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Monitoring of seizures during electroconvulsive therapy by the ‘cuff’ method is still relevant today

Department of Psychiatry, The University of Hong Kong, Pokfulam Road, Hong Kong SAR, China (Tel.: +86 852 28554487; Fax: +86 852 28551345; e-mail: kfchung{at}kucc.hku.hk)

Sir: I read with interest the article by Jan Wise et al (Psychiatric Bulletin, August 2000, 24, 301). The authors cast doubts about using the Hamilton cuff method for assessing seizure duration and recommended EEG monitoring as a standard procedure need of ECT. EEG seizure monitoring indeed helps to prevent unwarranted restimulation as well as detecting prolonged seizures (Mayur et al, 1999), however the use of the cuff technique needs to be viewed in terms of its benefit and risk, especially in places where EEG monitoring is not available. Jan Wise et al have not reported the dosage of the muscle relaxants used. For patients who require high dose of succinylcholine, > 1.0 mg/kg, (eg. patients with bone and joint problems who require complete muscle paralysis, or patients who need longer ECT session for stimulus dose titration), seizure could be masked. In addition, the finding that there was no significant difference in seizure duration between cuffed and uncuffed limbs could be limited by a lack of blindness between three observers. All raters were using a similar approach to note the seizure duration at the same time and place.

I have reservation in disregarding the cuff technique and would rather support the College recommendation (Royal College of Psychiatrists, 1995) that cuff duration should be kept to a minimum and the cuff inflation should be released as soon as adequate seizure duration has occurred. Care also needs to be taken for patients with severe osteoporosis, other major orthopaedic problems and sickle cell disease (Weiner et al, 1991).

References

MAYUR, P. M., GANGADHAR, B. N., JANAKIRAMAIAH, N., et al (1999) Motor seizure monitoring during electroconvulsive therapy. British Journal of Psychiatry, 174, 270-272.[Abstract/Free Full Text]

ROYAL COLLEGE OF PSYCHIATRISTS (1995) The ECT Handbook. Second Report of the Royal College of Psychiatrists' Special Committee on ECT. London: Royal College of Psychiatrists.

WEINER, R. D., COFFEY, C. E. & KRYSTAL, A. D. (1991) The monitoring and management of electrically induced seizures. Psychiatric Clinics of North America, 14, 845-869.

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