Split dose of succinylcholine for modification of seizure during multiple monitored electroconvulsive therapy

Abstract

Objective: Electroconvulsive therapy is a treatment for psychiatric patients who fail medical treatment or have severe manifestation. Multiple monitored electroconvulsive therapy, stimulating more than one convulsion in one treatment session, ensures adequate stimulation and results in rapid response. Single dose of short acting muscle relaxant is sometimes inadequate for the later stimulation and results in too strong convulsion and injury. We compared succinylcholine dispensed in two divided doses with the usual single dose for modification of convulsion. Design: Randomized double blind crossover trial. Setting: Tertiary care public hospital. Participants: Forty adult psychiatric patients who required multiple monitored electroconvulsive therapy Intervention: After anesthetized, patients in conventional single dose regimen received 1 mg/kg succinylcholine before stimulation then two consecutive electrical stimuli were given in 3 minutes apart. Split dose regimen consisted of 0.75 mg/kg succinylcholine before first stimulation and 0.25 mg/kg before second stimulation. The wash out period was at least 48 hours before switching to another regimen in the next session. Main outcome measures: Isolated limb with tourniquet and compared the convulsion severity with another side to identify the poor modification of convulsion. Result: The incident of poor session in single dose regimen was 43.6% compared with 10.3% in split dose regimen (p = 0.006). The period effect, sequence effect and carryover effect was not demonstrated. The average time from the end of seizure to 20% muscle twitch height recovery in single dose and split dose were 125 seconds and 183 seconds respectively (p = 0.001). Conclusion: Split dose of succinylcholine is suitable for modification of seizure during multiple monitored electroconvulsive therapy, even though the muscle recovery may be a little bit longer.