Improving Anesthetic Depth Assessment During Electroconvulsive Therapy with Bispectral Index Monitoring: A Pilot Quality Improvement Project

  • Frank J. Titch, CRNA, DNP Duke University School of Nursing
  • Tracey Holsinger, MD
  • Charles Vacchiano, CRNA, Phd
  • Jane Blood-Siefried, CPNP, DNSc


Background: Achieving adequate anesthetic depth during an ECT procedure without suppressing the therapeutic seizure is challenging and increases the risk of patient awareness during the procedure.


Aim: To assess provider satisfaction with, and identify potential barriers to the use of BIS monitoring during ECT as a means to determine the feasibility of adopting BIS monitoring in the clinical ECT setting.

Setting: The pilot project was conducted in a 274-bed general medical and tertiary care facility located on the mid-Atlantic coast that provides services to more than 200,000 patients and administers over 200 ECT treatments annually.


Participants: Psychiatry staff and nurse anesthetists caring for patients undergoing ECT.

Methods: A convenience sample of 11 patients scheduled for 25 ECT treatments received BIS monitoring. Provider (n= 12) satisfaction was anonymously assessed using an 8-question survey.

Results: While 7 of the 12 providers rated their overall satisfaction with using the BIS monitor during ECT as Very good only 2 providers affirmatively answered the BIS monitor added value to their decision-making process.

Two anesthetized patients, who responded purposefully to verbal commands despite BIS values in the deep hypnotic range indicating sufficient anesthetic depth, were considered at risk for awareness under anesthesia.

Conclusions: Provider acceptance of the introduction of BIS monitoring to assess anesthetic depth during ECT was lukewarm at best. While the concept appears sound, one must question if the technology and tools are sufficiently developed to warrant its routine use in the described setting. Given the response of the two patients with BIS values indicating sufficient anesthetic depth, these observations merit further studies to replicate our findings in the psychiatric population and further explore the potential value of BIS monitoring during ECT. 


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How to Cite
TITCH, CRNA, DNP, Frank J. et al. Improving Anesthetic Depth Assessment During Electroconvulsive Therapy with Bispectral Index Monitoring: A Pilot Quality Improvement Project. Anesthesia eJournal, [S.l.], v. 2, n. 2, dec. 2015. ISSN 2333-2611. Available at: <>. Date accessed: 09 dec. 2021.


Electroconvulsive therapy; ECT; Consciousness Monitors; Bispectral Index Monitor; Intraoperative Awareness; Anesthesia Awareness; Awareness During Anesthesia