Nigerian Journal of Psychiatry Vol. 15 No.
2 July - December 2017
Comparative Study of a Low-dose with Standard Dose Propofol in
Electroconvulsive Therapy (ECT) in Federal Neuropsychiatric Hospital, Kaduna
A. A YUNUS, I. K AGHADI, E. OGBOLI-NWASOR, S. O ADEYEMI, T. L SHEIKH
ABSTRACT
Background: Electroconvulsive
therapy (ECT) is a safe and effective
treatment for severe medication
resistant depression. A variety of
adverse physiological and physical
effects occur which could b e
potentially dangerous. Anaesthesia
must be of adequate depth without
adversely affecting treatment
efficacy. Anaesthesia for ECT aims
to achieve successful relaxation of
the voluntary muscles while
eradicating the risk of physical harm
to the patient. Propofol has rapid
onset and short duration of action
with minimal anticonvulsive
property. Low dose propofol
produces a very rapid recovery with
minimal or no adverse effect. This
may be an ideal agent for ECT.
Aim: To compare the efficacy of two
doses of propofol in ETC.
Methods: A randomized double
blinded prospective study was
conducted in seven hundred and
thirty-eight (738) psychiatric patients
undergoing modified ECT. Group A
was induced with low dose 0.8mg/kg
propofol. Group B was induced with
a standard dose 1 ,5mg/kg propofol.
Age, gender, induction time and
duration of convulsions were
assessed. Data was analyzed using
SPSS version 17.0.
Results: Induction of anaesthesia
was successful within 60 seconds in
93.3% of the patients in group A. In
group B, 99.2% of the patients were
induced within 60 seconds. All
patients in both groups became
conscious within 5 to 10 minutes
post-induction. The peak period
duration of convulsion in group A
was 61- 90 seconds. It was 31- 60
seconds in group B.
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Conclusion: Low-dose propofol has
equal efficacy as the standard dose
in modified ECT.
Key words: propofol, low-dose,
electroconvulsive therapy,
anaesthesia, seizure inhibition.
INTRODUCTION
In many psychiatric disorders,
electroconvulsive therapy (ECT) is a
safe and effective treatment (Aigul et
al., 2009; Eseret al., 2010). ECT is a
treatment for severe mental illness in
which a brief application of electrical
stimulus is used to produce a
generalized seizure. Propofol is one
of many anaesthetic agents for
electroconvulsive therapy. Clinically,
the efficacy of ECT relies on the
induction of cerebral seizure activity.
Barbiturates such as methohexital
and thiopental are used in ECT
(Anand et al., 2010; Dew et al.,
2005). The most recommended
anaesthetics for ECT remains
methohexital, but because of its
limitation of high incidence of pain at
injection, involuntary movement,
hiccup and laryngospasm, propofol
is the most preferable and current
anaesthetic agent for ECT (Jaffe &
Philadelphia, 2002; Ding & White,
2002). Use of low anaesthetic dose
minimizes its effect on seizure
elicitation and duration (Rasmussen
et al., 2014). The anaesthetist's goal
is to ensure the safety of patients
scheduled for ECT which is achieved
by identifying risks of anaesthesia
and undertaking appropriate
modifications, tests, and
consultations. Standard dose of
propofol is 1 ,5-2.5mg/kg. The
rationale for the choice of low dose
propofol was informed because
propofol reduces duration of seizure
induced by ECT in humans
(Schwilden et al., 1 989). This means
that the lower the dose, the higher
the seizure duration. Therefore,
there is need to investigate the
potency of a low-dose (0.8mg/kg)
p r o p o f o l i n E T C .
Pharmacodynamically, the
undesirable side effects of propofol
are likely to occur at higher blood
concentrations which result from
bolus dosing. Advent of low dose of
propofol is also necessary in order to
minimize the adverse effects
associated with high doses (Ding &
White, 2002; Hooten & Rasmussen,
2008).
The study objective was t o
investigate the potency of low-dose
propofol compared to standard dose
propofol in ECT. The effects of
dosage of propofol on the duration of
convulsion were also studied.
METHODS
Double-blinded randomized and
prospective study, carried out at
Federal Neuropsychiatric Hospital
Barnawa, Kaduna. After institutional
ethical approval a n d informed
consent were obtained, the patients
were randomized into two groups:
group A received propofol at a dose
of 0.8mg/kg; while group B were
given a dose of 1.5mg/kg. The
double-blinded randomization was
based on balloting. An alphabet (A or
B) was written on a piece of paper
and sealed in an envelope. A matron
who was not part of the study picked
an envelope for each patient, then
forming the two groups A and B.
There were a total of 738 subjects for
ECT during this study. Females were
215 (29.1%), while 523 (70.9%)
were male patients. In Group A
(Low-dose Propofol) 356 patients
were administered 0.8mg/kg
Propofol. In Group B (Standard dose
A. A YUNUS, I. K AGHADI, E. OGBOLI-NWASOR, S. O ADEYEMI, T. L SHEIKH

Propofol) 382 patients were
administered 1.5mg/kg propofol.
The nurse (matron) in charge of the
EOT unit who was not part of the
research administered the drugs in
both groups, making the researcher
and the patients to be blinded.
Inclusion criteria were patients who
met indications for ECT and adult
patients between the ages of 1 8 to
65 years. Exclusion criteria were
patients with epilepsy, congestive
cardiac failure (CCF), major bone
fracture, myocardial infarction (Ml) in
the last 3months, patients with space
occupying lesions, patients below 1 8
years and geriatric patients above 65
years. Others include patient's
refusal, hypertensive patients and
pregnant patients.
The following were observed and
recorded: age and gender, time to
induction of anaesthesia, duration of
convulsion using peri-orbital muscle
twitching. Null hypothesis was that
Table 1. Time to induction of Anaesthesia
Induction time
60 sec
Group A (0.8mg/kg) 332
Number of patients -*•
% 93.3
Group B (1.5mg/kg) 379
Number of patients
% 99.2
low-dose propofol will produce less
suppression of the convulsions
during modified ECT and the
alternate hypothesis was that
standard-dose propofol will not
produce less suppression of the
convulsions during modified ECT.
After a 6-8 hours fasting period, the
patients were put in supine position.
Intravenous line was accessed. The
blood pressure, temperature, ECG
electrodes were attached to the
patients. Capnograph was attached
to the anaesthetic circuit. Patients
were pre-medicated with atropine
(0.5mg), induction of anaesthesia
was with 0.8mg/kg (group A) or
1.5mg/kg (group B). After induction
of anaesthesia, suxamethonium
(50mg) was administered to facilitate
muscle relaxation. After
fasciculation, oropharyngeal airway
was inserted and the patient's
respiration was manually controlled.
Thymatron ECT machine electrodes
were applied to the bi-temporal
region and the current was
Induction time Total
>60 sec
24 356
6.7 100
3 382
0.8 100
discharged. The Thymatron ECT
machine gave a recorded data of the
duration and the electrical activities
of the convulsion. An adequate
seizure in ECT is defined as one
which lasts greater than 30 seconds
(Saxby et al., 2011). The data
obtained were analyzed using chi-
square test. Values of p<0.05 were
considered statistically significant.
RESULTS
Result of time to induction of
anaesthesia is presented in Table 1 .
In group A (low-dose propofol) in
which patients received low dose
propofol (0.8mg/kg). Out of the 356
total number of patients, greater
percent of the 332 patients (93.3%)
a c h i e v e d induction within 6 0
seconds, while only 6.7% (24
patients) of the patients achieved
induction after 60 seconds. In group
B, where patients received standard
dose of propofol (1.5mg/kg), out of
the total of 382 patients in the group,
379 patients (99.2%) attained
induction within 60seconds, while 3
patients (0.8%) achieved induction
after 60 seconds.
Profile of the recovery time after
induction is presented in Table 2.
Patients in group A, who were
administered with low-dose of
0.8mg/kg propofol had their eyelash
reflex fully recovered within 5 to 10
minutes. Also, in group B where
patients were induced with the
standard dose of 1 ,5mg/kg propofol,
all the patients attained eyelash
recovery within 5 to 1 0 minutes post

Table 2. Recovery time after the procedure

Number of patients Number of patients %

recovered eyelash reflex in recovered eyelash reflex after
lOminutes lOminutes

Group A (0.8mg/kg) 356/356 0 10

Group B (1.5mg/kg) 382/382 0 10

Number of patients 738 0

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Nigerian Journal of Psychiatry Vol. 15 No. 2 July - December 2017
Time duration of cerebral seizure
activity is shown in Table 3.
Generally, seizure duration as
observed in group A (patients who
received low-dose of 0.8mg/kg
propofol) o c c u r r e d w i t h i n 3 1
seconds to 120 seconds. Highest
number of the patients (Two hundred
and forty) had seizure duration
between 31 and 6 0 seconds,
followed by seventy-eight patients
whose seizure duration occurred
within 91 to 120 seconds. At 61 to 90
seconds, seizure duration was
observed for 38 patients. There was
no record of seizure duration below
30 seconds and above 120 seconds.
Table 3. Duration of the seizure
Time (seconds) Number of patients
Group A
>30 0 44(11.5%)
31-60 240 (67.4%)
61-90 38(10.7%)
91-120 78 (21.9)
>120 0 1(0.3%)
TOTAL 356(100%)
As can be seen concerning the
seizure duration for patients in group
B, seizure duration was revealed to
have occurred early in forty-four
(11 .5%) patients within 30 seconds.
The highest number of patients three
hundred and twenty-One (84%) had
seizure duration within 31 seconds
to 60 seconds. Sixteen (4.2%)
patients who recorded seizure
duration of 61 to 90 seconds. Only
one (0.3%) patient had seizure
duration up t o 120 seconds,
recorded seizure duration of 61 to 90
seconds. Only one (0.3%) patient
had seizure duration up to 120
seconds.
DISCUSSION
The most striking finding of this
randomized double-blinded
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comparative study of a low-dose
propofol with the standard dose is
that, both doses exhibited equal
potency. The ultimate target of
anaesthesia for EOT is to achieve
smooth induction of anaesthesia and
relaxation of the voluntary muscles
with the aim of minimizing the risk of
physical harm to the patient.
Clinically, the efficacy of
electroconvulsive therapy (ECT)
depends o n the induction of
generalized cerebral seizure activity
(Eseretal., 2010).
Knowledge of the recent advances in
p s y c h i a t r y a n a e s t h e s i a i s of
paramount importance in order to
have a good outcome of treatment.
Number of patients
Group B
321(84%)
16 (4.2%)
0 side effects associated with high
382(100%)
Having been considered as the
anaesthetic agent of choice in EOT,
it is pertinent to obtain its minimum
effective dose. Selection of suitable
anesthetics and dosages are crucial.
These factors can significantly
influence the seizure induction at
EOT (Anand et aL, 2010; Dew et al.,
2005).
Analysis of the time to induction of
anaesthesia, revealed that the
desired response from group B
(which received standard dose
propofol of 1.5mg/kg) was also
achieved in group A, as 93.3% of the
patients was successfully induced
with low dose propofol of 0.8mg/kg
within 6 0 seconds (Table 1).
Although 99.2% of the patients in
group B was induced, which could be
attributed to the high dose of
1.5mg/kg propofol, it doesn't differ
significantly from the effect obtained
with low dose of 0.8mg/kg propofol.
This implies that low dose 0.8mg/kg
propofol is as efficacious as the
standard dose of 1 .5mg/kg propofol,
with a distinctive advantage of
minimal or no side effects on patients
receiving EOT (Amornyotin et al..
2002). This suggests that the
numerous side effects associated
with propofol as a result of high
doses could perhaps be avoided.
Subsequently, the recovery duration
after anaesthesia induction was
studied, as presented in Table 2.
Interestingly, all the patients in both
groups had recovery of their eyelash
reflex within 5 to 10 minutes and
were able to obey commands. Our
study indicates that low dose
propofol is equally as potent as the
standard dose. Our finding supports
the clinical study by Nishiyama and
Togashi (2009). It means that
irrespective of the two doses, the
same recovery pace for eyelash is
achieved. In addition to curbing the
dose of propofol, use of low dose of
0.8mg/kg could conserve propofol.
Propofol focuses on five outcome
measures which include seizure
duration, hemodynamics, post
anesthesia recovery, cognitive
adverse effects, and therapeutic
efficacy (Hooten & Rasmussen,
2008). Anticonvulsant properties of
propofol could decrease seizure
duration (Eser et al., 201 0). Profile of
the seizure duration is shown in
Table 3. Generalized seizures for
30-60 seconds in duration are
required for therapeutic effects and
c a n b e induced b y adjusting
waveform, frequency, duration of
electrical stimuli (Amornyotin et al.,
2002). As can be seen in group B,
seizure duration was observed to
have occurred just half a minute
earlier in 1 1 .5% of the patients within
30 seconds. The highest number of
patients (84%) had seizure duration
within 31 seconds to 60 seconds.
Compared to the seizure duration of
A A YUNUS, I. K AGHADI, E. OGBOLI-NWASOR, S. O ADEYEMI, T. L SHEIKH

the group B patients, had earlier
onset of time to seizure duration.
Although the observed duration was
a bit earlier in group B patients, the
thirty seconds difference could be
considered negligible. This indicates
that there was n o significant
difference in the two doses; rather,
the low dose regimen being as
potent as the standard dose, offers
an advantage of minimized side
effects. However, it is important to
ascertain the degree of the adverse
effect associated with a low dose
propofol in the future which is
expected to be minimal, compared to
the standard dose.
CONCLUSION
Low-dose propofol of 0.8mg/kg
possesses equal potency as the
standard dose of 1.5mg/kg, hence
achieves the desirable effects on
ECT. Duration of convulsion is better
with low-dose propofol and should
be used in modified ECT.
RECOMMENDATIONS
We strongly recommend the use of
low dose propofol for ECT.
Psychiatrists and Anaesthetists
should work in tandem before,
during and after ECT. Propofol
should be used professionally, by
trained anaesthetists so as to avoid
subjecting the patients to the risks
associated with propofol, especially
s e v e r e h y p o t e n s i o n , postictal
headache and cardiac arrest.
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CORRESPONDENCE: A. A YUNUS. Department of Anaesthesia, Ahmadu Bello
University Teaching Hospital, Shika Zaria, Kaduna State Nigeria. E-mail:
niyigafar@gmail.com
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