Impact of different anesthetic agents (propofol, etomidate, ketamine) on seizure duration and cognitive recovery in electroconvulsive therapy

Table 1 Risk of bias assessment for randomized controlled trials (n = 11)

Ref.	Random sequence generation	Allocation concealment	Blinding of participants	Blinding of outcome assessment	Incomplete outcome data	Selective reporting	Other bias	Overall risk
Shahu et al[5], 2024	Low	Low	Low	Low	Low	Low	Low	Low
Zhong et al[14], 2016	Low	Low	Unclear	Low	Low	Low	Low	Some concerns
Erdogan Kayhan et al[22], 2012	Low	Unclear	Low	Low	Low	Low	Low	Some concerns
İkiz et al[9], 2021	Low	Low	Low	Low	Low	Low	Low	Low
Jindal et al[6], 2020	Low	Low	Low	Low	Low	Low	Low	Low
Canbek et al[7], 2015	Low	Low	Low	Low	Low	Low	Low	Low
KJ et al[21], 2025	Unclear	Unclear	Unclear	Unclear	Unclear	Unclear	Unclear	High
Mathur et al[10], 2024	Low	Low	Low	Low	Low	Low	Low	Low
Joshi et al[20], 2021	Low	Low	Low	Low	Low	Low	Low	Low
Brunelin et al[18], 2020	Low	Low	Low	Low	Low	Low	Low	Low
Guha et al[19], 2022	Low	Unclear	Low	Low	Low	Low	Low	Some concerns

Risk of bias summary statistics: Low risk of bias: 8 studies (72.7%). Some concerns: 3 studies (27.3%). High risk of bias: 1 study (9.1%).

Table 2 Newcastle-Ottawa Scale assessment for observational studies (n = 13)

Ref.	Selection (max 4 stars)	Comparability (max 2 stars)	Outcome (max 3 stars)	Total score	Quality rating
Bernardoff et al[15], 2026	4	2	3	9	High
Hoyer et al[12], 2014	4	2	3	9	High
Krystal et al[16], 2003	3	2	3	8	High
Kavakbasi et al[24], 2023	4	2	3	9	High
Tufek et al[13], 2014	3	1	3	7	Moderate
Kök Kendirlioğlu et al[25], 2025	3	2	3	8	High
Lundin et al[17], 2025	4	1	3	8	High
Yang et al[8], 2025	3	2	2	7	Moderate
Gurel et al[28], 2022	3	2	3	8	High
Sartorius et al[11], 2021	4	2	3	9	High
Yoon et al[27], 2023	3	2	3	8	High
Methfessel et al[26], 2023	3	2	3	8	High
Beyazyüz et al[23], 2023	3	1	3	7	Moderate

Newcastle-Ottawa Scale summary statistics: High quality (≥ 8 stars): 10 studies (76.9%). Moderate quality (6-7 stars): 3 studies (23.1%). Low quality (< 6 stars): 0 studies (0%).

Table 3 Characteristics of included studies

Ref.	Study type	n	Age (years)	Anesthetic agents	Primary outcomes	Follow-up
Shahu et al[5], 2024	RCT	60	42.3 ± 12.1	Propofol vs etomidate	Seizure duration, hemodynamics	Immediate
Zhong et al[14], 2016	RCT	90	35.2 ± 10.5	Ketamine (different doses)	Mood, neuropsychological	1 month
Erdogan Kayhan et al[22], 2012	RCT	48	44.7 ± 15.2	Ketofol vs propofol	Seizure duration, recovery	Immediate
İkiz et al[9], 2021	RCT	80	46.1 ± 13.7	Propofol vs propofol + remifentanil	Hemodynamics, seizure duration	Immediate
Jindal et al[6], 2020	RCT	60	38.9 ± 11.3	Etomidate vs propofol	Motor seizure duration	Immediate
Canbek et al[7], 2015	RCT	120	41.6 ± 14.8	Propofol vs etomidate vs thiopental	Seizure parameters, recovery	Immediate
Mathur et al[10], 2024	RCT	100	43.2 ± 12.9	Propofol vs ketofol	Seizure duration, hemodynamics	Immediate
Joshi et al[20], 2021	RCT	80	40.5 ± 13.2	Ketofol vs etomidate	Seizure duration, recovery	Immediate
Brunelin et al[18], 2020	RCT	58	47.8 ± 15.1	Propofol + ketamine vs propofol	Clinical response	6 weeks
Guha et al[19], 2022	RCT	50	39.7 ± 12.6	Propofol vs ketamine	Efficacy, cognitive function	2 weeks
Bernardoff et al[15], 2026	Observational	156	52.3 ± 16.4	Various	Cognitive function	6 months
Hoyer et al[12], 2014	Observational	1253	54.7 ± 17.2	Ketamine, etomidate, thiopental, propofol	Seizure parameters	Immediate
Krystal et al[16], 2003	Observational	89	48.2 ± 14.3	Ketamine vs methohexital	Seizure duration, cognitive	1 week
Kavakbasi et al[24], 2023	Observational	124	45.9 ± 13.8	Thiopental vs propofol	Cognitive effects, seizure	1 month
Tufek et al[13], 2014	Observational	210	47.3 ± 15.6	Various	Seizure duration, recovery	Immediate
Kök Kendirlioğlu et al[25], 2025	Observational	78	44.1 ± 12.7	Ketamine + ECT	Treatment resistance	3 months
Lundin et al[17], 2025	Observational	892	49.6 ± 16.8	Various	Treatment outcomes	17 years
Yang et al[8], 2025	Observational	186	41.2 ± 14.5	Various	Cognitive function	6 months
Gurel et al[28], 2022	Observational	120	43.8 ± 13.9	Ketofol, etomidate, propofol, thiopental	Seizure parameters	Immediate
Sartorius et al[11], 2021	Observational	234	52.1 ± 17.3	S-ketamine + propofol	Seizure quality	Immediate
Yoon et al[27], 2023	Observational	98	46.7 ± 14.2	Etomidate vs propofol	Clinical response	3 months
Methfessel et al[26], 2023	Observational	67	51.4 ± 16.1	Propofol/esketamine vs methohexital	Seizure quality	Immediate
Beyazyüz et al[23], 2023	Observational	84	42.9 ± 13.4	Propofol vs ketamine-propofol	ECT parameters	Immediate

RCT: Randomized controlled trial; ECT: Electroconvulsive therapy.

Table 4 Seizure duration outcomes by anesthetic agent

Ref.	Propofol (seconds)	Etomidate (seconds)	Ketamine (seconds)	Ketofol (seconds)	P value
Shahu et al[5], 2024	20.4 ± 4.6	32.8 ± 6.2	-	-	< 0.001
Erdogan Kayhan et al[22], 2012	22.1 ± 5.3	-	-	28.7 ± 6.4	< 0.05
Jindal et al[6], 2020	20.1 ± 4.8	28.4 ± 6.2	-	-	< 0.001
Canbek et al[7], 2015	23.2 ± 5.7	29.6 ± 7.1	-	-	< 0.001
Mathur et al[10], 2024	21.5 ± 4.9	-	-	26.8 ± 5.7	< 0.01
Joshi et al[20], 2021	-	31.2 ± 7.8	-	29.3 ± 6.9	0.082
Hoyer et al[12], 2014	22.8 ± 6.2	30.1 ± 8.4	25.6 ± 7.1	-	< 0.001
Krystal et al[16], 2003	-	-	28.3 ± 6.7	-	-
Gurel et al[28], 2022	19.7 ± 4.2	28.9 ± 6.8	-	27.4 ± 5.9	< 0.001

Table 5 Cognitive outcomes by anesthetic agent

Ref.	Cognitive assessment tool	Propofol	Etomidate	Ketamine	P value
Zhong et al[14], 2016	MMSE, TMT-A, TMT-B	-	-	Dose-dependent improvement	< 0.05
Bernardoff et al[15], 2026	MoCA, RBANS	Moderate impairment	Mild impairment	-	< 0.05
Krystal et al[16], 2003	MMSE, orientation	-	-	Less impairment	< 0.01
Kavakbasi et al[24], 2023	MMSE, clock drawing	Moderate impairment	Mild impairment	-	< 0.05
Yang et al[8], 2025	MoCA, RBANS	Variable	-	-	NS
Guha et al[19], 2022	MMSE	Moderate impairment	-	Mild impairment	< 0.05

Individual study recovery times: Propofol: Consistently shorter recovery times across studies (range: 6.2-10.4 minutes). Etomidate: Moderate recovery times (range: 10.1-14.7 minutes). Ketamine: Longer recovery times (range: 13.2-18.2 minutes). Ketofol: Intermediate recovery times (range: 8.1-12.3 minutes). MMSE: Mini-Mental State Examination; TMT-A: Trail Making Test - Part A; MoCA: Montreal Cognitive Assessment; RBANS: Repeatable Battery for the Assessment of Neuropsychological Status; NS: Not significant.

Table 6 Hemodynamic outcomes by anesthetic agent

Ref.	Parameter	Propofol	Etomidate	Ketamine	P value
Shahu et al[5], 2024	MAP change (mmHg)	+18.2 ± 8.4	+12.3 ± 6.7	-	< 0.01
Shahu et al[5], 2024	HR change (bpm)	+22.1 ± 9.3	+16.4 ± 7.2	-	< 0.05
İkiz et al[9], 2021	MAP change (mmHg)	+16.7 ± 7.9	-	-	-
İkiz et al[9], 2021	HR change (bpm)	+19.8 ± 8.6	-	-	-
Mathur et al[10], 2024	MAP change (mmHg)	+17.3 ± 8.1	-	-	-
Zhong et al[14], 2016	MAP change (mmHg)	-	-	+24.6 ± 10.2	-
Zhong et al[14], 2016	HR change (bpm)	-	-	+28.3 ± 11.7	-

MAP: Mean arterial pressure; HR: Heart rate.

Table 7 Adverse event patterns from individual studies

Adverse event	Propofol studies	Etomidate studies	Ketamine studies	Ketofol studies
Nausea/vomiting	Lower rates reported across studies	Higher rates consistently reported	Variable rates across studies	Intermediate rates reported
Myoclonus	Minimal occurrence reported	Frequently reported across studies	Low occurrence reported	Low to moderate occurrence
Emergence phenomena	Rare occurrence	Occasional reports	Frequently reported concern	Occasional reports
Prolonged recovery	Minimal reports	Moderate occurrence	Consistent reports across studies	Variable reports
Hypotension	Occasional reports	Rare occurrence	Minimal reports	Occasional reports
Hypertension	Rare occurrence	Rare occurrence	Frequently reported	Moderate occurrence