When the ECT anaesthetic methohexitone was unexpectedly withdrawn earlier this year we switched to the alternative agent propofol, and very quickly found the expected trends emerging - on average patients have shorter fits, fewer have ‘adequate’ fits (according to either the motor fit or the electroencephalogram), and in consequence higher stimulus charges were being used as well as routine caffeine augmentation and hyperventilation. Unsurprisingly, our local clinical teams soon began commenting on the increase in the post-ECT confusion.

We have, therefore, begun using thiopentone for those patients who have an unacceptably high seizure threshold with propofol. We have found that thiopentone appears to have noticeably less anticonvulsant effect so that relatively lower charges and longer fits are possible - in one case a 90% reduction in charge was achieved.

Interestingly, with propofol, a number of patients are responding well even though their fit duration does not meet the usual criteria for ‘adequacy’ in line with the observations on monitoring seizure activity in the College's ECT Handbook (1995).

We would, therefore, suggest keeping the dose as low as possible if using propofol, to minimise its anticonvulsant effect. If the patient is having short fits it may not be necessary to significantly increase the charge, if feedback from the clinical team indicates the patient is responding well anyway. Thiopentone may be an acceptable alternative for those patients who cannot be given effective treatment using propofol.

A comparison of the last 23 courses of ECT using methohexitone alone with the first 20 not using methohexitone showed 13/23 ‘unequivocally good’ outcomes in the methohexitone group versus 17/20 in the non-methohexitone group, a non-significant trend in favour of ‘non-methohexitone’ (0.10 > P > 0.05 using χ² with Yates correction).

Thus, the administration of effective ECT is possible without the use of methohexitone.