Electroconvulsive therapy (ECT) performed with rocuronium-sugammadex requires both agents to be prepared before each session, creating a persistent syringe-swap risk that compounds with repetition. A 48-year-old woman scheduled for her sixth ECT session received sugammadex 200 mg instead of rocuronium due to syringe misidentification driven by task automaticity accumulated over 5 uneventful preceding sessions. Because the entire sugammadex dose remained unbound in plasma (a state we term "zero-complexation"), subsequently administered rocuronium 100 mg (1.41 mg/kg) failed to achieve adequate neuromuscular blockade. This scenario is pharmacokinetically distinct from the well-described post-reversal re-dosing situation: 200 mg of free sugammadex sequesters ~56 mg of rocuronium, leaving an insufficient effective dose regardless of the total amount administered. The session was postponed and completed the following day uneventfully with standard-dose rocuronium. We present a management algorithm and a safety checklist designed for the repeated-session context of ECT. This case demonstrates that anesthetic teams using rocuronium-sugammadex for ECT must recognize the cumulative automaticity risk inherent in serial sessions and implement structural safeguards accordingly.

Klazomania is a rare phenomenon characterized by compulsive, uncontrollable shouting or yelling without an emotional trigger or reason. It has been reported to be associated with various psychiatric and neurological conditions. No specific treatment has been recommended as the etiology is not known. Trials of antipsychotics, antidepressants, and antiepileptic drugs have been used. Hereby, we report a case of Klazomania in a patient with Obsessive Compulsive Disorder who initially responded to Electroconvulsive Therapy but later on became refractory to it.

Tardive seizures are a rare but serious complication of electroconvulsive therapy, which can lead to early termination of an ECT course. A recent review by Warren et al discussed the reported prevalence of and risk factors for these events. While uncommon, our experience at Yale Psychiatric Hospital has revealed that tardive seizures occur more frequently than historically described, requiring urgent treatment for seizure termination and adjustments to subsequent ECT treatments. In our experience, most patients can safely continue ECT without further tardive seizures if appropriate adjustments are made. To our knowledge, there is no standardized algorithm for the management of tardive seizures, nor an explicit set of guidelines for risk mitigation if ECT will be continued. We provide both based on the data for management of status epilepticus, guided by our clinical experience and focused on short-acting agents appropriate for an ECT PACU setting. We also provide recommendations about when ECT should be paused and further workup pursued.

Electroconvulsive therapy (ECT) is usually performed under general anesthesia using a sedative-hypnotic and a short-acting neuromuscular blocker, typically without instrumentation of the airway. We report a case of pulmonary aspiration during ECT in a 27-year-old man on multiple psychotropic medications who was fully compliant with standard American Society of Anesthesiologists (ASA) preoperative fasting (Nil per Os, NPO) guidelines. A postprocedure point-of-care (POC) gastric ultrasound revealed a full stomach with solid contents. The cumulative anticholinergic burden of his medication regimen, including clozapine, benztropine, quetiapine, paliperidone, and prazosin, combined with the recognized association between psychiatric illness and disordered gastric motility, likely contributed to retained gastric contents at the time of induction. We review the limitations of fasting-based risk assessment, the prevalence of residual gastric content in appropriately fasted patients, the evidence supporting POC gastric ultrasound as a decision-support tool, and the practical constraints of equipment availability and operator training. We propose a risk-stratified approach in which preprocedural POC gastric ultrasound is recommended for ECT patients with one or more risk factors for delayed gastric emptying-rather than as a universal, mandatory examination.

Electroconvulsive therapy (ECT) is a highly effective intervention for treatment-resistant catatonia and severe neuropsychiatric disorders. We present the case of a 67-year-old patient with a long-standing diagnosis of schizophrenia who developed catatonic symptoms in the context of Parkinson disease (PD) and neuroborreliosis. After a medication switch from risperidone to quetiapine the patient rapidly deteriorated, displaying psychotic symptoms, disorganized behavior, and aggression. Multiple pharmacological interventions, including clozapine, high-dose risperidone, and benzodiazepines, were ineffective despite therapeutic plasma levels. The patient required seclusion over 50 times due to persistent agitation. Subsequently, he became increasingly withdrawn, refusing food and fluids, and developed pronounced catatonic features (mutism, echopraxia). After 3 months of unsuccessful pharmacotherapy, bilateral ECT was initiated. Within 6 sessions, the patient showed marked clinical improvement. A total of 18 ECT sessions led to full remission of catatonic and psychotic symptoms, with no further need for coercive measures. The patient was discharged home and continues to receive maintenance ECT. This case highlights the efficacy of ECT in managing complex catatonic states in patients with comorbid neuropsychiatric and neuroinflammatory conditions. It also emphasizes the importance of early ECT consideration when pharmacological approaches fail in multifactorial clinical scenarios.

Electroconvulsive therapy (ECT) is an established treatment strategy for a range of psychiatric disorders, including depression, mania, psychosis, and catatonia. A growing body of evidence suggests that ECT may affect motor symptoms in movement disorders. In a systematic review, we aim to review the evidence on the use of ECT in movement disorders. We searched PubMed, SCOPUS, Cochrane, Web of Science, and Embase to identify relevant publications. Fifty-eight papers were retained for data extraction. The existing evidence suggests a beneficial impact of ECT on both motor and nonmotor symptoms across various movement disorders, with the most substantial findings reported for Parkinson disease. Conversely, the evidence pertaining to Huntington disease and related disorders cannot rule out a potentially negative effect. Given that the data reviewed are constrained in both quantitative and qualitative rigor, predominantly derived from case reports, further research through the publication of case reports and the conduct of standardized clinical trials is warranted.