Introduction
Electroconvulsive therapy (ECT) is widely used as an effective treatment option in psychiatric patients, especially in conditions such as refractory cases, risk of suicide, and any situations with the need for immediate therapeutic response [1, 2, 3]. During the procedure, a series of generalized epileptic seizures are induced under general anesthesia (GA) [4, 5]. Although ECT is considered a low-risk procedure, managing these cases can be highly challenging for the anesthesiologist and is not comparable to other conditions [6]. Before the time that ECT was performed safe and acceptable under GA, it was not considered humane [7]. In this process, the anesthesiologist should be aware of the potential adverse effects of ECT on the cardiovascular and nervous systems. During the procedure, significant hemodynamic fluctuations occur because of stimulating the sympatric and parasympathetic nervous systems [8].
The cardiovascular response to ECT is initially a brief parasympathetic activity leading to bradycardia, with the possibility of asystole. This phase is immediately accompanied by marked sympathetic stimulation, an acute increase in plasma epinephrine, and norepinephrine concentrations [9]. 
This stimulation can cause hemodynamic instability. Several case reports have demonstrated severe morbidity and even mortality in ECT patients [10]. Therefore, it is necessary to maintain hemodynamic stability during and after the procedure [11, 12]. So far, several studies have been performed to maintain hemodynamic stability in ECT patients. However, no study has investigated the hemodynamic status of ECT patients in Shafa Hospital, the only referral and academic center for all types of psychiatric disorders in Guilan.
Study Objective
This study aims to evaluate the patterns of hemodynamic changes in ECT patients in Shafa Hospital, Rasht City, Iran.
Methods
This longitudinal study was conducted in the Shafa Hospital in Rasht City, Iran in 2020.
The inclusion criteria comprised the following items: patients over the age of 18 years undergoing ECT treatment, having the consent of the legal guardian of the patient, and having the physical status classifications of I & II according to the American Society of Anesthesiologists (ASA).
The exclusion criteria were any change in the type of anesthesia or any unexpected event during the procedure.
A fasting time of 6 to 8 h was considered for all the patients and they were visited by the anesthesiologist before the procedure. To prevent bradycardia and salivation, atropine sulfate (0.01 mg/kg, IM) was administrated 30 min before admission. All patients underwent standard monitoring, including an electrocardiogram (ECG), a saturation of peripheral oxygenation (SpO2), and noninvasive blood pressure (NIBP). After the induction of anesthesia with propofol 1 mg/kg and confirmation of the ability of proper mask ventilation, 0.5 mg/kg succinylcholine (500 mg/10 mL, Caspian Tamin Co, Iran) was injected. At first, the patient was pre-oxygenated with oxygen 100% via an appropriate face mask followed by active hyperventilation at a rate of 40 to 50 breaths per minute. Before the seizure induction, bitemporal electrodes and a mouth grad were placed. Next, a brief grand mal seizure was produced and 70 to 120 V were applied resulting in approximately 800 mA of direct current for a duration of 100 milliseconds to 6 s. At the end of the seizure stimulation, the mouth guard was removed and an airway was replaced. Then, the face mask ventilation was started until the spontaneous respiration returned. Hemodynamic parameters, including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded before the induction of anesthesia (T0), 1 min after the induction of anesthesia (T1), 1 min after the seizure (T2), and 15 min after the wakefulness (T3). The trend of changes in these parameters was determined during the above-mentioned time intervals. The obtained data were analyzed by the IBM SPSS Statistics software version 22.0 for Windows operating system (IBM Corp., Armonk, NY, USA).
Repeated measures analysis of variance and the Bonferroni tests were used to compare the mean of study variables at different time points. 
Results
The data from 126 patients with a mean age of 43.14±10.46 were analyzed. A total of 50.8% of our patients were men and 50.8% were in the range of 19 to 25 kg/m2. Most of the cases were diagnosed with a psychotic disorder of schizophrenia (59.5%) and a minority had major depression (14.3%). Also, 15.9% of the patients suffered from comorbidities. In terms of SBP, DBP, and MAP, the trend of changes was significant (P=0.0001) at four intervals, but this was not true for HR (P=0.74). However, all changes in the hemodynamic parameters were kept in the normal range (Figure 1). The trend of changes in HR during the measured times was significantly related to gender (P=0.009) and in terms of MAP, it was significantly related to body mass index (P = 0.003).
Discussion
ECT causes significant hemodynamic fluctuations because of parasympathetic and sympathetic system activation which can expose the patients to cardiovascular and cerebrovascular fatal complications [9]. In this regard, several studies have focused on maintaining hemodynamic stability during the ECT process [9, 11, 13]. The results of this study showed that the trend of changes in SBP, DBP, and MAP values from T0 to T3 was statistically significant. Regarding HR, although the trend of changes was not significant, it was different between men and women, which was higher in men compared to women.
This study showed that, despite the changes that occurred in the hemodynamic parameters, the values remained within the normal range which indicates the acceptable performance of the treatment team in the ECT ward. One of the key interventions in this process is the use of the preparation checklist that helps patients receive ECT under optimal conditions. This checklist which is prepared by the anesthesia team provided the opportunity to determine the underlying diseases and the need for further clinical and paraclinical examinations. Another strength of the treatment team is the presence of an anesthesiologist at all stages of the process, from the beginning to the transfer of the patient to the recovery ward. Therefore, there was strict control over the exact determination of the type of drugs, dosage, and timing. Meanwhile, standard monitoring was considered for all cases. The safe and successful management of these patients was the result of proper communication between anesthesia and psychiatry teams along with the good cooperation of the ECT staff and nurses. In summary, despite maintaining the hemodynamic parameters relatively in the stable range, because of the observed significant fluctuations, it is necessary to consider appropriate premedication in the elderly with comorbidities. In addition, the arrangements for any emergency intervention to control blood pressure levels should be readily available.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the Guilan University of Medical Sciences (Ethics Code: IR.GUMS.REC.1399.451). All ethical principles were considered in this research. The study participants were aware of the research process. The patient’s information was kept confidential.

Funding
This study was supported by the Deputy for Research and Technology of Guilan University of Medical Sciences.

Authors' contributions
Study concept and design: Gelareh Biazar, Robabeh Soleimani; Data acquisition, analysis, and interpretation: Batul Montazery, Samin Khoshnoud Speily Samira Mirzababaei, Fatemeh Baghernezhad, Ebrahim Haddad Komleh; Drafting of the manuscript: Samaneh Ghazanfar Tehran; Editing and review: Sahar Erabi; Investigation and resources: Gelareh Biazar; Statistical analysis: Habib Eslami Kenarsari, Samaneh Ghazanfar Tehran; Study supervision: Robabeh Soleimani.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to thank the personnel of the Anesthesiology Research Center of Guilan University of Medical Sciences for their collaboration in this study.


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