We present a case of successful anesthetic management in m-ECT for a patient with CAAs through prompt responses to changes in circulatory dynamics. As far as we know, this is the first report of m-ECT for a patient with CAA.
In most cases, CAA is asymptomatic, but the slow flow of blood on the irregular internal surface of the aneurysm wall predisposes to the formation of thrombi with subsequent embolization, resulting in myocardial ischemia and infarction and sudden death . We found some reports of CAA rupture [3, 4], and there is also a report that hypertension triggered CAA rupture . Therefore, we needed to control BP closely in m-ECT and decided to target systolic blood pressure below 180 mmHg.
It is known that rapid fluctuations in circulatory dynamics occur during m-ECT . We have to be careful because, before or after the HR and BP increase due to sympathetic nerve stimulation accompanying the electrical stimulation, sometimes a parasympathetic response dominates, and there have been some case reports of bradycardia and 10 s of asystole [6, 7]. There have also been reports of cases in which asystole has occurred almost simultaneously with electrical stimulation . Therefore, we thought that strict hemodynamic monitoring during m-ECT was needed. Because this case was complicated by CAAs, we decided to use the ClearSight™ system to see the hemodynamic change clearly during m-ECT, with the goal of not raising blood pressure excessively, to prevent CAA rupture.
The ClearSight™ system is a hemodynamic monitoring system that allows for real-time non-invasive BP measurements. Juri et al. reported the efficacy of the ClearSight™ system during cesarean section with accurate BP management . Sumiyoshi et al. also reported that there is a significant relationship between mean arterial pressure and mean arterial pressure of the ClearSight™ system in patients with abdominal aortic aneurysm surgery . Earle et al. reported that the ClearSight™ system was useful in m-ECT for a patient with abdominal aortic aneurysms . In Earle’s report, the waveform of the ClearSight™ system disappeared for approximately 20 s due to electrical stimulation in m-ECT. However, when we used the ClearSight™ system, the arterial pressure waveform did not disappear during m-ECT, so we could monitor BP continuously and manage patient safety.
The first and second m-ECTs with the ClearSight™ system showed that electrical stimulation increased HR and BP but did not cause asystole and that prophylactic nicardipine administration did not cause excessive BP reduction.
We performed a total of 10 m-ECTs. No rupture of CAAs or myocardial ischemia occurred, and depressive symptoms improved through this series of m-ECTs.
In conclusion, we successfully managed the anesthesia in m-ECT for a depressed patient with CAAs by using the ClearSight™ system, which was used for the effective management of BP fluctuations during m-ECT.