P031: REEVALUATING NEUROMUSCULAR BLOCKADE STRATEGIES: ADDRESSING SUCCINYLCHOLINE HESITANCY IN CEREBRAL PALSY PATIENTS UNDERGOING ELECTROCONVULSIVE THERAPY
Asad H Bashir, MD; Sehrish Saleem; Brent R Carr, MD
University of Florida
Introduction: Electroconvulsive therapy (ECT) remains a cornerstone intervention for patients with severe mood disorders (1). An ideal ECT anesthetic protocol involves a short-acting induction agent such as methohexital, coupled with a paralytic agent like succinylcholine which offers a rapid onset and short duration of action, making it particularly suited for patients to safely obtain their therapy (2). However, concerns regarding potential hyperkalemia in patients with neuromuscular disorders may occasionally lead to unwarranted hesitancy in its use. This report describes a cerebral palsy (CP) patient undergoing ECT in which rocuronium, a non-depolarizing neuromuscular blocker necessitating pharmacologic reversal, was used instead of succinylcholine.
Case Presentation/Methods: A 44-year-old female with past medical history of major depressive disorder and cerebral palsy (CP) was scheduled for her 16th round of ECT in 16 weeks. Institutional protocol mandated a review of prior anesthetic records, which revealed that rocuronium had been consistently used as the paralytic agent. Sugammadex was used for reversal at the end of the each ECT session which requires paralysis for only a few seconds. Discussion with the treating psychiatrist indicated that succinylcholine had been avoided during the initial treatment due to perceived risks associated with CP.
Comprehensive pre-anesthetic evaluations, including electrolyte panels confirming normokalemia, were performed prior to the administration of succinylcholine. 60 mg of Methohexital (10mg/ml) was used for induction and 60 mg of succinylcholine (20mg/ml) was used for paralysis during her 16th ECT session. Anesthetic protocols were adjusted accordingly, and neuromuscular function was closely monitored throughout the procedure.
Outcome: The patient successfully completed her 16th ECT session with succinylcholine as the paralytic agent, breaking the chain, and leading to evidence-based care for the patient. The session was uneventful, with rapid onset of muscle relaxation and swift recovery, obviating the need for pharmacologic reversal. No hyperkalemia, prolonged paralysis, or other complications were observed. Clinical outcomes, including seizure duration and post-ECT recovery, were comparable to previous sessions, but procedural time and medication costs were notably reduced.
Discussion/Conclusion: Use of succinylcholine is not contraindicated in patients with CP (3). However, anesthesiologists remain reluctant to deviate from established practices. Succinylcholine was clinically introduced as a muscle relaxant in 1951 (4), almost half a decade before rocuronium. It has safely been used in patients with CP with no significant difference in potassium release. The continued use of rocuronium without indication introduces unnecessary complexity, increased pharmacologic burden, prolonged paralysis in non-operating room settings, and elevated costs. There is also a need for reversal with another agent and risk of awareness with residual muscle weakness. Moreover, after several ECT sessions, the patient reported improved functional outcomes, including enhanced leg strength and greater ease in activities of daily living. This observation further underscored the inappropriateness of prolonged neuromuscular blockade in this context, where only brief paralysis is required. This case highlights a broader trend in non-operating room anesthesia (NORA) settings, where reliance on past medical records for routine outpatient procedures such as ECT and adherence to prior regimens often supersedes critical re-evaluation (5).