Difference between revisions of "Electroconvulsive therapy"

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{{Infobox surgical procedure
| anesthesia_type = General
| airway = Natural airway
| lines_access = 1 PIV
| monitors = Standard ASA, EEG
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}'''Electroconvulsive therapy''' (ECT) is a medically induced generalized seizure that consists of a 2 to 3 second latent phase is followed by a tonic (prolonged muscular contraction) phase lasting 10 to 12 seconds, then a clonic (repeated contraction) phase of 30 to 50 seconds.<ref name=":0">{{Cite book|last=Murray, Michael J, Steven H. Rose, Denise J. Wedel, C T. Wass, Barry A. Harrison, and Jeff T. Mueller.|first=|title=Faust's Anesthesiology Review|publisher=|year=2015|isbn=|location=Print|pages=Anesthesia for Electroconvulsive Therapy; 490-492}}</ref><ref name=":1">{{Cite book|last=Pardo, Manuel, Ronald D Miller|first=|title=Basics of Anesthesia 7th Edition|publisher=|year=2017|isbn=0323401155|location=Print|pages=669-671}}</ref> It is used for refractory depression (unipolar and bipolar types), depression with psychotic features, schizophrenia, and catatonia.<ref name=":1" /><ref name=":2">{{Cite web|last=ACCRAC|date=2019-03-13|title=Episode 112: Anesthesia for ECT with Christina Miller|url=http://accrac.com/episode-112-anesthesia-for-ect-with-christina-miller/|access-date=2021-08-22|website=ACCRAC Podcast|language=en}}</ref>
 
ECT is monitored by EEG, with electrodes placed in left unilateral, right unilateral (most common, fewer memory side effects), and bifrontal. Goal seizure duration is 30-60 seconds. For seizures lasting longer than 120 seconds, termination can be achieved with midazolam/propofol. The initial session may require a dose titration to determine the appropriate electrical stimulus to evoke a seizure. Both the duration of individual seizure & cumulative seizure time between treatments correlated w/ clinical improvement of depression, with total number of ECT sessions determined by patient's clinical response. Repeated rounds of ECT have been shown to increase seizure threshold (try to decrease dose of methohexital or other induction agent if possible to limit size of electrical charge administered).
 
Mortality risk is extremely low, at <1 in 75,000 treatments.<ref name=":0" /> Most common adverse events include transient arrhythmias (10%–40%), gastric aspiration (2.5%), and MSK disorders (0.4%) including fractures. Additional adverse events include pulmonary edema, headache, memory disturbance, and agitation. Very rarely Takotsubo cardiomyopathy, febrile reactions, or neurologic dysfunction may occur.
 
Absolute contraindications include:
* Untreated Pheochromocytoma
* Intracranial mass/↑ ICP
* Recent MI or Stroke w/in last 30 days
Relative contraindications include:
* Angina pectoris, CHF
* COPD
* Glaucoma, Retinal detachment
* High-risk pregnancy
* Severe osteoporosis (fracture risk)
* Thrombophlebitis
 
Generally speaking, anesthetic considerations for the procedure are as follows:<ref name=":0" /><ref name=":1" />
# Pre-oxygenate well prior to induction
# Once induction medications given & patient unconscious start mask ventilating & give paralytic
# Hyperventilate -> Hypocarbia (↓ seizure threshold)
# Bite guard placed prior to ECT initiation
# After ECT & seizure completed remove bite guard and provide supportive airway management until patient regains consciousness.
 
== Preoperative management ==
 
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|Careful titration of psych meds (see below)
|-
|Cardiovascular
|Electrical activity can affect ICD/pacemaker (see below)
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}
 
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
 
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
 
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --><ref name=":0" /><ref name=":1" /><ref name=":2" /> ===
 
* ''Psychiatric Medication Management'':
** Can continue MAO inhibitors, TCAs, SSRIs, & antipsychotics w/ ECT
** MAO Inhibitors: Avoid ephedrine (indirect-acting sympathomimetics cause exaggerated BP). Be aware they ↓ plasma cholinesterase activity → ↑ succinylcholine duration
** Lithium – Risk for delayed awakening, memory loss, and postictal confusion. Hold for 12hr before ECT
**Benzodiazepines – Hold for 12hr before ECT. May need to give flumazenil before ECT to have an adequate seizure duration.
*''Pacemaker vs Implantable Cardioverter-Defibrillator (ICD)'':
** Pacemaker
*** If ''not'' dependent on the device, a magnet should be available in event of device failure.
*** If dependent on pacemaker, program device to asynchronous mode & a backup pacing mode should be available.
** ICD:
*** Risk that the device misinterprets muscle movements as an abnormal cardiac rhythm and a discharge is possible.
*** Device should be deactivated & an external defibrillator should be immediately available with placement of external defibrillator pads strongly considered.
** For a patient with an ICD & who is pacemaker dependent, the EP service should be consulted or in any other cases with pacing concerns.
 
== Intraoperative management ==
 
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
 
* PIV x 1
* Standard ASA monitors with 5 lead ECG
* Single lead EEG
 
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
 
*'''Induction''':
** Methohexital (Brevital) 0.5 to 1 mg/kg; least effect on Sz threshold
** Etomidate: 0.2 to 0.3 mg/kg; maintains hemodynamic stability
** Propofol: ↑ seizure threshold & ↓ seizure duration. Need higher stimulus voltages to achieve adequate seizure. ''May be useful in patients with history of long seizures''.
** Ketamine: can cause post-ECT confusion.
** Remifentanil 200-400 mcg as an adjunct to lower dose of methohexital needed; net '''↓''' Sz threshold. Monitor for ↓HR/↓BP & chest wall rigidity. If unable to ventilate or very small TV, consider succinylcholine.
** Sevoflurane can be used for inhalational induction when no IV access possible.
*'''Paralytic''':
*# Succinylcholine 1- 1.5 mg/kg, titrate to adequate paralysis
*# Rocuronium - Low dose & only if patient has contraindication to succinylcholine (reverse with sugammadex)
*'''Initial PARAsympathetic discharge''':
*# Glycopyrrolate 0.2mg to prevent bradycardia. Usually given prior to induction agents
*'''Subsequent Sympathetic discharge''':
*# Nitroglycerin &/or Beta blockers (esmolol, labetalol) can be used to attenuate sympathetic response.
*#''Hyperglycemia'' often seen in insulin dependent Pt -> BG Pre/Post
 
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
Supine or with HOB elevated
 
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --><ref name=":0" /><ref name=":2" /> ===
 
* ECT stimulus -> short initial parasympathetic response caused by vagal nerve stimulation followed by a large sympathetic discharge
*''Cardiovascular''
** 1st: Parasympathetic response may cause '''asystole''', bradycardia, PVCs, '''hypotension''', & ventricular escape rhythm.
***''If known profound parasympathetic response, can blunt w/ glycopyrrolate pre-induciton''
** 2<sup>nd</sup>: Sympathetic tone ↑ with seizure generation -> ↑ HR, PVCs, bigeminy, trigeminy, sinus tachycardia, '''ST segment changes''' (↑ myocardial O2 consumption) & '''severe HTN'''.
*** Often resolves quickly, but if Pt requires intervention consider nitroglycerin, esmolol, or labetalol
*''Respiratory'': Parasympathetic discharge -> at risk for laryngospasm, bronchoconstriction/wheezing
*''Neuro:'' Initial constriction of cerebral vessels is followed by ↑ cerebral blood flow (1.5–7 times baseline) secondary to ↑ cerebral O2 consumption & ↑BP -> ↑ICP
*''Neuroendocrine'': ↑ corticotropin, cortisol, & catecholamines.
** Effects on glucose levels vary; consider Pre/Post glucose in insulin dependent patients.
*''GI'': ↑ intragastric pressure
*''Eye'': ↑ intraocular pressure
 
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
 
== Postoperative management ==
 
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
 
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
Minimal pain
 
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
 
* Post-ECT Delirium (or if flumazenil given pre-induction): treat with midazolam 1-2mg
 
== References ==
<references />
 
[[Category:Surgical procedures]]

Latest revision as of 22:11, 21 February 2022

Electroconvulsive therapy
Anesthesia type

General

Airway

Natural airway

Lines and access

1 PIV

Monitors

Standard ASA, EEG

Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
Editor rating
Comprehensive
User likes
0

Electroconvulsive therapy (ECT) is a medically induced generalized seizure that consists of a 2 to 3 second latent phase is followed by a tonic (prolonged muscular contraction) phase lasting 10 to 12 seconds, then a clonic (repeated contraction) phase of 30 to 50 seconds.[1][2] It is used for refractory depression (unipolar and bipolar types), depression with psychotic features, schizophrenia, and catatonia.[2][3]

ECT is monitored by EEG, with electrodes placed in left unilateral, right unilateral (most common, fewer memory side effects), and bifrontal. Goal seizure duration is 30-60 seconds. For seizures lasting longer than 120 seconds, termination can be achieved with midazolam/propofol. The initial session may require a dose titration to determine the appropriate electrical stimulus to evoke a seizure. Both the duration of individual seizure & cumulative seizure time between treatments correlated w/ clinical improvement of depression, with total number of ECT sessions determined by patient's clinical response. Repeated rounds of ECT have been shown to increase seizure threshold (try to decrease dose of methohexital or other induction agent if possible to limit size of electrical charge administered).

Mortality risk is extremely low, at <1 in 75,000 treatments.[1] Most common adverse events include transient arrhythmias (10%–40%), gastric aspiration (2.5%), and MSK disorders (0.4%) including fractures. Additional adverse events include pulmonary edema, headache, memory disturbance, and agitation. Very rarely Takotsubo cardiomyopathy, febrile reactions, or neurologic dysfunction may occur.

Absolute contraindications include:

  • Untreated Pheochromocytoma
  • Intracranial mass/↑ ICP
  • Recent MI or Stroke w/in last 30 days

Relative contraindications include:

  • Angina pectoris, CHF
  • COPD
  • Glaucoma, Retinal detachment
  • High-risk pregnancy
  • Severe osteoporosis (fracture risk)
  • Thrombophlebitis

Generally speaking, anesthetic considerations for the procedure are as follows:[1][2]

  1. Pre-oxygenate well prior to induction
  2. Once induction medications given & patient unconscious start mask ventilating & give paralytic
  3. Hyperventilate -> Hypocarbia (↓ seizure threshold)
  4. Bite guard placed prior to ECT initiation
  5. After ECT & seizure completed remove bite guard and provide supportive airway management until patient regains consciousness.

Preoperative management

Patient evaluation

System Considerations
Airway
Neurologic Careful titration of psych meds (see below)
Cardiovascular Electrical activity can affect ICD/pacemaker (see below)
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Operating room setup

Patient preparation and premedication[1][2][3]

  • Psychiatric Medication Management:
    • Can continue MAO inhibitors, TCAs, SSRIs, & antipsychotics w/ ECT
    • MAO Inhibitors: Avoid ephedrine (indirect-acting sympathomimetics cause exaggerated BP). Be aware they ↓ plasma cholinesterase activity → ↑ succinylcholine duration
    • Lithium – Risk for delayed awakening, memory loss, and postictal confusion. Hold for 12hr before ECT
    • Benzodiazepines – Hold for 12hr before ECT. May need to give flumazenil before ECT to have an adequate seizure duration.
  • Pacemaker vs Implantable Cardioverter-Defibrillator (ICD):
    • Pacemaker
      • If not dependent on the device, a magnet should be available in event of device failure.
      • If dependent on pacemaker, program device to asynchronous mode & a backup pacing mode should be available.
    • ICD:
      • Risk that the device misinterprets muscle movements as an abnormal cardiac rhythm and a discharge is possible.
      • Device should be deactivated & an external defibrillator should be immediately available with placement of external defibrillator pads strongly considered.
    • For a patient with an ICD & who is pacemaker dependent, the EP service should be consulted or in any other cases with pacing concerns.

Intraoperative management

Monitoring and access

  • PIV x 1
  • Standard ASA monitors with 5 lead ECG
  • Single lead EEG

Induction and airway management

  • Induction:
    • Methohexital (Brevital) 0.5 to 1 mg/kg; least effect on Sz threshold
    • Etomidate: 0.2 to 0.3 mg/kg; maintains hemodynamic stability
    • Propofol: ↑ seizure threshold & ↓ seizure duration. Need higher stimulus voltages to achieve adequate seizure. May be useful in patients with history of long seizures.
    • Ketamine: can cause post-ECT confusion.
    • Remifentanil 200-400 mcg as an adjunct to lower dose of methohexital needed; net ↓ Sz threshold. Monitor for ↓HR/↓BP & chest wall rigidity. If unable to ventilate or very small TV, consider succinylcholine.
    • Sevoflurane can be used for inhalational induction when no IV access possible.
  • Paralytic:
    1. Succinylcholine 1- 1.5 mg/kg, titrate to adequate paralysis
    2. Rocuronium - Low dose & only if patient has contraindication to succinylcholine (reverse with sugammadex)
  • Initial PARAsympathetic discharge:
    1. Glycopyrrolate 0.2mg to prevent bradycardia. Usually given prior to induction agents
  • Subsequent Sympathetic discharge:
    1. Nitroglycerin &/or Beta blockers (esmolol, labetalol) can be used to attenuate sympathetic response.
    2. Hyperglycemia often seen in insulin dependent Pt -> BG Pre/Post

Positioning

Supine or with HOB elevated

Maintenance and surgical considerations[1][3]

  • ECT stimulus -> short initial parasympathetic response caused by vagal nerve stimulation followed by a large sympathetic discharge
  • Cardiovascular
    • 1st: Parasympathetic response may cause asystole, bradycardia, PVCs, hypotension, & ventricular escape rhythm.
      • If known profound parasympathetic response, can blunt w/ glycopyrrolate pre-induciton
    • 2nd: Sympathetic tone ↑ with seizure generation -> ↑ HR, PVCs, bigeminy, trigeminy, sinus tachycardia, ST segment changes (↑ myocardial O2 consumption) & severe HTN.
      • Often resolves quickly, but if Pt requires intervention consider nitroglycerin, esmolol, or labetalol
  • Respiratory: Parasympathetic discharge -> at risk for laryngospasm, bronchoconstriction/wheezing
  • Neuro: Initial constriction of cerebral vessels is followed by ↑ cerebral blood flow (1.5–7 times baseline) secondary to ↑ cerebral O2 consumption & ↑BP -> ↑ICP
  • Neuroendocrine: ↑ corticotropin, cortisol, & catecholamines.
    • Effects on glucose levels vary; consider Pre/Post glucose in insulin dependent patients.
  • GI: ↑ intragastric pressure
  • Eye: ↑ intraocular pressure

Emergence

Postoperative management

Disposition

Pain management

Minimal pain

Potential complications

  • Post-ECT Delirium (or if flumazenil given pre-induction): treat with midazolam 1-2mg

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Murray, Michael J, Steven H. Rose, Denise J. Wedel, C T. Wass, Barry A. Harrison, and Jeff T. Mueller. (2015). Faust's Anesthesiology Review. Print. pp. Anesthesia for Electroconvulsive Therapy, 490–492.CS1 maint: multiple names: authors list (link)
  2. ↑ 2.0 2.1 2.2 2.3 Pardo, Manuel, Ronald D Miller (2017). Basics of Anesthesia 7th Edition. Print. pp. 669–671. ISBN 0323401155.CS1 maint: multiple names: authors list (link)
  3. ↑ 3.0 3.1 3.2 ACCRAC (2019-03-13). "Episode 112: Anesthesia for ECT with Christina Miller". ACCRAC Podcast. Retrieved 2021-08-22.

Top contributors: Alexander Jaksic, Tony Wang and Chris Rishel

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