Anesthesia for Electroconvulsive Therapy

7/31/2019 Anesthesia for Electroconvulsive Therapy

1/28

ANESTHESIA FORELECTROCONVULSIVE THERAPY

Husong Li, M.D., Ph.D.

Assistant Professor

Department of Anesthesiology

University of Texas Medical Branch

Galveston, Texas


2/28

ELECTROCONVULSIVE

THERAPY


3/28

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


4/28

MENTAL HEALTH CARE

PRE-1930S


5/28

Cerletti and Bini (1934): ECT

Initiallydonewithoutmuscle

blocker oranesthetic


6/28


7/28

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)


8/28

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


9/28

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


10/28

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Patient is severely withdrawn or starving:effects seen in days rather than weeks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


11/28

CONTRAINDICATIONS TO ECT

CV

Recent MI < 3 months;

Severe angina, CHF

Aneurysm of majorvessel

Pheochromocytoma

CNS

Cerebral tumor oraneurysm

Recent CVA


12/28

PHYSIOLOGIC EFFECTS OF

ECT-INDUCED SEIZURES Initial Parasympathetic

Discharge (15 seconds)

Bradycardia: markedBradycardia


13/28

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


14/28

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


15/28

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.


16/28

ECTDEVICE


17/28

EEG ACTIVITY

EEG Seizure Activity EEG Seizure Termination


18/28

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


19/28

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)


20/28

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


21/28

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)


22/28

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


23/28

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


24/28

SUGGESTED REGIME

Preoperative Evaluation

Fasting

Preoperative MedicationsIV placement

Monitors

EKG, SpO2Blood Pressure


25/28

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


26/28

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


27/28


28/28

SEVOFLURANE BST

Documents

Anesthesia for Electroconvulsive Therapy