Under supervision Of

DR: AMR KAMAL

The purpose of the electrical stimulus in ECT is to induce a generalized grand mal type of seizure.

The seizure produced is not an all-or-nothing phenomenon.

seizures can be monitored both by observing

the ictal motor response (convulsion)

monitoring ictal EEG activity (the electrophysiological activity

of the brain occurring during the Seizure) , ( use muscle relaxant)EEG seizure activity is typically

10–20 seconds longer.

The intensity of convulsive motor activity is influenced by two factors:

the dose of muscle relaxant (generally succinylcholine)

intensity of the electrical stimulus

Most physicians use a practice known as the cuff technique to allow

the motor convulsion to be monitored after giving muscle relaxant

the cuff technique to allow the motor convulsion to be monitored.

Just before the muscle relaxant is administered, a blood pressure cuff is placed on a distal extremity(wrist or ankle) and inflated well above the systolic pressure (about 200 mm Hg).

This activity procedure prevents the flow of muscle relaxant distal to the cuff and enables unblocked muscles to manifest convulsive

.The ECT stimulus and the induced

seizure both exert cardiovascular effects,

primarily through the direct neuronal transmission from the hypothalamus

to the heart via parasympathetic tracts (the vagus nerve) and sympathetic

tracts (primarily in the spinal cord). The activation of the parasympathetic

system causes a decrease in blood pressure and heart rate. t

The cardiovascular response pattern can best be described

as a four-stage process, involving shifts from

parasympathetic to sympathetic to parasympathetic to sympathetic phases The activation of the sympathetic system produces opposite effects: blood pressure, venous pressure, and heart rate increase, resulting in an overall acceleration of cardiac output

MISSED SEIZUREINADEQUATE SEIZUREPROLONGED SEIZURE

Missed Seizureswhen no motor and ictal evidence

of seizure activity is seen following the electrical stimulus,

Causes Insufficient stimulus intensityPremature termination of stimulusPoor electrode contact with the

skinPatient’s high intrinsic seizure

thresholdHypercarbia due to

hypoventilation

NB the patient should be restimulated within 20–30 seconds, using a 25%–125% increase in stimulus intensity

Seizures of “inadequate” duration

Restimulation (should be delayed for 30–60 sec)

Evidence suggests that missed or inadequate seizures occurring at maximum stimulus intensity decrease the likelihood that the patient will respond to treatment.

When these phenomena occur, efforts should be directed at: Decreasing the seizure threshold Increasing the seizure duration or both

(Krystal et al. 2000).

Presently, four methods of seizure enhancement are commonly used:

Decreasing the anesthetic dosage anesthetic dosage (if possible and if the agent used has anticonvulsant properties)

HyperventilatioHyperventilationn (inducing hypocarbia) CaffeineCaffeine (and other adenosine receptor

antagonists) KetaminKetamin anesthesia

(Weiner et al. 1991).

Seizure activity lasting longer than 3 minutes

(American Psychiatric Association 2001).

1) At the first treatment2) During benzodiazepine

withdrawal3) In patients in whom

proconvulsant medications (e.g., caffeine, theophylline) and lithium

4) In patients who have epilepsy or preexisting paroxysmal EEG activity

In addition to making the decisions of ECT, the practitioner must also make a determination of: How frequently How frequently the seizures should be

induced (i.e., the interval between treatments)

How many treatments How many treatments should be administered in the treatment course.

Most ECT treatments are given three times a week whereas in other countries they may be administered twice weekly.

Increased frequency is associated with a more rapid response, it may also be associated with increased cognitive side effects

A three-times-weekly schedule appears to be an acceptable

A total number of treatments averaging between six and twelve but no exact number

The number of treatments will vary according to the individual and severity of medical condition.

After the conclusion of a course of ECT, three options are available for continued treatment:

1.Administration of applicable psychotropic medications (e.g., antidepressant, antimanic, and/or antipsychotic agent)

2.Administration of continuation ECT3.Psychotherapy combined with either

medication or continuation ECT.

A fourth option, involving the use of both continuation medication and ECT, may be necessary for patients with a patients with a history of failure of prophylaxis with history of failure of prophylaxis with either treatment alone.either treatment alone.

Multiple psychiatric disorders respond to maintenance ECT including:

major depressive disorder psychotic depression bipolar disorder and schizoaffective disorder

(Birkenhager et al. 2005).

Use of maintenance ECT in the geriatric population is also well documented

(Thienhaus et al. 1990).

Particular forms of schizophrenia (catatonia, refractory positive symptoms) may also be responsive to the combination of ECT and combination of ECT and antipsychotic medication antipsychotic medication

(Shimizu et al. 2007; Suzuki et al. 2006)

A typical arrangement would involve weekly ECT for 4 weeks, then incremental increases in the interval between ECT treatments to once a month over the next few months

(Clarke et al. 1989).

) 30مــادة: (ال يجوز إجراء العالج الكهربائى الالزم لحالة

تأثير مخدر عام وباسط المريض النفسى إال تحت على ذلك ويتعين الحصول على موافقته ،للعضالت

كتابة بناء على إرادة حره مستنيره وبعد إحاطته علما بطبيعة هذا العالج والغرض منه ،واألثار

الجانبيه التى قد تنجم عنه، والبدائل العالجيه له، فإذا رفض المريض الخاضع إلجراءات الدخول

والعالج اإللزامى هذا النوع من العالج وكان الزما لحالته فرض عليه بعد إجراء تقييم طبى مستقل.

Presented by Shaiamaa

wageih