Electroconvulsive therapy (ECT) is a definitive treatment for patients with psychiatric disorders that are severe, acute, or refractory to pharmacologic therapy. Providing anesthesia for ECT is challenging, as the effect of drugs on hemodynamics, seizure duration, comfort, and recovery must be considered. We highlight and aim to review the common anesthetics used in ECT and related evidence. While drugs such as methohexital, succinylcholine, and etomidate have been used in the past, other drugs such as dexmedetomidine, ketamine, and remifentanil may provide a more balanced anesthetic with a greater safety profile in select populations. Overall, it is essential to consider the patient’s co-morbidities and associated risks when deciding on an anesthetic drug.
Patient: Female, 1Final Diagnosis: Parietooccipital brain tumorSymptoms: Drowsiness • failure to thrive • irritability • seizure-like activityMedication: —Clinical Procedure: Massive transfusion during tumor resectionSpecialty: AnesthesiologyObjective:Management of emergency careBackground:We present a case in which extremely rapid massive transfusion was successfully used to combat severe acute bleeding during a parietooccipital tumor resection in a 14-month-old patient.Case Report:An 8-kg patient was found to have a 4×5×5-cm parietooccipital tumor on computed tomography scan, for which resection was urgently planned. Sudden acute bleeding was encountered, which was communicated to the anesthesia team. Transfusion was initiated and a total of 5 units of packed red blood cells, 3 units of fresh frozen plasma, 160 ml of platelets, 200 ml of albumin, and 500 ml of 0.9% normal saline were transfused during a 4-h period. We administered 4 g of mannitol and 0.8 mg of furosemide to deal with anticipated fluid overload. The patient was sent to the intensive care unit and extubated the next day. No clinically significant hemostatic or fluid overload complications were noted after the treatment.Conclusions:Massive transfusion (MT) was found to be safe and effective in this case. Most of what we know about pediatric MT is an extrapolation of data from adult studies. Although practical, it might not be ideal due to the differences in the physiology and incomplete development of hemostatic mechanisms in children, especially those younger than 12 months. Studies evaluating the use of pediatric MT protocols have not shown a significant advantage over transfusion per clinician discretion.
Hypoxia-inducible factor prolyl hydroxylase inhibitors are a relatively new class of drugs that act by inhibiting the enzyme hypoxia-inducible factor-proline dioxygenase (HIF prolyl-hydroxylase or HIF-PHD).
Patient: Female, 48-year-old Final Diagnosis: Major depressive disorder Symptoms: Depression and anxiety • loss of appetite • mania Medication: — Clinical Procedure: Electroconvulsive therapy Specialty: Anesthesiology • Psychiatry Objective: Unusual or unexpected effect of treatment Background: The choice of pharmacologic agents used for electroconvulsive therapy (ECT) is critical as this can affect seizure duration and, ultimately, the effectiveness of ECT for the underlying condition. We report the use of nitrous oxide (N 2 O) to sedate and place an intravenous (IV) catheter in a combative patient for the induction of anesthesia. We found no significant clinical effect on seizure duration while using N 2 O in the pre- and intra-procedural period. Case Report: We present the case of a 48-year-old woman with a history of major depressive disorder scheduled for electroconvulsive therapy (ECT). We used 50% nitrous oxide (N 2 O) to sedate her and facilitate the placement of a 22-gauge IV catheter. When IV access was established, induction of anesthesia was done with 80 mg of methohexital, which was later switched to 16 mg of etomidate and 80 mg of succinylcholine. After multiple ECT treatments, we observed no significant clinical effect on seizure duration while using N 2 O when home medications were optimized. There is limited literature on the use of N 2 O as a sedative agent in the perioperative period with other agents known to have no effect or beneficial effect on ECT treatments. We found no studies assessing the effect of N 2 O on seizure duration. Conclusions: Considering the pleasant odor, independent antidepressant activity, vasodilatory effect, low blood-gas partition coefficient, and minimal effect on respiration, N 2 O may serve as the ideal adjunct to intravenous induction of anesthesia in an uncooperative or anxious patient. Further studies are warranted to confirm the efficacy and the safety of N 2 O for use during ECT.
There is currently an increasing number of international refugees due to political warfare and natural calamities. Over the recent years, countries are shying away from assisting with the provision of healthcare to this vulnerable population either in their home country through humanitarian aid and services or in the host country by providing free healthcare coverage. World leaders and politicians have attempted to ignore the morality behind these decisions and have put forth a false narrative of scarcity and racism to appeal to the population of developed countries. As this question remains unsolved, we have attempted to look at the question from the perspective of our moral obligations as a species. We have discussed some of the popular moral theories that support providing healthcare services to global refugees and refuted theories that object to the same. We conclude with a brief look at the direction that countries could take without violating established moral code while attempting (without evidence) to prioritize the welfare of their citizens.
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