Anesthetic management during electroconvulsive therapy in a patient with burn injury.

Sir,

The anesthetic regimen during electroconvulsive therapy (ECT) includes an intravenous anesthetic drug (propofol, thiopentone, or etomidate) and a short-acting neuromuscular blocking agent (succinylcholine) to facilitate stimulus application and produce therapeutic seizures in a controlled fashion. Airway management during anesthesia for ECT is generally performed by manually ventilating the lungs with oxygen using a facemask and a rebreathing bag. Succinylcholine is usually avoided in patients with burns, as it can cause severe hyperkalemia.[1] In this report, we describe anesthetic management using a novel airway device, the AMBU laryngeal mask airway (LMA), for ventilation during ECT in a patient with burns involving face, neck, and the chest.

A 30-year-old lady with a diagnosis of undifferentiated schizophrenia with a history of self-inflicted burns 30 days earlier was posted for index ECT. The patient was conscious and systemic examination was normal. A second-degree burn injury was noted on the face, neck, and upper chest extending to the back. Mouth opening was adequate with an inter incisor distance of 2.5 cm; however, the neck extension and flexion were restricted [Figure 1a]. The biochemical parameters were normal with a serum potassium level of 4.5 mEq/L. In the ECT room, the difficult airway cart was arranged and ECG, pulse-oximeter and noninvasive blood pressure cuff were attached to the patient. Anesthesia was induced with propofol 80 mg and after assessing the adequacy of mask ventilation, atracurium 20 mg was administered and a size 3 AMBU LMA (Ambu® Aura40™ Reusable Laryngeal Mask, Ambu A/S, Denmark) was inserted and ventilation was confirmed [Figure 1b]. A 60 mc stimulus was delivered in the bi temporal region resulting in a motor seizure of 34 s duration. The lungs were ventilated for 20 min till the return of spontaneous respiration, following which the neuromuscular blockade was reversed and the AMBU LMA was removed. Rest of the stay in the observation unit was uneventful.

Figure 1

(a) shows the patient with facial, neck, and chest burn injury and restricted neck movements awaiting electroconvulsive therapy (ECT). (b) Shows the airway management with AMBU laryngeal mask airway in place during ECT

Performing ECT in patients with burns generally requires the use of non depolarizing neuromuscular blocking agent and maintenance of the airway with endotracheal intubation.[2] ECT, which induces muscle seizures, and succinylcholine may both lead to hyperkalemia. Also, in the background of burns, the use of succinylcholine is not warranted. Airway management in patients with post burn scars and contracture of the face, mouth, neck, and chest is often difficult and can potentially result in “cannot ventilate, cannot intubate” scenario.[3] In our patient, the burn was 30 day-old, with post burn scarring of the above areas causing restriction of neck movements. Anticipating a difficult airway and because of the nature of this short procedure, LMA was preferred over endotracheal intubation. Classical LMA has been safely used previously for airway management in patients undergoing ECT.[4] A recent study has shown advantages of the AMBU LMA over classical LMA in terms of better airway seal and lesser post airway intervention sore throat.[5] These advantages are important in patients undergoing ECT, as it offers better airway protection from aspiration during induced seizures and reduced patient discomfort from sore throat. When AMBU LMA is not available, classic or proseal LMA and even endotracheal intubation are the alternative tools to achieve secure airway and provide oxygenation and ventilation during ECT in such patients.

To conclude, this case demonstrates the safe and successful use of AMBU LMA for maintenance of airway during ECT in patients with face, neck, and chest wall burns. In scenarios of difficult mask ventilation, anticipated difficult airway and when succinylcholine is contraindicated necessitating non-depolarizing neuromuscular blocking agents, LMA offers an excellent alternative to tracheal intubation during ECT.