Electroconvulsive therapy

 

https://academic.oup.com/bjaed/article/10/6/192/299664

 

Procedure:

·        Unilateral or bilateral probe

·        Ideal seizure duration unknown. <10 seconds too short, >2 mins too long

·        Repeated twice weekly for 3-4 weeks

 

Indications:

·        Depression

·        Bipolar

·        Schizophrenia

 

Contraindications:

CVS

·        Phaeochromocytoma*

·        Recent AMI (3/12)

·        Severe coronary artery disease

·        Severe cardiac disease (e.g. AS, PHTN)

CNS

·        Raised ICP*

·        Recent CVA (3/12)

·        Untreated aneurysm

·        Space occupying lesion

·        Retinal detachment

·        Glaucoma

·        Cochlear implant (can do contralateral)

MSK

·        Unstable fracture

·        Pathological lesion

·        Osteoporosis

*Absolute contraindication

 

Effects:

 

CVS:

Effects

If not paralysed: valsavla manoeuvre

 

Mild PSNS:

·        First 10-15 seconds

·        ↓HR, ↓BP, salivation

Major SNS:

·        Next several mins, peak 3-5 mins

·        ↑HR 20%, ↑SBP 30-40%, ↑MvO2

Risks

·        PSNS: bradyarrhythmia, asystole

·        SNS: tachyarrhythmia, AMI

 

CNS:

Effects

·        Seizure

·        ↑CMRO2, ↑CBF, ↑ICP

Risks

·        Status epilepticus

·        Emergence agitation

·        Bleed

·        Ischaemia

·        Cognitive dysfunction

 

MSK:

Effect

·        Attenuated seizure

·        Myalgia, weakness

Risks

If not paralysed:

·        Fracture

·        Dislocation

·        Dental damage

·        Fall off table

·        Injury to staff

 

Issues:

·        Effects of seizure: CVS, CNS, MSK

·        Remote environment anaesthesia

·        Psychiatry patient: ±involuntary, ±distressed

 

Assessment:

Questions

·        Any consent issues?

·        Any contraindications to ECT?

·        Appropriate for remote environment?

·        What is my induction plan?

Hx

·        Prev ECT anaes record

·        PMHx: CVS, CNS, MSK

·        Meds: NRI, SRI, etc

·        Fasting status, reflux, exercise tolerance

Ex

·        A: incl dental

·        B

·        C

Ix

·        ±Serum biochem (if using sux)

·        ±ECG (if risk factors)

 

Anaesthesia:

Prepare

·        Access: PIVC

·        Monitoring: SpO2, NIBP, ECG

·        Emergency drugs: atropine, adrenaline, amiodarone

·        Emergency equipment: airway, IV giving set, defibrillator

·        Personnel: anaes assistant

Induce

·        Drugs: alf 10mcg/kg + prop 1mg/kg + sux 1.5mg/kg
(IRL: use the cocktail from last time)

·        Airway: BMV + bite block

 

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