Comparison of Rocuronium-Sugammadex and Succinylcholine during Electroconvulsive Therapy: A Small Observational Case Series Study

Review Article

Austin J Anesthesia and Analgesia. 2022; 10(1): 1107.

Comparison of Rocuronium-Sugammadex and Succinylcholine during Electroconvulsive Therapy: A Small Observational Case Series Study

Moutaoukil MD*, Najout H, Elkoundi A and Bensghir M

Department of Anesthesiology and Critical Care, Mohammed V University of Rabat, Morocco

*Corresponding author: Mohamed Moutaoukil, Department of Anesthesiology and Critical Care, Military Teaching Hospital Mohammed V, FAR Avenue, 10100, Rabat, Morocco

Received: June 07, 2022; Accepted: July 14, 2022; Published: July 21, 2022


Introduction: The use of neuromuscular relaxants is needed in electroconvulsive therapy (ECT) to minimize the convulsive motor activity. Succinylcholine is the most useful and commonly available neuromuscular relaxant agent for ECT. However, rocuronium with subsequent use of sugammadex was proposed for ECT as an alternative to succinylcholine.

Methods: A small case series of four patients with major depressive disorder recruited as part of a preliminary study is presented. The purpose of this study was to investigate the effect of a small dose succinylcholine (0.5 mg/ kg) and rocuronium (0.3 mg/kg)-sugammadex (4 mg/kg) complex on clinical recovery during ECT as well as ECT quality and the incidence of side effects.

Results: Forty-eight ECT sessions were conducted in total in the post anesthesia care unit. The mean extent of motor seizure modification score was significantly higher in the group rocuronium-sugammadex (p=0.003). The mean time to resume spontaneous respiration and time to eye opening to verbal command were shorter following rocuronium blockade with 4 mg/ kg of sugammadex compared with succinylcholine (p=0.011 and p=0.028 respectively). Agitation and myalgia were significantly lower in rocuroniumsugammadex group (p=0.043 and p=0.01 respectively).

Conclusion: This small case series study demonstrates the efficacy of rocuronium (0.3 mg/kg)–sugammadex (4 mg/kg) as an alternative to succinylcholine (0.5 mg/kg).

Keywords: Electroconvulsive Therapy; Rocuronium; Sugammadex; Succinylcholine; Motor Seizure Modification; Myalgia; Agitation


Electroconvulsive therapy (ECT) is a therapeutic method used for almost sixty years in the treatment of mental illnesses. It is based on the generation of a generalized seizure by means of an electric current applied bytranscranial route. The goal is to obtain a clonic phase of several tens of seconds [1]. Despite an often negative image, ECT remains a highly effective treatment for major depression [2], particularly in cases of treatment-resistance, poor tolerance to psychotropic drugs, or when short-term vital risk is engaged. The renewed interest in this therapy is linked to the technical progress made concerning anesthesia and neuromuscular blockade along with a best definition of stimulation parameters.

Succinylcholine is considered the neuromuscular blocking agent of choice for ECT due to its rapid onset and short duration of action. However, succinylcholine has many side effects and its use is limited in certain situations (metabolic, neuromuscular, or neurologic comorbidities, pseudocholinesterase deficiency..). Sugammadex, a selective relaxant-binding agent allowing a rapid reverse of neuromuscular block, has been introduced as an alternative for succinylcholine during ECT [3,4].

To date, only three studies have investigated the benefit of using rocuronium–sugammadex as an alternative to succinylcholine for muscle relaxation during ECT with different described protocols [5]. The purpose of this study was to add to the body of literature by demonstrating the efficacy of rocuronium–sugammadex as an alternative to succinylcholine during ECT with a new protocol and examine ECT quality and outcome.

Materials and Methods

In this single site case series, we review prospectively collected data on ECT use in four patients who were diagnosed with major depressive disorder. Forty-eight ECT sessions were conducted in total in the post anesthesia care unit at Military Teaching Hospital in Rabat, Morocco.

Study subjects were all ASA physical status I aged 28 to 45 years. None of the patients had a history of cardiovascular disease, neuromuscular disorders, hypertension, and history of drug allergy, significant renal or liver dysfunction or electrolyte abnormalities. All patients were right handed and were taking psychotropic medications as indicated by their psychiatric condition.

Informed consent was obtained from all patients. All protocols were approved by the local institutional clinical study committee and the institutional review board. Each patient underwent 12 sessions of ECT (three times per week). Patients were unpremedicated and fasted overnight and ECT was performed the next morning.

Patients received preoxygenation and measured parameters during ECT included systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), oxygen saturation (SpO2), end-tidal CO2 (ETCO2) at the nostrils and electrocardiogram.

Anesthesia was induced using propofol 1-1.5 mg/kg IV to obtain unconsciousness and loss of eyelash reflex. Two patients received 0.5 mg/kg of succinylcholine (group S) and the two others were given 0.3 mg/kg of rocuronium by intravenous route (group R).

Assisted mask ventilation was initiated with 100% oxygen to maintain an ETCO2 of 30 to 35 mm Hg and a minimum SpO2 of 97%. Esmolol (40–80 mg IV) was administered to treat hypertension and tachycardia, when necessary. ECT was given via bitemporally placed electrodes at the end of the muscle fasciculation’s in group S and 90 seconds after administration of the muscle relaxant in group R.A Thymatron® System IV ((Somatics LLC, Lake Bluff, IL, USA) was used in accordance with the manufacturer’s instructionsThe stimulus intensity of ECT was adjusted accordingly by an energy percentage based on the patients’ ages and was increased appropriately at each session to achieve a minimum seizure duration of 20 seconds. Reversal of the residual neuromuscular block in Group R was accomplished with sugammadex 4mg/kg IV immediately after completion of the ECT procedure.

EEG seizure duration using the digital counter in the ECT machine, extent of motor seizure modification on five-point scale (A score < 3 or more on the scale were defined as poor and good modifications respectively), the time to spontaneous breathing from the moment of administration of the muscle relaxants and the time to eye opening to verbal stimuli were recorded in both groups. Patients were also assessed for the presence of agitation, myalgia, headache and nausea and vomiting post-ECT.

Data are reported as mean with standard deviation, number and percentage, depending on underlying distribution. P < 0.05 was considered statistically significant. Data analysis was performed using SPSS 25.0 software package for Windows (SPSS, Chicago, IL).


Demographic characteristics of the patients are shown in (Table 1).