2024 FSA Podium and Poster Abstracts
P020: ANESTHETIC AND PHARMACOLOGICAL MANAGEMENT OF MALIGNANT HYPERTENSION IN ECT: A CASE STUDY
Michael Jayson, BS1; Jacob Surges, BS2; Brent Carr, MD3; 1Nova Southeastern University College of Osteopathic Medicine; 2University of Florida College of Medicine; 3University of Florida Department of Psychiatry
Background: A 60-year-old male with a history of obstructive sleep apnea, but no diagnosed hypertension, underwent electroconvulsive therapy (ECT) for recurrent major depressive disorder. Despite having previously undergone ECT five years prior without adverse effects, this treatment series posed unique challenges in managing episodes of malignant hypertension.
Methods: The initial seven sessions employed a consistent anesthetic regimen of IV Methohexital (MHX) 100mg and Succinylcholine (SUX) 100mg. However, starting from the eighth session, the patient began exhibiting malignant hypertensive responses, prompting the need for tailored pharmacological interventions.
Interventions & Outcomes: Throughout sessions 1 to 7, standard doses of MHX and SUX were used without any hypertensive responses. During session 8, the patient experienced significant blood pressure spikes, necessitating the use of Labetalol 75mg and intranasal Nitroglycerin (NTG) twice to manage pre- and post-procedure blood pressures of 170/98mmHg and 184/109mmHg, respectively. From sessions 9 to 22, the treatment team continued ECT while adjusting doses of Labetalol, Hydralazine (HYD), NTG, and introduced Clevidipine, in response to specific blood pressure challenges noted in each session. Notably, session 10 saw a shift to a higher dose of HYD (30mg) for better blood pressure normalization. Sessions 11 to 13 required escalated doses and combinations of medications, including NTG and Nitroprusside, to address severe hypertension. Starting from session 14, Clevidipine was introduced and dosages were adjusted to achieve effective blood pressure control. The final session, session 23, successfully controlled blood pressure with Labetalol 50mg and Clevidipine 1500mcg.
Conclusion: This case exemplifies the complexities of managing malignant hypertensive responses during ECT in patients with non-typical medication responses. The necessity for tailored, responsive pharmacological strategies was paramount in ensuring both the safety and efficacy of ECT. It underscores the importance of vigilant monitoring and flexibility in both anesthetic and antihypertensive management, highlighting the need for individualized care approaches in such challenging clinical scenarios.