A COMPARATIVE STUDY OF FLAXEDIL AND SYNCURINE COMBINED WITH PENTOTHAL ANESTHESIA IN MODIFYING ELECTROCONVULSIVE THERAPY

The authors have treated over 200 patients with electroconvulsive therapy modified by Sodium Pentothal anesthesia and curarization with Syncurine or Flaxedil or both. Sodium Pentothal was the usual cause for the infrequently occurring cough, bronchospasm, and rash. No case of Flaxedil allergy was encountered in 111 patients. The availability of several intravenous anesthetics and several types of curarizing drugs supplemented by antihistaminics helps the therapist to avoid or control allergic respiratory reactions, but intubation should be available.

After maximal softening of the seizure with Flaxedil, the time required for return of self-sustaining respiratory movement can be greatly shortened with the use of prostigmine or Tensilon. This cuts the time of oxygen administration after the seizure in half as compared with Syncurine-treated cases, as for the latter drug no antidote is available. Tensilon, 5 to 10 mg., must be given only intravenously after the seizure. Its use permits avoidance of atropine, needed when prostigmine is employed. As we believe atropinization is needed to prevent seizure-induced salivation and cardiac arrest, we prefer to give 2 to 2.5 mg. of prostigmine intramuscularly, conserving available veins for the more essential curarizing injection.

After Flaxedil injection, pulse rates rose 10 to 40 beats per minute, whereas Syncurine produced no change. Blood pressure changes with Flaxedil are essentially the same as with Syncurine. Hypertensive patients may show a fall of 40 to 60 mm. systolic and 10 to 20 mm. diastolic, attributed to Pentothal anesthesia. Of 21 "Flaxedil" cases tested, two-thirds (including 2 markedly hypertensive patients) showed less than 10 mm. change in blood pressure before their seizure. During and immediately after the seizure blood pressure rose 40 to 60 mm. systolic and 10 to 30 mm. diastolic even when the seizure was externally perceptible only in the face. We believe that complete abolition of seizure muscle rigor decreases but does not remove the element of danger in the giving of ECT to patients with cardiovascular disease, as changes in blood pressure and cardiac rate and rhythm, probably of central origin, nonetheless occur. This produced coronary occlusion in one of our cases.

Within the limitations outlined above, Flaxedil joins Syncurine as a valuable addition to available synthetic curarizing drugs employed in modification of the electroconvulsion.