Comparison of remimazolam and etomidate as induction agents for electroconvulsive treatment

Background: Electroconvulsive therapy (ECT) is used to treat severe psychiatric disorders through seizure induction via electrical currents, typically under general anesthesia. Although etomidate is known to extend the seizure duration and maintain hemodynamic stability, concerns regarding its effects on the adrenocortical axis limit its use. Remimazolam, a novel ultra-short-acting benzodiazepine, offers rapid onset and recovery with a favorable safety profile. Therefore, we compared remimazolam with etomidate as induction agents for ECT, focusing on their impact on seizure activity and recovery time. Methods: This prospective, randomized, crossover study included 30 patients aged 18–65 years scheduled for ECT with an American Society of Anesthesiologists Physical Status I and II. The primary outcomes were recovery time of self-respiration and eye opening, which were compared between the remimazolam and etomidate groups. We also recorded mean arterial pressure and heart rate at several time points and assessed the energy delivered during the shock, seizure duration, duration of recovery-room stays, and complications. Results: There was no significant difference in the energy required to induce seizures between the etomidate- and remimazolam-treated groups. However, the motor seizure duration was significantly longer in the etomidate group than in the remimazolam group. There were no significant differences in the blood pressure, heart rate, or self-respiration recovery times between the two groups. Conclusions: Remimazolam can effectively replace etomidate as an ECT-induction agent with comparable hemodynamic stability, recovery parameters, and seizure shock thresholds. It is particularly suitable for patients at high risk of adrenal insufficiency.