electroconvulsive therapy ECT .presentation

Ect procedure

1. Electroconvulsive therapy

2. Specific objectives definition of ECT understand brief history of ECT evolution discuss indications & contraindications of ECT explain types and technique of ECT discuss pre, intra and post ECT procedure and role of nursing officer understand mechanism of ECT enlist complications and side effects of ECT understand ECT physical set up and team members.

3. Definition ECT therapy is a type of somatic treatment in which electric current is applied to the brain through electrodes placed on the temples of the patient. The passage of the electrical stimulus of 70-150 volts to the brain for 0.1 to 0.5 second to produce a grandmal seizure.

4. Father of Electroconvulsive the rapy ‘ Lucio Carletti’ used First ECT machine

5. Nobel Laureate Paul Greengard suggested the term “Electro cortical therapy”

6. Milestones in the history of convulsive therapy 1500s: Paracelsus induces seizures by oral administration of camphor. 1785- First published report of use of seizure induction to treat mania by using camphor 1934- Ladislaus meduna began new era by IM injection of 25% camphor oil 1938- Lucio Cerletti & Ugo Bini conducted first electrical induction of seizures in catatonic and was successful Termed as EST-Electo shock therapy

7. Contd... 1940- Curare developed for muscle relaxation 1951 - introduction of succinylcholine 1960- seizure activity is necessary for ECT 1970- Right unilateral electrode positioning 1978- APA first task force report on ECT 1988- RCT on ECT Vs Lithium found both are equally effective in mania 1990- APA task force redefined the indications, gave guidelines for consent & standards for training, treatment & privileging of ECT. 2000- Found Rt unilateral ECT is found with fewer cognitive effects and Convulsion is induced with magnetic stimulation by H.S. Lisanby 2001 - Found post ECT pharmacotherapy ↓ relapse

8. Strychnos toxifera ; curare

9. Technique There are two types: Direct ECT: ECT is given in the absence of muscular relaxation & general anesthesia Modified ECT: ECT is modified by drug induced muscular relaxation and general anesthesia

10. Types based on position of electrodes Bilateral ECT: the standard form and most commonly used. One stimulating electrode is placed several centimeters apart over each hemisphere. Each electrode is placed fronto-temporally 2.5-4 cm above the mid- point, on a line joining tragus of the ear and lateral canthus of the eye.

11. 2. Unilateral: electrodes are placed only on one side of the head usually non-dominant side Both electrodes are placed several centimeters apart over the nondominant hemisphere. One stimulus electrode is placed over nondominant frontotemporal area & the other on non dominant centro-parietal scalp just lateral to the midline vertex .

12. The most common approach is unilateral (more favorable adverse effect profile) If not effective even after 4-6 unilateral treatment, bilateral placement is used. Immediate bilateral is indicated in severe depression, marked agitation, suicide risk, manic symptoms, catatonic stupor, Px resistant schiz and risk of anaesthetic adverse effects.

13. Indications ECT as a first-line treatment - febrile catatonia* - malignant neuroleptic syndrome* - severe depressive episode** - schizoaffective psychosis** - schizophrenia**, *** - in case of life-threatening or intolerable side effects of psychopharmacological treatments

14. ECT as a second-line treatment Medication treatment failures in: - depression - schizoaffective psychosis - schizophrenia - mania - depression or psychotic symptoms in case of organic diseases

15. ECT as last-resort treatment - treatment-resistant obsessive compulsive disorder (OCD) - treatment-resistant dyskinesias - treatment-resistant Gilles de la Tourette syndrome - treatment resistant epilepsy - Parkinson's disease (treatment-resistant)

16. General indications Major severe depression: With suicidal risk (first & foremost indication) With stupor With Poor intake of food & fluids With melancholia With psychotic features With Unsatisfactory response to drug therapy Where drugs are contraindicated / have serious side effects

17. General indications (Contd..) 2. Severe catatonia: With stupor With poor intake of food & fluids With unsatisfactory response to drug therapy Where drugs are contraindicated / have serious side effects Where speedier recovery is needed

18. General indications (Contd..) 3. severe psychoses (schizophrenia or mania) With risk of suicide/ homicide or danger of physical assault With unsatisfactory response to drug therapy Where drugs are contraindicated / have serious side effects With very prominent depressive features

19. The 1990 APA Task force suggestions Organic mental disorders (organic mood syndrome, organic hallucinations, organic delusional disorders, and delirium) Medical disorders (organic catatonia, hypopituitarism, intractable seizure disorder, neuroleptic malignant syndrome and parkinsonism)

20. contraindications

21. clinical condition Category Enhanced intracerebral pressure* at present Cerebral infarction not older than 3 months Myocardial infarction* not older than 3 months Intracerebral tumor* including intracerebral edema Any life-threatening anesthesia risk* at present Cardiovascular disorders: Cardiac arrhythmias, CAD, Unstable angina, MI (older than 3 months), hyper-or hypotonia, aortic aneurysm. Medical disorders: Disturbance of blood coagulation, severe liver diseases, severe pulmonary diseases, pheochromocytoma

22. Contraindications (Contd..) Neurological disorders: intracerebral neoplasias/ bleeding/ vascular malformations, cerebral ischemia / inflammations, hydrocephalus, dementias, diseases of the basal ganglia, craniotomies, severe cerebral traumas Orthopedic disorders: osteoporosis Esophageal hernia: increased aspiration risk, intubation recommended Concomitant pharmacological treatment: if enhancing the ECT risks or reducing ECT efficacy

23. PROCEDURE OF ECT

24. Pre treatment evaluation Nurse’s role It consists of the following steps: An informed consent taken from the patient or the guardian Detailed medical and psychiatric history taking, which includes the current and past treatment history General and systemic physical examination Routine laboratory investigations like TC,DC,ESR , Urine routine & microscopic examination, EKG, X-ray chest & skull. Optimal investigations are EEG, estimation of plasma cholinesterase activity for patients who would receive succinylcholine for general anesthesia

25. Pre treatment evaluation: Nurse’s role (Contd..) ECT is usually administered in the morning after an overnight fast. (empty stomach for at least 4 hrs) Medications like benzodiazepines, lithium, clozapine, bupropion, lidocaine which interferes with ECT should be withdrawn before. The bladder (and bowel) should be emptied just before procedure Dentures if present, should be removed and loose teeth should be ruled out Tight clothing, & metallic & sharp objects should be removed Usual aesthetic precautions are taken Patient is placed on a hard bed which is well insulated A slow intravenous drip is started if needed

26. Pre treatment evaluation: Nurse’s role (Contd..) A mouth gag is inserted to prevent tongue bite The place of electrode placement has to be cleaned with NS or 25% bicarbonate solution or a conducting gel is applied.

27. PRE ECT MEDICATIONS

28. Anticholinergic: 0.6 mg of atropine IV is given just before or it is given IM or SC 30 minutes before treatment to decrease oral secretions and vagal stimulation which can cause cardiac arrest Anesthetic agent: like thiopentone 150-250 mg or Methohexital (0.75 to 1.0 mg/kg IV bolus) Muscle relaxant: like succinylcholine 0.5 – 1.5 mg / kg as an IV bolus or drip. An anesthetic mask is placed on the face and ventilation with 100% oxygen is given.

29. Care during procedure-Role of nurse ECT administration is followed by muscular fasciculations which move from above downwards. When fine twitching movements disappear from the lower extremities, it is the time of complete muscular relaxation. Pressure is applied on the mandible to approximate upper and lower teeth till the convulsions stops.

30. Positioning the client for ECT

31. Procedure of giving ECT

32. Therapeutic adequacy: Therapeutic adequacy of the treatment is measured by a generalized tonic clonic seizures lasting for not less than 25-30 secs. This is made sure by: Observing the seizure (in direct ECT) EEG recording during ECT(in modified ECT) Occluding the circulation of one extremity with a B.P apparatus cuff, before giving succinylcholine. Thus the whole body is paralyzed but one extremity convulses and can be observed Observing plantar extension and eyelid contractions, which may be seen despite muscular relaxation (not a very reliable method)

33. Plantar extension

34. Understanding EEG

35. Normal EEG

36. EEG Changes outof ECT

37. Therapeutic adequacy: Therapeutic adequacy of the treatment is measured by a generalized tonic clonic seizures lasting for not less than 25-30 secs. This is made sure by: Observing the seizure (in direct ECT) EEG recording during ECT(in modified ECT) Occluding the circulation of one extremity with a B.P apparatus cuff, before giving succinylcholine. Thus the whole body is paralyzed but one extremity convulses and can be observed Observing plantar extension and eyelid contractions, which may be seen despite muscular relaxation (not a very reliable method)

38. After care-Role of nurse Mouth gag is removed, secretions are sucked from oral cavity and O2 mask is applied Till consciousness is regained, patient is turned to one side to prevent aspiration Vital parameters are constantly monitored till recovery Patient is made to rest, for about 30 minutes to 1 hr on bed.

39. Dose Usual dose for obtaining an adequate seizure response is 90-150 volts for 0.1-1.0 seconds average 0.6 secs. The usual amount of current passed is 200-1600mA.

40. Duration of therapy Duration and total number of treatments depends on the diagnosis, presence of side effects Usually 6-10 treatments can be given MDD - 6 to 12 treatments (although up to 20 are possible) Manic episodes - can take 8 to 20 Schizophrenia - 15 treatments Catatonia and delirium - as few as 1 to 4 treatments

41. Mechanism of action Although exact mechanism is unclear, one hypothesis states that ECT possibly affects the catecholamine pathways PET studies reveal that the degree of decrease in c erebral metabolism (blood flow & glucose use) after ECT is correlated with therapeutic response.

42. ECT itself acts as an anticonvulsant because its administration is associated with an increase in the seizure threshold. ECT changes neurotransmitter receptors activity (recently, changes in second-messenger systems) resulting downregulation of postsynaptic β-adrenergic receptors Some have reported an increase in postsynaptic serotonin receptors, no change in serotonin receptors, and a change in the presynaptic regulation of serotonin release . ECT has also been reported to effect changes in the muscarinic, cholinergic, and dopaminergic neuronal systems.

43. Side effects Deaths during ECT are due to general anesthesia. Mortality rate is 0.002% per treatment and 0.01% for each patient. Memory disturbances both anterograde and retrograde & recovery occurs within 1-6 months Confusion in post-ictal phase Other side effects include headache, prolonged apnea, prolonged seizures, CV dysfunction, emergent mania, muscle aches, apprehension

44. Complications Life threatening complications are rare ECT does not cause brain damage Fractures can occur in elderly clients Respiratory arrest in clients with h/o heart disease, dysarythmias

45. Treatment facilities There should be a suit of three room: A pleasant waiting room (pre ECT room) ECT room equipped with ect machine, suction apparatus, face mask, oxygen cylinder, tongue depressor, mouth gags, resuscitation apparatus, emergency drugs. Immediate access to defibrillator 3.A well equipped recovery room

46. ECT team Psychiatrist Anesthesiologist Trained nurse Aides

47. Multiple-Monitored Electroconvulsive Therapy (MMECT) Giving multiple ECT stimuli during a single session, most commonly two bilateral stimuli within 2 minutes. This approach may be warranted in severely ill patients and in those at especially high risk from t he anesthetic procedures .

48. Other brain stimulation methods Repeated transcranial magnetic stimulation (rTMS) Vagal nerve stimulation Deep brain stimulation