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ANESTHESIA FORELECTROCONVULSIVE THERAPY
Husong Li, M.D., Ph.D.
Assistant Professor
Department of Anesthesiology
University of Texas Medical Branch
Galveston, Texas
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ELECTROCONVULSIVE
THERAPY
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INTRODUCTION TO
ELECTROCONVULSIVE THERAPY
Electroconvulsive therapy (ECT) is a
treatment for severe mental illness inwhich a brief application of electricalstimulus is used to produce a
generalized seizure
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MENTAL HEALTH CARE
PRE-1930S
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Cerletti and Bini (1934): ECT
Initiallydonewithoutmuscle
blocker oranesthetic
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INTRODUCTION TO ECT
ECT has changed substantially duringthe past decades. The use of general
anesthesia has promoted the interest inECT (Ottoson 1962)
ECT become more complex, more
precise, and safer procedure (mortality1/1000 early to 3-4/100,000 now)
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INTRODUCTION TO ECT
Generalized seizures for 30-60 secondsin duration are required for therapeuticeffects
75-90% of patients exhibit a dramaticand sustained improvement
Transient neurological dysfunction doesoccur but permanent neuronal injury isquestionable
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TREATMENT PROTOCOL FOR ECT
Generalized seizure can be induced byadjusting waveform, frequency, duration ofelectrical stimuli.
Seizure should last at least 30-60 seconds in
duration Good therapeutic effect is generally not
achieved until 400-700 seizure seconds
Treatments are usually given every other daysunto 12 sessions
Treatment endpoints are based on clinicalexperience and evaluation
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INDICATIONS FOR ECT
Severe depression: if drug treatment failsor is not tolerated ( i.e. elderly withParkinson's disease )
Bipolar disorder: manic or depressedphase
Acute or Catatonic Schizophrenia
Patient is severely withdrawn or starving:effects seen in days rather than weeks
Depression in pregnancy: with acutemania
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CONTRAINDICATIONS TO ECT
CV
Recent MI < 3 months;
Severe angina, CHF
Aneurysm of majorvessel
Pheochromocytoma
CNS
Cerebral tumor oraneurysm
Recent CVA
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PHYSIOLOGIC EFFECTS OF
ECT-INDUCED SEIZURES Initial Parasympathetic
Discharge (15 seconds)
Bradycardia: markedBradycardia
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ADVERSE EFFECTS TO ECT
Muscle contractions: can result infractures and dislocations; prevented bysmall doses of muscle relaxants
Injury to teeth, tongue or lips:stimuluscauses intense contraction of themasseter muscles and forceful
movement of the jaw; use a bite blockElectrical injury to the staff or patient
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ADVERSE EFFECTS TO ECT
Postictal Headache (45%) and muscleache
Short-term memory loss and cognitive
deficitsDifficult relationship with patients:
frightened; withdrawn; suspicious;uncooperative
Anesthesia related problem: i.e. air wayissue (more pt with OSA); aspiration
Line infection and sepsis
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TREATMENT PROTOCOL
PremedicateGlycopyrrolate andBeta blocker ?
Patient not intubated Bite block
Cuff leg to monitorseizure activity
EEG and EMG
Length of seizure:30 sec to 1 min.
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ECTDEVICE
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EEG ACTIVITY
EEG Seizure Activity EEG Seizure Termination
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PRE-ECT EVALUATION
Regular anesthesia pre-op evaluation:Esp. airway, CV, CNS
Psychotropic medication should be
stopped before ECT (antidepressants,benzodiazepine, lithium) for 7 days?
Pre-ECT sedation: hydroxyzine orpromethazine 25-50 mg, droperidol 2.5-5mg (promote seizure)
Pain medication prior to ECT
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ANESTHETIC AGENTS
SELECTIONOBJECTIVE:To leave the patient unawareof (amnesia) frightening sensations,particularly muscle paralysis and feelings of
suffocation and the image of a light flashthat may accompany the beginning of thestimulus, without obstructing the seizure
(McCleave & Blackmore, 1975)PRINCIPLE:To provide ultra-brief, light
general anesthesia with moderate degreeof muscular relaxation (APA, 1990, 2001)
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INDUCTION AGENTS
An ideal agent: rapid unconsciousness,painless on injection, no hemodynamiceffects, no anticonvulsant properties,
rapid recovery, and inexpensive (APA1990,2001; Folk et al, 2000)
Brevital Sodium : 0.5-1 mg/kg
thiopental: 2-4 mg/kg
ketamine: 0.5-2 mg/kg
propofol: 1.5-3 mg/kg
etomidate: 0.15-0.3 mg/kg
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MUSCLE RELAXANTS
Succinylcholine: 0.3-1.5 mg/kg.
Atracurium, 0.3-0.5 mg/kg (Hickey
et al, 1987)Mivacurium, 0.15-0.2 mg/kg (Kelly &
Brull, 1994)
Rocuronium, 0.45-0.6 mg/kg(Motamed et al, 1997)
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ADJUNCTIVE AGENTS
Caffeine 0.25-1.5 gm IV Flumazenil: 0.2-1 mg IV (benzodiazepine
antagonist)
Benzodiazepine: Valium 5-10 mg IV (statusepilepticus)
Anticholinergics: atropine 0.4-0.8 mg IV orglycopyrrolate 0.2-0.4 mg IV
Beta blockers: Labetalol and Esmolol Nitroglycerine
Antihypertensives: Labetalol, Trimethaphan,Nicardipine
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POST-ECT RECOVERY
Headache: Up to 45 % (Devanandet al. 1995; Freeman and Kendell 1980)
N/V: 1.4% - 23% (Gomez 1975;Sackeim et al. 1987d)
Muscle achePost-ECT confusion
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SUGGESTED REGIME
Preoperative Evaluation
Fasting
Preoperative MedicationsIV placement
Monitors
EKG, SpO2Blood Pressure
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SUGGESTED REGIME-INDUCTION
Preoxygenation
Inform MD and RN for the readiness ofinduction
Methohexital or others /Succinylcholine
Hyperventilate until fasciculation completed
Insertion of bite block or part of oral airway for
tooth protection
Ascertain the muscle relaxation with stimulator
ECT
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SUGGESTED REGIME
EmergenceHyperventilate with 100% O2 until normalvital signs obtained, then slow assistedbreaths until spontaneous ventilation
resumes.Turn patient on side and transport to PACU
Drugs ready to use
Atropine or glycopyrrolate, esmolol or
labetalol, ephedrine, phenylephrineEquipment ready to use
Laryngoscopes, ETT, stylet, airways, suction,defibrillator, alternative airway devices
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SEVOFLURANE BST
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