Prevention of Oxygen Desaturation in Morbidly Obese Patients During Electroconvulsive Therapy

Abstract

In general, preoxygenation is performed using a face mask with oxygen in a supine position, and oxygenation is maintained with manual mask ventilation during electroconvulsive therapy (ECT). However, hypoxic episodes during ECT are not uncommon with this conventional method, especially in morbidly obese patients. The most important property of ventilatory mechanics in patients with obesity is reduced functional residual capacity (FRC). Thus, increasing FRC and oxygen reserves is an important step to improve oxygenation and prevent oxygen desaturation in these individuals. Head-up position, use of apneic oxygenation, noninvasive positive pressure ventilation, and high-flow nasal cannula help increase FRC and oxygen reserves, resulting in improved oxygenation and prolonged safe apnea period. Furthermore, significantly higher incidence of difficult mask ventilation is common in morbidly obese individuals. Supraglottic airway devices establish effective ventilation in patients with difficult airways. Thus, the use of supraglottic airway devices is strongly recommended in these patients. Conversely, because muscle fasciculation induced by depolarizing neuromuscular blocking agents markedly increases oxygen consumption, especially in individuals with obesity, the use of nondepolarizing neuromuscular blocking agents may contribute to better oxygenation in morbidly obese patients during ECT.

Ventilation Adjustment in ECT During COVID-19: Voluntary Hyperventilation is an Effective Strategy

“…Our findings suggest that preoxygenation and 2 minutes of VHV is useful and well tolerated during the COVID-19 pandemics because, in addition to minimize BMV hyperventilation, it still induces moderate hypocapnia, which has been tied to seizure optimization and less hypercapnia during the apnea period in ECT sessions. Additionally, the results strengthen the importance of preoxygenation 24 and support the role of VHV, the impact of ventilation in gas dynamics during ECT sessions, 20,25 and the relevance of CO 2 and O 2 values in the obtained seizure characteristics. 8…”

“…Patient positioning, ventilation maneuvers, airway devices, and neuromuscular blocking agent recommendations have been reported to minimize desaturation incidence in morbidly obese patients. 24 Using our study’s proposed ventilation approach, SpO 2 <90% occurred in only 5.9% of sessions. However, in another recent study where 3–5 minute preoxygenation was performed with a nonrebreather mask while avoiding BMV hyperventilation before the stimulus, SpO 2 decreased below 85% during the apneic period in 51/106 (48.1%) of the patients, and BMV was required to recover adequate saturations.…”

“…Desaturation can occur during ECT, especially in patients with risk factors (obesity, 10 , 23 , 24 high seizure length, 23 baseline respiratory compromise 10 ), and ventilation management is important to prevent this. Patient positioning, ventilation maneuvers, airway devices, and neuromuscular blocking agent recommendations have been reported to minimize desaturation incidence in morbidly obese patients.…”

Effective Adaptation of Ventilation Maneuvers in Electroconvulsive Therapy Sessions During the Coronavirus Disease 2019 Pandemic

“…This modified ventilation protocol effectively induced adequate seizures despite avoiding energetic hyperventilation 7 without eliciting significant side effects. This reinforces the importance of preoxygenation 8 and the role of voluntary hyperventilation 9 performed actively by the patient before anesthesia induction to help to maintain a good oxygenation during ECT treatments.…”

Microlaryngeal surgery in severely obese elite vocal performers

“…This position is recommended as a good choice for tracheal intubation in such cases. 3 , 4 , 5 However, due to the ramp position, the microlaryngeal surgery, usually performed sitting in a chair, was performed standing (Figure 3 ). When performed in the standing position, the angle of entry of the scalpel and forceps to the horizontal direction is slightly steeper.…”