Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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On Sep 2018




Prof. Somashekhar Nimbalkar

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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : June | Volume : 17 | Issue : 6 | Page : UC01 - UC05 Full Version

Effect of Intravenous Etomidate versus Propofol on Seizure duration and Haemodynamic Response during Modified Electroconvulsive Therapy: A Randomised Clinical Trial


Published: June 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/63454.18030
GK Vishwas, GS Ashwini, RS Deepak, CS Sanikop, LK Shivavanand, Suzanne Sonali Edwin

1. Associate Professor, Department of Anaesthesia, SS Institute of Medical Sciences and Research Centre, Davanagere, Karnataka, India. 2. Associate Professor, Department of Anaesthesia, Basaveshwara Medical College and Hospital, Chitradurga, Karnataka, India. 3. Associate Professor, Department of Psychiatry, Basaveshwara Medical College and Hospital, Chitradurga, Karnataka, India. 4. Professor, Department of Anaesthesia, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India. 5. Associate Professor, Department of Anaesthesia, BLDE DU Shri B M Patil Medical College, Vijayapura, Karnataka, India. 6. Junior Resident, Department of Anaesthesia, Basaveshwara Medical College and Hospital, Chitradurga, Karnataka, India.

Correspondence Address :
Dr. GS Ashwini,
Associate Professor, Department of Anaesthesia, Basaveshwara Medical College and Hospital, Chitradurga-577502, Karnataka, India.
E-mail: dr.ashu1185@gmail.com

Abstract

Introduction: Seizure duration in Electro convulsive Therapy (ECT) is a clinically important factor in managing psychiatric patients subjected to the procedure. Various induction agents are being used with varying efficacy on seizure duration and haemodynamic response like thiopentone, propofol, ketamine and etomidate. As repeated ECT sessions pose significant risk of general anaesthesia and its complications, in this study the efficacy of etomidate and propofol was compared.

Aim: To assess the seizure duration and compare haemodynamic variables using etomidate and propofol.

Materials and Methods: A randomised double-blinded, clinical trial was done in the Department of Anaesthesiology, at tertiary care hospital between July 2021 to June 2022 on 40 patients of age group 18-60 years of either sex, belonging to American Society of Anaesthesiologists (ASA) Grade I and II scheduled for ECT. Patients were allocated into two groups. Preinduction baseline values of Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP) and Mean Arterial Pressure (MAP) were recorded using pulse oximeter and Non Invasive Blood Pressure (NIBP). Patients were induced with either, inj. etomidate 0.2 mg/kg (Group E) or inj. propofol 1 mg/kg (Group P). HR, SBP, DBP and MAP were recorded soon after induction, after application of stimulus and at one minute interval after electric 156 shock for five minutes and then at five minutes interval. Statistical analysis was done by using the unpaired Student’s t-test for quantitative data. The p-value <0.05 was considered significant.

Results: Demographic data were similar in both the groups. The mean seizure duration in Group E (51.25±9.01 seconds) was greater than in Group P (38.30±9.92 seconds) and was statistically significant. There was significant increase in the HR in both groups and the HR did not reach the baseline even after 10 minutes. There was a rise in the mean SBP by approximately 7 mmHg in the Group P compared to 4 mmHg in the Group E. The mean DBP rise in the propofol group was 6 mmHg as compared to 5 mmHg in the Group E. The MAP in both the groups increased by 7 mmHg. The parameters reached the baseline earlier with Group P compared to Group E.

Conclusion: The study concludes etomidate has a distinct advantage over propofol in producing seizures of adequate duration during ECT whereas propofol blunts the sympathetic response to ECT more effectively than etomidate.

Keywords

Cardiovascular effects, Psychiatry patient, Sympathetic response

The ECT, also known as electroshock, is a well-established, albeit controversial psychiatric treatment in which seizures are electrically induced in anaesthetised patients for therapeutic effect. ECT is most often used as a treatment for severe major depressive disorder which has not responded to other treatment (1), and is also used in the treatment of mania (often in bipolar disorder), catatonia and schizophrenia. For the safe conduct of ECT, an effort to avoid or minimise the physiologic sequelae and the attendant complications of ECT, a technique of modified ECT has evolved gradually, featuring use of muscle relaxation and induction agents without the concomitant abolition of the beneficial effects (2). The commonly used muscle relaxant is a short acting depolarising agent succinylcholine. Various induction agents were tried viz., diazepam, ketamine, methohexitone, sodium thiopentone. However, the attendant cardiovascular effects are inadequately attenuated with its use (3). The search for an ideal anaesthetic agent for ECT has been an ongoing process. Most of the anaesthetic agents used possess anticonvulsant properties because of their effects on the Gamma-Aminobutyric Acid (GABA) receptors.

Following application of the electrical stimulus during ECT, there is a vagally mediated short lived bradycardia which is replaced by a sympathetically mediated tachycardia and rise in blood pressure (4). Accordingly there is a sharp rise in the plasma catecholamine levels. This produces a short lived sharp increase in myocardial workload which may pose significant risk for patients with coronary artery disease and congestive cardiac failure. Hence, use of agents which would attenuate this adverse physiologic consequence would be preferred.

Etomidate, a imidazole derivative is a short acting intravenous anaesthetic agent used for the induction of general anaesthesia. It acts by inhibiting the reticular activating system and mimics action of GABA inhibition. The R (+) isomer of Etomidate particularly appears to bind specifically to a subunit of the GABAA receptor, thus increasing the affinity for inhibitory neurotransmitter i.e., GABA (5).

Propofol structure includes phenol ring substituted with two groups of isopropyl (2, 6-diisopropylphenol) is primarily a hypnotic agent and has rapid onset of action for induction of anaesthesia. Propofol allosterically increases affinity of binding GABA to GABAA receptor. This receptor is coupled to a chloride (Cl-) channel and activation of the receptor results in hyperpolarisation of the nerve membrane. Propofol binds to multiple ion channels and receptors.

The α2- adrenoceptor system indirectly causes sedation due to propofol. Propofol also causes inhibition of NMDA (N-methyl D-aspartate) receptor, which is a subtype of glutamate receptor (6).

Administration of etomidate in ECT has variable impact on seizure duration and haemodynamic parameters, when compared to propofol. Improved seizure duration observed with etomidate versus propofol has been reported in various studies. However, some studies have shown that etomidate has better haemodynamic profile in patients undergoing modified ECT. Jindal S et al., in their study concluded that among haemodynamic parameters, there was a significant increase in HR and significant fall in MAP after induction with propofol as compared to etomidate. Hence, stating etomidate has stable haemodynamics compared to propofol (7). Another study conducted by Mansuri Y and Dave J, showed that etomidate has stable haemodynamics compared to propofol during modified ECT (8). This study was undertaken to study the effect of propofol in suppressing the sympathetic response induced by modified ECT, thus enhance safety in patients undergoing ECT. Thus, the present study aimed to compare the effect of propofol and etomidate on seizure duration and haemodynamic response when administered during ECT.

The primary and secondary measure of this study was to assess the seizure duration and to compare haemodynamic response of etomidate and propofol, respectively.

Material and Methods

A randomised double-blinded, clinical study was conducted in the Department of Anaesthesiology, at tertiary care hospital between July 2021 to June 2022 for the period of one year after approval from Institutional Ethical Committee (IEC) (MDC/DOME/2158).

Inclusion criteria: A total of 40 patients between the age group of 18-60 years belonging to ASA grade I and II, taking ECT for first time, of either gender and with no absolute contraindication to ECT were included in the study. Informed written consent was obtained from the patient’s close relative before being included in the study.

Exclusion criteria:

• Pregnant women.
• Hypertensive patients.
• HR less than 60 beats/minute.
• History of allergy to any drug.

Sampling was done by simple random sampling using computer generated table. Consolidated Standards of Reporting Trials (CONSORT) flow diagram is given in (Table/Fig 1).

Sample size calculation: Sample size was calculated using Open-epi software (AG Dean, KM Sullivan, MM Soe–3.03/ September 22, 2014) considering 95% confidence interval, 90% power of study.

Sample size calculation formula:

n=(Zα+Zβ)2*2*(S)²/ d²

Where, Zα: Two tailed significance level 5%=1.96
Zβ: Power of study 90%=0.94
(Zα+Zβ) 2=(1.96+0.94)2=8.4
S=16.4 (S=standard deviation of SBP, d=mean difference of SBP) (9)
d=15

n=8.4×2×(16.4×16.4)/ (15×15)
=20 in each group
The sample size obtained was 20 in each group.

Study Procedure

A thorough preanaesthetic evaluation was conducted a day prior to ECT and routine investigations like Haemoglobin%, urine routine, blood sugars, blood urea, serum creatinine, ECG, Chest X-ray were carried out for all patients. On the day of ECT, each patient’s investigations verified and were found to be within normal limits. Antipsychotic drugs were omitted on the day of ECT. Overnight fasting of eight hours before the procedure was confirmed. Patients were randomly allocated using computer generated random numbers into two groups of 20 patients each.

Anaesthetic machine and all equipments were checked and kept ready along with the crash cart. On arrival of the patient to the ECT room, ECG, pulse oximeter and NIBP monitors were attached and baseline HR, SBP, DBP and MAP were recorded using a NIBP monitor (Larsen and Turbo model star 50). An intravenous line was secured on the dorsum of left hand using a 20 G intravenous cannula. All patients were premedicated with Inj. glycopyrrolate 0.2 mg i.v. and preoxygenated for three minutes. Induction was done using etomidate (0.2 mg/kg) or propofol (1 mg/kg) depending on the group allocated by an anaesthesiologist who was blinded for the study.

Group E (Etomidate): Patients in this group received etomidate (0.2 mg/kg) slowly over 15 seconds. Induction was confirmed by loss of eyelash reflex.

Group P (Propofol): Patients in this group received propofol (1 mg/kg) slowly over 15 seconds.

After noticing of loss of eyelash reflex, blood pressure cuff applied to the lower limb was inflated to isolate the foot and permit accurate measurement of motor seizure duration. After confirming, the patient could be ventilated. Injection succinylcholine 1.0 mg/kg was given for muscle relaxation. Patients were ventilated with 100% O2 until fasciculations subsided.

As soon as the patient was relaxed, a mouth gag was inserted and a bitemporal ECT was administered by the psychiatrist. Motor seizure duration was noted again by the anaesthesiologist who was blinded for the study and was different from the anaesthesiologist who allocated the groups. The mouth gag was changed to Guedel airway after the seizure subsided and ventilation was assisted with the face mask and 100% oxygen until return of spontaneous respiration. The patient was observed for 10 minutes in the ECT room and later was monitored in the recovery room for an hour.

The seizure duration is defined as time interval between administration of electrical stimulus and loss of visible fasciculation’s in the isolated limb (7).

Monitoring: Seizure duration was noted in all patients. All patients had continuous pulse oximeter, ECG monitoring and systolic, diastolic and MAP were recorded and monitored using an automated blood pressure machine set to record every minute.

Baseline HR, SBP, DBP and MAP were noted just before securing the intravenous cannula. The same parameters were noted after loss of eyelash reflex following induction, immediately after seizure cessation following delivery of the electric shock and at 1 minute interval for 5 minutes and once after five minutes (10 minutes post ECT).

Statistical Analysis

Data are presented as mean and standard deviation. Statistical analysis was done by using the unpaired Student’s t-test for quantitative data. Comparison of proportions (percentage) of the two groups was done using test for proportions was done using data analysis and p<0.05 was considered significant.

Results

In this comparative study, 40 patients (20 in each group) undergoing ECT were randomly selected. Both the groups were comparable with respect to age, sex, weight and diagnosis. (Table/Fig 2) shows mean age in Group E was 28.6 years and 34.25 years in Group P and weight in Group E was 48.90 kg and 51.40 kg in Group P which are not statistically significant. Male to female proportion was similar.

(Table/Fig 3) depicts the percentage of distribution of diagnosis of disease in the two groups, with a varying pattern of distribution. Majority of the patients receiving ECT were subjects diagnosed as schizophrenia followed by psychosis and depression.

(Table/Fig 4) shows the mean seizure duration in Group E which was greater than in Group P and was statistically significant.

(Table/Fig 5) depicts that the HR in the both groups significantly increased after application of electric shock, the increase continued for three minutes after the electric shock but does not reach the baseline even at 10 minutes. The HR trend in the Group E and that in the Group P were significantly different and the values immediately after applications of electric shock were significantly higher with the Group E compared with the Group P.

(Table/Fig 6) shows that the SBP in the Group E increased after application of electric shock and the increase continued until four minutes after the application of electric shock. In the Group P, there was an increase in the SBP until two minutes of application of electric significantshock. The increase was greater at two minutes of application of electric shock in the two groups.

(Table/Fig 7) depicts that the DBP in the Group E increased after application of electric shock and the increase continued until four minutes after the application of electric shock. In the Group P, there was an increase in the DBP until two minutes of application of electric shock.

(Table/Fig 8) shows that the MAP in the Group E increased after application of electric shock and the increase continued until four minutes after the application of electric shock. In the Group P, there was an increase in the MAP until two minutes of application of electric shock. The trends of the MAP were significantly increased in the Group E compared with the Group P.

With regards to the complications observed during the study the incidence of pain on injection was 25% in the Group P and none had pain in the Group E. There were no complaints of pain on injection, myoclonus or increased tonus-related complications.

Discussion

The ECT has a well-established role in the management of patients who have not responded to psycho-pharmacological treatment (10). The procedure itself consists of programmed electrical stimulation of the central nervous system to initiate seizure activity. In terms of haemodynamic effects, seizure activity causes an initial parasympathetic discharge, later followed by sympathetic discharge. In terms of patient comfort and amnesia during the operation, anaesthesia has elevated ECT to a new level with the introduction of intravenous anaesthetic drugs, neuromuscular blockade, and assisted or controlled ventilation with 100% oxygen in 1963 (10). The ideal ECT induction drug would guarantee quick unconsciousness, be painless upon injection, have no haemodynamic side-effects, not change seizure duration or amplitude, and be reasonably priced. (11). The present study has compared the seizure duration and haemodynamic responses to ECT with etomidate and propofol as induction agents. The results of the present study indicate that there are differences in seizure duration and the haemodynamic responses on induction with these two agents.

In the present study, the mean seizure duration was significantly prolonged in etomidate group (51.25±9.01 seconds) when compared to propofol group (38.30±9.92 seconds). This is attributed to the lack of anticonvulsant properties of etomidate which makes it preferred induction agent as it provides better therapeutic efficacy due to seizure prolongation. The seizure duration is defined as time interval between administration of electrical stimulus and loss of visible fasciculation’s in the isolated limb. The aim of ECT is to obtain generalised convulsions over 20 seconds. Although there is no beneficial effect with only one seizure, clinical improvement can be observed with a total seizure time over 210 seconds. In the present study, in terms of SBP, DBP and MAP remained elevated upto four minutes in etomidate group compared to propofol group where the increase was only upto two minutes. The HR was considerably high in etomidate group compared to propofol group and did not reach the baseline in both the groups even after 10 minutes postshock. This can be explained by the cardiovascular depressant effect of propofol which dominates over the sympathetic stimulation caused by the seizure induced during ECT. Similar results were noted by Mehta D et al., in which propofol maintained stable haemodynamics during modified ECT, yet clinical applicability of etomidate outstripped propofol by a reasonable margin due to its better effect on seizure parameters. The increase in haemodynamic parameters in etomidate group here is explained by the increased apnoea time secondary to increased motor duration of the seizure and also its perceived effects on adrenocortical axis which were feared to be sustained than transient (12). Shastry SB et al., compared propofol and etomidate on haemodynamic variables and seizure duration and concluded that seizure duration recorded was prolonged in a statistical significant manner whereas the scores used to assess haemodynamic parameters in both the groups were the same indicating similar efficacy in stabilising the haemodynamic changes (13). This was attributed to the inherent advantage of blunting the autonomic response to induced seizures by the induction agents. Mansuri Y and Dave J, compared the effects between etomidate and propofol for anaesthesia during ECT in which they observed that duration of seizures was significantly prolonged in former group (8). This can be explained by the propensity to prolong the seizure duration by etomidate.

A study carried out by Stadtland C et al., concluded a switch from propofol to etomidate during ECT course increases EEG and motor seizure duration (14), which was similar with the present study. Etomidate has the distinct advantage of producing seizures of adequate duration during ECT and should be used as first line measure in augmenting seizures in patients who have difficulties in inducing seizures by conventional method was the conclusion derived from a study carried out by Jensen KR et al., (15). A retrospective study done by Patel AS et al., observed that patients who received propofol had longer courses of ECT and, consequently longer and costlier inpatients stays and concluded that etomidate could be an alternative induction agent (16). Patil M et al., have studied neuroendocrinal responses in 60 patients undergoing ECT under propofol and thiopentone anaesthesia (17). They found that subjects given propofol had significantly reduced Adrenocorticotropic Hormone (ACTH) and cortisol responses compared to thiopentone. These humoral responses could have resulted in the lesser rise in the haemodynamic parameters in the propofol induced subjects. After application of the electric shock in the present study, there was a rise in the mean SBP of approximately 7 mmHg (124.6 mmHg to 131.50 mmHg) in the propofol group. In comparison, in the etomidate group the rise was 4 mmHg (124.8 mmHg to 128.50 mmHg). The mean DBP rise in the propofol group was 6 mmHg (80.35 mmHg to 86.25 mmHg) as compared to 5 mmHg (76.40 mmHg to 81.00 mmHg) in the etomidate group. The MAP in the both the groups increased by 7 mm of Hg. Although significant increase in mean blood pressure values were observed after ECT with both the agents, increase in blood pressure was slightly higher with propofol, when compared with etomidate but the values reached the baseline earlier i.e., by 2 minutes in Group P when compared four minutes in Group E following administration of electrical stimulus. Analysis of the data suggested that propofol was more effective in controlling haemodynamic response to ECT than etomidate. Also, it was found that the mean HR in both the groups increased from the baseline after application of electric shock. However the rise was lesser in the propofol group than the etomidate group. Propofol had the advantage of smooth induction, stable haemodynamic parameters, and rapid recovery as compared to etomidate. However, it was associated with shorter seizure duration. Etomidate had longer seizure duration which results in better clinical outcomes over propofol (11). The results were similar to what was noted in the present study.

A similar comparative study by Jindal S et al., here apart from seizure duration, cognitive recovery profiles, haemodynamic parameters viz., HR and MAP were observed. Their observations were similar to the present study in which propofol was associated with a reduced acute haemodynamic responses compared to etomidate (7). Following induction with propofol, there was slight fall in the systolic, diastolic and the mean blood pressure. This is attributed to its vasodilating property of propofol, which reduces the peripheral vascular resistance. In a study conducted by Lisanby SH, propofol and etomidate were compared during the ECT of patients with depression on the basis of their impact on seizure activity and on seizure induced haemodynamic reactions. When using propofol, the increase in MAP was significantly lower than when etomidate was used. They concluded that propofol was more effective in attenuating the seizure-induced increase in MAP than etomidate, and supported the use of propofol in patients with greater cardiovascular risk (18). In a comparison study of thiopentone sodium, propofol, and etomidate for anaesthetic efficacy and effect on seizure duration in ECT, Vansola RH et al., found that propofol was more advantageous than etomidate and thiopentone due to stable haemodynamic boundaries, smooth enlistment and fast recuperation in contrast with etomidate and thiopentone. (19). In a study on ECT by Rasmussen KG, has shown that after the electrical stimulus, there is a vagally mediated short lived bradycardia following sympathetically mediated tachycardia and rise in blood pressure (20). The initial bradycardia was not noticed in any of the patient in our study. Premedication with intravenous glycopyrrolate could have aborted that phase in present study. The choice of anaesthetic for ECT depends on the anaesthetic needs to be met and agent’s effect on the seizure threshold. Thus, the non barbiturate anaesthetic etomidate showed qualities to prolong the seizure. During the application of ECT, complications can occur at the induction and recovery stages. Present study did not encounter any complaints of pain on injection, myoclonus or increased tonusrelated complications.

Limitation(s)

The study was conducted only in patients belonging to ASA Class-I and II physical status. Therefore, effects of propofol and etomidate for ECT in geriatric population and those having associated comorbidities are yet to be studied. Since, the study was conducted with a sample size of 40 patients, 20 in each study group, results obtained cannot be generalised for entire population. Thus, further studies should be designed and conducted with larger study groups including patients with co-morbidities.

Conclusion

Propofol has superior haemodynamics during ECT, yet the clinical utility of etomidate outpace it by a reasonable margin due to its improved effect on seizure parameters and the clinical conditions that require ECT. Hence, the present study infers that etomidate can be a potential first line drug of choice in ECT in seizure resistant patients.

References

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DOI and Others

DOI: 10.7860/JCDR/2023/63454.18030

Date of Submission: Feb 13, 2023
Date of Peer Review: Mar 03, 2023
Date of Acceptance: May 03, 2023
Date of Publishing: Jun 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 16, 2023
• Manual Googling: Apr 22, 2023
• iThenticate Software: Apr 25, 2023 (23%)

ETYMOLOGY: Author Origin

EMENDATIONS: 6

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