Dear Editor,
Electroconvulsive Therapy (ECT) is a procedure indicated for the treatment of several neuropsychiatric conditions, including severe and life-threatening disorders and situations such as depression with risks of suicide or malnutrition, catatonia, refractory schizophrenia, mania with severe psychomotor agitation and status epilepticus.1 Although this is a life-saving treatment, maintaining the ECT services during the COVID-19 pandemic has become a challenge due to the intrinsic risks of anesthetics and airway management during the procedure.2 Anesthesia for ECT consists in the use of a short-acting hypnotic agent (propofol, etomidate or thiopental) followed by a neuromuscular blocker, the most used is succinylcholine due to its rapid onset and offset of action. Oxygen supply is provided through a non-invasive bag and mask ventilation.3 This is a critical point in the procedure because non-invasive ventilation poses a higher risk of contamination due to aerosol release from contaminated patients. To address this challenge, some services are using a Laryngeal Mask (LMA) for ventilation, others are trying not to ventilate patients during the procedure, using preoxygenation via a non-rebreather mask. The latter can be dangerous because the patient’s oxygen saturation may drop to a level that requires some kind of ventilatory support. Although the procedure is fast enough to allow the use of LMA, the risk of contamination due to the aerosol spray does not decrease significantly; in addition, LMA can induce the patient to cough.4

In our ECT service, we modified the non-invasive ventilation technique (Fig. 1) by installing a HEPA (High-Efficiency Particulate Arrestance) filter between the bag and the mask to retain the viral particles. Additionally, a sterile plastic bag surrounding the mask and the patient’s face is attached to the ventilatory system. This device protects against the aerosol that may escape from between the mouth and the mask and spread viral particles around the ECT room. The edge of the plastic bag can be fixed with clamps. All ventilatory material is replaced among patients. The use of low O2 flow during ventilation is also a recommended measure. The psychiatrist, anesthesiologist, and nurses should all use personal protective equipment such as a N95 mask, face shield, gloves, and an impermeable gown.