in popularity in the United States, with over 100,000 procedures performed annually (1). Although serious complications after ECT are rare, fracture-dislocations have been described when ECT treatments are performed without muscle relaxants (2). Succinylcholine is commonly used to reduce the intense muscle contractions associated with the induced seizure activity (3). A survey in California found that 98% of the hospitals responding routinely used succinylcholine as the muscle relaxant (4). However, this short-acting muscle relaxant produces myalgias and is a potent triggering drug for malignant hyperthermia (MH).
This Case Report describes the anesthetic management of a patient at risk for MH who underwent a series of ECT procedures with rapacuronium, a recently Food and Drug Administration-approved nondepolarizing muscle relaxant.
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Report of Case
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A 51-yr-old man (96 kg, 178 cm) was hospitalized for major depression and scheduled for a series of ECT treatments. His family history was remarkable for a brother who developed MH after receiving a tracheal-intubating dose of succinylcholine 3 mo earlier for an elective operation. Despite his positive family history, the patient refused to undergo a muscle biopsy to determine his MH-susceptibility. Of interest, he had undergone a series of ECT treatments 30 yr earlier without anesthesia. As a result of severe postprocedural muscle and low back pain, he was unwilling to agree to ECT unless he was assured that he would receive medication to minimize these side effects. As a result of his risk for developing MH (and/or myalgias) if succinylcholine was given for his ECT treatment, rapacuronium was used for muscle relaxation.
After induction of anesthesia with methohexital (100 mg IV), rapacuronium (75 mg IV) was administered. Approximately 2–3 min after induction of anesthesia, the electrical stimulus was administered with "minimal" movement. At 5 min after administering the muscle relaxant, the patient exhibited marked fade with tetanic stimulation. Therefore, atropine (1 mg IV) and edrophonium (90 mg IV) was administered for reversal of the residual neuromuscular blockade. Within 2 min, the patient was breathing spontaneously with a well-sustained motor response to tetanic stimulation. He did not complain of any muscle pain after the procedure.
At his three subsequent ECT treatments, he received rapacuronium doses of 70 mg, 60 mg, and 65 mg, respectively, with similar good results. His ECT treatments were terminated after only four sessions because of insurance coverage problems.
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Discussion
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Given his MH-susceptible sibling, this patient had a 50% chance of also being MH-susceptible. Although Franks et al. (5) performed ECT on an MH-susceptible patient using thiamylal without any muscle relaxant, the patient required physical restraint during the seizure and experienced severe muscle pain after the procedure. Therefore, we elected to use rapacuronium (Raplon®), a new aminosteroid, nondepolarizing muscle relaxant with a rapid onset and short duration of action (6). Although the usual intubating dose of rapacuronium is 1.5 mg/kg IV, smaller dosages (0.6–0.8 mg/kg) were administered to facilitate recovery of neuromuscular function after these short procedures.
Another nondepolarizing alternative to succinylcholine is mivacurium. However, small-dose mivacurium (0.08 mg/kg IV) is less effective than standard doses (0.5–1 mg/kg) of succinylcholine for ECT (7). Fredman et al. (8) performed a dose-ranging assessment of mivacurium in a patient with a history of neurolept malignant syndrome and found that only a "full" intubating dose (0.2 mg/kg IV) was associated with effective muscle relaxation during ECT-induced seizures. This observation has been subsequently confirmed by other investigators (9,10). Of concern, intubating doses of mivacurium can be associated with clinically significant histamine release and hypotension (11).
Therefore, rapacuronium appears to be an alternative to both succinylcholine and mivacurium for ECT in patients at risk for developing MH. Further studies are clearly needed to define the minimally effective dose of rapacuronium, the risk of cumulative effects with repeated administration during the acute phase of ECT, and the optimal use of reversal drugs in this patient population.
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Acknowledgments
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Supported, in part, by the White Mountain Institute of Los Altos (Dr. P. F. White, President)
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References
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Hermann RC, Dorward RA, Hoover CW, Brody J. Variation in ECT use in the United States. Am J Psychiatry 1995; 152: 869–75.[Abstract/Free Full Text]
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Sarpel Y, Togrul E, Herdem M, et al. Central acetabular fracture-dislocation following electroconvulsive therapy: report of two similar cases. J Trauma 1996; 41: 342–4.[ISI][Medline]
-
Marks RJ. Electroconvulsive therapy: physiological and anesthetic considerations. Can Anaesth Soc J 1984; 31: 541–8.[ISI][Medline]
-
Kramer BA. Practice patterns of electroconvulsive therapy: a California perspective (1984). Convuls Ther 1986; 3: 239–44.
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Franks RD, Aqueille B, Mahowald MC, Masson N. ECT use for a patient with malignant hyperthermia. Am J Psychiatry 1982; 139: 1065–6.[Abstract/Free Full Text]
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Zhou TJ, White PF, Chiu JW, et al. Onset/offset characteristics and intubating conditions of rapacuronium: a comparison with rocuronium. Br J Anaesth 2000; 85: 246–50.[Abstract/Free Full Text]
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Cheam EWS, Critchley LAH, Chiu PT, et al. Low dose mivacurium is less effective than succinylcholine in electroconvulsive therapy. Can J Anaesth 1999; 46: 49–51.[Abstract/Free Full Text]
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Fredman B, Smith I, d’Etienne J, White PF. Use of muscle relaxants for electroconvulsive therapy: how much is enough? Anesth Analg 1994; 78: 195–6.
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Kelly D, Brull SJ. Neuroleptic malignant syndrome and mivacurium: a safe alternative to succinylcholine? Can J Anaesth 1994; 41: 845–9.[Abstract/Free Full Text]
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Janis K, Hess J, Fabian JA, Gillis M. Substitution of mivacurium for succinylcholine for ECT in elderly patients. Can J Anaesth 1995; 42: 612–3.[Abstract/Free Full Text]
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Savarese JJ, Ali HH, Basta SJ, et al. The cardiovascular effects of mivacurium chloride in patients receiving nitrous oxide-opiate-barbiturate anesthesia. Anesthesiology 1989; 70: 386–94.[ISI][Medline]
Accepted for publication January 22, 2001.
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Introduction
Report of Case
