Anaesthesia for ELECTROCONVULSIVE THERAPY/ECT

INDICATION, C/I SIDE EFFECTS

1. DR.ZIKRULLAH

2. Introduction to ECT
History
Indications
Practicalities
Side Effects
Anaesthesia for ECT
Patient factors –Hx/ Exam / Ix
Venue / Equipment
Conduct
Induction / Muscle relaxation
Recovery

3. It is a treatment for severe mental illness in
which brief application of electrical stimulus
is used to produce genaralized seizure.
ECT induces a generalized, tonic–clonic
epileptic seizure, yet despite being first
described in 1937 the exact mechanism of
action remains elusive.

4. 1934 Von Meduna –Insulin
induced seizures for
schizophrenia
1937 Cerletti and bini–
Electric shock induced
seizures
For almost 30 year it was
used without anaesthesia.
Safer (Mortality 2-5 : 100
000)

5. Life threatening illness
Sever depression-if drug tt fail or is not tolerated.
Bipolar disorder-manic or depressed phase.
Acute or catatonic schizophrenia.
Refusal of food / fluids
Depressive delusions / hallucinations
Prolonged / severe manic episode
Treatment resistance
Depression
Mania
Schizophrenia (4
th
line treatment)
Patient choice

7. In-or out-patients
First / repeat visit
Consent
ECT suite
Anaesthetic
Equipment
ECT machine
EEG monitor
Electrode placement
Dosing / duration
Anaesthetic
Recovery / Home

8. ABSOLUTE-
CVS-
-Recent MI<3mths
-Sever angina, CHF
-Aneurysm
-Pheocromocytoma
CNS-
-Cerebral tumor or
aneurysm
-Recent CVA<1mth
RESPIRATORY-
Severe resp. failure

9. RELATIVE-
-Pregnacy
-Thyrotoxicosis
-Cardiac
dysrythmias
-Glaucoma
-Retinal
detatchment

10. An electrical current applied transcutaneous
to brain via two electrode positioned either
bilaterally or unilaterally.
BILATERAL ECT-used more commonly and
preferred when speed of clinical recovery
take priority.
UNILATERAL ECT-performed on nondominant
hemisphere.
-it performed twice weekly until lack of
further improvement( on average 3-4 week)

12. Genaralizedseizure for 30-60s in duration
are required for therapeutic effect.
-To short(<10s) or to long(>120s) may
reduce clinical efficacy.
-Amount of current deliverdis more
important than length of seizure.
-Almost 75-90% ptexhibit dramatic and
sustained improvement.
-Transient neurological deficit but permanent
neurological deficit is rare.

13. Initial parasympathetic discharge(15 s )
-Coincident with tonic phase
-Bradicardia<30 bpm
-Transient asystole
-Sustained sympathetic discharge(1-3min)
-Coicidentwith clonicphase
-Tachycardia
-Hypertension
-dysarrythmiasand T wave abnormalities.

14. CNS-
Initial vasoconstriction.
Sustained increase in cerebral blood flow.
Increase cerebral metabolism.
Increase intracranial HTN.
TIA,intracranialhaemorrhage,cortical
blindness.
Cognitveadverse effects-disorientation,
impaired attention, Short term memory
loss.
-Intraocular and intragastricpressure rises.

15. Unmodified ECT-Incidence of fracture and
dislocation( now rare).
-Headache ,myalgia.
-Drowsiness,weakness, nausea , anorexia.
-Increased salivation.
-Dental damage and oral cavity laceration.

16. Procedure should be provided at remote site.
Anaesthesia should be provided by
experienced anaesthetist.
Appropriate resuscitation equipment drugs
must be immediately available.
-Trained assistance and recovery facilities
must be available.

17. Routine Hx
Previous AnaesHx
IHD / MI / HT /
Valvularpathology /
Dysrhythmias
CVA / Raised ICP
HH / GORD
Diabetes
Medications
Drugs / Alcohol

18. Behaviour
Airway (incl
wobbly teeth)
Vitals
Routine
Examination
Ix only as needed

19. Uncontrolled CCF
DVT (untreated)
Acute respiratory tract infection
Recent MI / CVA
Unstable major fracture
Untreated phaeochromocytoma
Raised ICP / untreated cerebral aneurysm

20. ECT Suite –Remote site !
Resuscitation equipment
Experienced Anaesthetist
Minimum mandatory
monitoring +/-PNS
Tilting trolley / padded cot
sides
Flow controlled oxygen supply
+ suction
Anaesthetic / Emergency
drugs
Airway / Circuits / Disposables
Mouth guards
EEG machine / ECT machine
Staffed recovery area
Written records

21. IV access
Monitoring
Pre-oxygenation
IV induction
Muscle relaxant
Mouth block
Seizure induction
Recovery

22. To provide ultra brief, light general
anaesthesia with moderate degree of
musle relaxation.
Minimizing aforementioned physiological
and physical effect.
Avoiding drug having anticonvulsant
properties.
Balance b/w to provide adequte
anaesthesia without affecting efficacy of
ECT.

23. Rapid unconciousness.
Painless on injection.
No hemodynamics effect.
No anticonvulsant properties.
Rapid recovery.
Inexpensive.
CONT.

24. Methohexitol-0.5-1mg/kg
Thiopental -2-4mg/kg
Ketamine -0.5-2mg/kg
Propofol -1.5-3mg/kg
Etomidate -0.15-0.3mg/kg

25. Gold standard.
Methylbarbiturate.
White powder with 6% anhydrous sodium
carbonate.
Induction similar to STP.
Less cvsand respiratory depression than STP.
Recovery within 3-4 min after single dose.
S/E-
-Pain on injection.
-causes convulsion in epileptic pt.
-incidence of involuntary movement, hiccup
and laryngospasm.

26. Phenol derivative.
Widely used.
Increase seizure threshold, reduces duration.
Better cardiovascular stability.

27. Imidazole derivatives.
Greater hemodynamic response.
Longer seizure duration.
Useful in resistant cases.
PONV/HP axis suppresion.

29. Objective-
to prevent injuries to musculoskeletal system.
to improve airways management.
adequecyof muscle relaxation should be
ascertained before applying ECT stimulus.
Cont.

30. Suxamethonium–0.5-1mg/kg
Atracurium-0.3-0.5mg/kg
Mivacurium-0.15-0.2mg/kg
Rocuronium-0.45-0.6mg/kg

31. Adequate no. of trained personnel.
Should be Fully equipped
O2 until awake and maintaining Saturation.
Written instructions

32. ECT is safe and effective if appropriately
administered.
-Anaestheticsmust be aware of not only
physiological response to ECT and how to
modify this, but also understand the
anaestheticfactors that may influence the
efficacy of ECT.

33. THANKS