Clinical Experience With Dexmedetomidine for Postictal Agitation After Electroconvulsive Therapy

BACKGROUND: Postictal agitation (PIA) is a clinically significant complication of electroconvulsive therapy (ECT), reported in approximately 7% to 12% of treatments and associated with safety and workflow concerns. Dexmedetomidine (DEX), a selective α2-adrenergic agonist, may help mitigate PIA while minimizing respiratory suppression. METHODS: We retrospectively reviewed 137 ECT sessions in 7 high-risk patients with documented prior PIA requiring rescue anesthetics. DEX was administered using an infusion-rate-based loading protocol of 6 µg/kg/h for 10 minutes, followed by individualized maintenance dosing at 0.2 to 0.7 µg/kg/h until 15 minutes after seizure termination. Posttreatment agitation and sedation were quantified using the Richmond Agitation-Sedation Scale (RASS). RESULTS: RASS scores were within the prespecified target range (-1 to +1) at 15 minutes in 88/137 sessions (64%). Rescue anesthetics were administered for agitation in 18/137 sessions (13%), and extended observation beyond the routine 30 minutes was required in 31/137 sessions (23%). No respiratory depression occurred. CONCLUSIONS: In this high-risk cohort, DEX prophylaxis was generally safe and clinically useful for improving postictal behavioral stability, although marked interindividual and intraindividual variability in dose requirements highlights the need for individualized titration and careful monitoring.