Use of the cuff method in electroconvulsive therapy – a response

Sir: The study by Jan Wise et al (Psychiatric Bulletin, August 2000, 24, 301) is interesting. The authors have found no significant difference in seizure duration between the cuffed and uncuffed limbs and suggest that the use of the cuff method to ‘observe’ absent seizure cease, as it merely delays addressing the real cause of ‘absent’ seizures. The following issues also need to be considered in this respect:

1. (a) A tonic—clonic seizure that is not witnessed may be owing to inattention, absence of seizure activity or excessive muscle relaxation (Fink, 1983). Electroencephalogram (EEG) monitoring is helpful in detecting the occurrence of a cerebral seizure, while the ‘cuff’ method is useful where excessive muscle relaxation may obscure an overt motor seizure. Thus, the two seizure monitoring methods address different (although related) aspects of the electroconvulsive therapy (ECT) session.

2. (b) The absence of any significant difference between the cuffed and the uncuffed limbs is perhaps more indicative of the absence of excessive muscle relaxation (so as to obscure a visible seizure) during ECT rather than the ‘ineffectiveness’ of the cuff method itself — as is suggested by the authors.

3. (c) The cuff method does not necessarily delay addressing the real cause of ‘absent’ seizures because it oft-times helps to rule out excessive relaxation as a cause for an apparently absent seizure.

Therefore, both EEG and the cuff method have a role in monitoring seizures in ECT sessions, especially so because there are no recommended dosages of succinylcholine for purpose of administering ECT.

Perhaps, an assessment of the difference in seizure intensity across limbs and the mean dosage of relaxant used would have been informative regarding the degree of modification achieved during ECT.