Anaesthesia, 1996, Volume 51, pages 702-704

Oxygen saturation of patients recovering from electroconvulsive therapy

A. S. M. McCormick*, MB, ChB, FRCA, Registrar, D. A. Saunders, PhD, FRCA, Consultant, Shackleton
Department of Anaesthetics, Southampton General Hospital, Tremona Road, Southampton SO 16 6YD.

Summary
Oxygen saturation was measured by pulse oximetry in 33 psychiatric patients breathing air during recovery from 60 episodes
of electroconvulsive therapy. Desaturation to less than 90% occurred in 17% of patients. Oxygen saturation values in recovery
were significantly lower than pre-operative saturations @ = 0.0014 using ANOVA), with a significant difference @ = 0.001)for
up to Srnin in recovery.

Key words
Anaesthesia; electroconvulsive therapy.
Recovery.
Hypoxia.

There have been no studies on the recovery phase of
patients receiving electroconvulsive therapy (ECT). Patients
requiring ECT are frequently elderly or medically unwell
and the peri-operative period may be hazardous. Patients
may be cared for by nurses who have had little training
in recovery or resuscitation. Monitoring during and after
treatment may be less than ideal, desaturation and other
complications remaining undetected. In addition, lack of
adequate facilities for the treatment of medical emergencies
and the necessity to transfer patients to an intensive care
unit at a different hospital, frequently puts patients at risk.
Despite recommendations to the contrary, the provision of
anaesthesia for ECT is still designated to junior anaesthetic
staff with inadequate experience or training. This study was
designed to observe the incidence of desaturation in patients
during recovery from electroconvulsive therapy to establish
whether routine measurement of oxygen saturation is
warranted.
Methods
All patients receiving electroconvulsive therapy (ECT)
during nine separate sessions over 8 weeks were included
in the study. All patients had consented to ECT, had been
fasted for at least 4 h pre-operatively and were unpremedi-
cated. Since the study was designed as an audit of normal
clinical practice, the local ethics committee advised that
informed consent from patients was unnecessary.
On entering the ECT room the patient lay supine on a
trolley and an 18-G cannula inserted. A baseline saturation
reading was taken from the patient's index finger using a
Datascope pulse oximeter. Pre-oxygenation was performed
in three patients in whom pre-operative saturations was less
than 95%. The justification for this intervention was that
the treatment of patients should not be altered by their
inclusion in the study. Anaesthesia was induced with
methohexitone (0.5-1 .O mg.kg - I) and suxamethonium
(0.5-1 .O mg.kg- I). Each patient's lungs were manually
ventilated with oxygen 6 1.min-' using a face mask and a
self-inflating Ambu bag, until relaxation occurred. The
ECT stimulus was then applied. Following cessation of the
fit, manual ventilation was performed until spontaneous
respiration resumed. The time taken from administration of
the suxamethonium to the start of regular respirations was
measured. A Guedel oral airway was used as considered
necessary, particularly in edentulous patients. The patient
was turned to the left side and taken to the recovery room
once spontaneous respiration and an oxygen saturation of
at least 98% whilst breathing 6 I.min-' of oxygen were
sustained. The patient remained on their left side and
oxygen saturations were monitored from the patient's index
finger using a Nellcor N20 portable pulse oximeter.
Recordings of oxygen saturation were taken by nursing staff
on arrival in recovery and every minute for up to 10 min.
None of the patients received oxygen during the recovery
period. The same anaesthetist (A.S.M. McC) gave
anaesthesia to each patient throughout the study, but was
not aware of the results obtained in recovery. The results
were analysed using analysis of variance with repeated
measures (ANOVA) and Dunnett's t-test for parametric
data [l].

*Present address: Department of Anaesthetics, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street,
London WClN 3JH.
Accepted 1 December 1995.
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Forum 703
Results Table 1. Parametric analysis of data comparing oxygen saturations
pre- and post electroconvulsive therapy using Dunnett's r-test.
A total of 33 patients underwent 60 episodes of ECT during
the study. Of these, five episodes in three patients were Time t-value p value
excluded because of the inability of recovery staff to record
postoperative saturations due to the agitated state of the Pre-ECT vs Post-ECT 3.99 < 0.001
patient. vs recovery 0.16 ns
The age range for the remaining 30 patients was 25 to 89 vs 1 min 1.88 ns
years (mean 60.4 years, S D 18.0), consisting of 21 females vs 2 min 3.20 <0.002
and nine males. The range of doses of methohexitone was vs 3 min 3.48 <0.001
35-70 mg and of suxamethonium was 30-50 mg. The mean VS 4 min 3.92 < 0.00I
vs 5 min 3.48 < 0.001
time taken to achieve regular spontaneous respiration after vs 6 min 2.50 <0.01
administration of suxamethonium was 177 s (SD 56.5, vs 7 min 2.19 <0.02
range 83-373 s). vs 8 min 1.73 ns
Pre-operative saturations ranged from 93 to 100%. vs 9 min 0.89 ns
Three patients received pre-oxygenation because pre- vs 10 min I .92 0.06
operative saturations were low (two cases) or because the
*F = 8.701 p < 0.001 (p = 0.0008).
patient had a history of treated angina (one case). All
patients left the ECT room with saturations of 98% or
above. causes profound hypoxaemia unless the lungs are ventilated
Saturations taken in the recovery room varied between 87 with oxygen.
and 100%. There were seven recovery episodes in five The benefits of administering oxygen to patients during
patients (two of whom had received pre-oxygenation), ECT have been in dispute. One study found that ventilating
in whom saturations fell to less than 90% for one or the lungs with 40 to 50% oxygen in air throughout the
more minutes. In five of these episodes, desaturation convulsion produced less hypoxaemia than if ventilation
occurred for less than 3 rnin of the time recorded in recovery was withheld while the convulsion lasted [3]. It was
but two patients remained desaturated for 4 and 5 min postulated that hypoxaemia, in combination with the
respectively. The lowest saturation reached in recovery was increased myocardial oxygen demand during ECT, may
87%. lead to a higher incidence of cardiovascular complications
Statistical analysis was performed on the first set of and therefore mortality [3]. In a study of anaesthetised
results obtained for each of the 30 patients. Mean patients, desaturation was inversely related to the number
saturation was lowest after 4 rnin in recovery (Fig. 1). Using of positive pressure ventilations performed after the
ANOVA with repeated measures, recovery values were administration of suxamethonium, but prior to ECT
significantly different from pre-operative values (p = therapy [4]. However, in this study, comparison was made
0.0014), but not from saturation measurements taken between four groups, each group being anaesthetised by a
immediately on arrival in recovery (p = 0.04). Values of different anaesthetist. During a study of 12 patients
p < 0.002 at 2 min and p < 0.001 at 3, 4 and 5 min were undergoing 40 episodes of ECT it was found that the
obtained using Dunnett's [-test to compare saturations incidence of arrhythmias during the seizure and in the
pre- and post-ECT (Table I). postconvulsive period was not affected by inspired oxygen
concentration or saturation [5]. Hypoxaemia occurred even
in patients breathing inspired oxygen concentrations of
100% if apnoea occurred or control of the airway and
Discussion ventilation was lost [5]. Theoretically, breathing 100%
During ECT unmodified by drugs the initial vagal oxygen may lead to vasoconstriction and a greater degree
discharge, causing bradycardia and hypotension, is of hypertension during the seizure, with increasing left
followed by a sympathetic phase, with tachycardia and ventricular work and oxygen consumption [5]. However,
hypertension and a post-convulsive stage of rebound passive ventilation using 20 breaths of 100% oxygen
bradycardia [2]. Apnoea lasts throughout the seizure and significantly prolonged seizure duration in 30 patients

H lool
D
99 -
n = 30
T

98 -

97 -

96 -
n
95 -

94 -

93 -

I I I I I I I I I I I 1
Pre Recovery 1 2 3 4 5 6 7 8 9 10
ECT Time (min)
Post
ECT
Fig. 1. Mean saturation (2 SEM)before and after electroconvulsive therapy.

Anaesthesia, Volume 51, July 1996


704 Forum
undergoing ECT and may therefore be therapeutically
beneficial [6].
In this study the patients represented a sample drawn
from the population of patients who present for ECT. The
patients tended to be elderly; ECT is widely used as a
treatment in psychogeriatrics. In a study which looked at
the oxygen saturations of 150 health service volunteers,
the incidence of baseline saturation less than 94% was
13.3% (compared with 7.1 % in our study). The same study
also observed the postoperative course of 350 patients
recovering from a variety of surgical and anaesthetic
procedures. Of patients who did not receive additional
oxygen in recovery, because they were not deemed to
require it by the anaesthetist, 16.7% desaturated to less
than 90% compared with I . 1 % of patients who received
additional oxygen [7].
The majority of patients in this study (83%) did not
desaturate to a level less than 90% during the recovery
period when a technique was employed that ensured regular
respiration and adequate oxygenation before the patient left
the ECT room. However, a proportion of patients (17%)
showed desaturation to less than 90% for varying amounts
of time in recovery, two of them despite pre-oxygenation.
None of these patients received oxygen postoperatively.
Despite many studies of postoperative hypoxaemia, no
specific level of desaturation has been shown to be
detrimental, nor has the effect on morbidity of the duration
of an episode of hypoxaemia been demonstrated. None of
the patients in the study appeared to suffer adverse effects
from oxygen saturations as low as 87%, although the
numbers were small and electrocardiographic monitoring
was not performed in recovery. Mortality from ECT has
been quoted at 0.16%, as a result of combining four series
reported between 1975 and 1982, in which the number
of deaths were recorded as a proportion of the number of
patients treated [2]. It is unlikely that a small study would
reveal significant morbidity or mortality and patients were
not assessed for any psychological changes which could
be attributed to hypoxaemia. However, the elderly nature
of the population studied and the concomitant medical
conditions of this group would appear to warrant
optimisation of care throughout the peri-operative period.
A standard anaesthetic technique was used; the effect on the
results of different anaesthetists using varying techniques
was not studied. It might be possible in a larger study to
isolate possible predictive factors for desaturation; these
might include weight, age, cardiovascular and respiratory
disease and smoking habits.
Anaesthesia, Volume 51, July 1996
13652044, 1996, 7, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.1996.tb07861.x by Jordan Hinari NPL, Wiley Online Library on [21/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
The costs of providing oxygen for every patient
recovering from ECT are low. The rental and filling of an
oxygen cylinder t o provide 4 I.min-’ for 5 min, for each of
840 ECT episodes per annum in West Dorset has been
quoted as approximately f50. The cost of providing each
patient with a new recovery mask is an additional f268 per
annum, giving a cost per anaesthetic of 38 pence. The cost
of a Nellcor N20 portable pulse oximeter is f900 (Nellcor,
1995). Further training of ECT recovery staff in the use and
limitations of the measurement of oxygen saturation would
be necessary.
It is now routine practice to give supplementary oxygen
to the majority of patients recovering from general
anaesthesia for a range of surgical procedures. The results
of this study would suggest that monitoring of oxygen
saturation in patients recovering from ECT should
be routine. In addition, provision should be made
for each patient recovering from general anaesthesia
after electroconvulsive therapy to receive supplementary
oxygen.
Acknowledgments
The authors thank the staff at the Forston Clinic, West
Dorset Hospital, for their co-operation with this study
and Nellcor for the loan of the pulse oximeter.
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