ECT
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Electro Convulsive Therapy (This contains details of indication, contraindications of ECT)
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ECT
- 1. ECT K. Kavindya M. Fernando JMJ 1
- 2. ECT • Safe and effective • Rapid onset of action • Safe in elderly, if patient is fit for anesthesia • It should be considered in resistance cases, cause increasing doses may develop more side effects JMJ 2
- 3. Indications for ECT • 1st choice in patients with severe depression who have suicidal ideations • Effective in unipolar and bipolar depression • Effective in acute mania • Not the 1st line treatment • Indicated when there is severe agitation with poor response to medication JMJ 3
- 4. Indications for ECT • Schizophrenia • Not the 1st line treatment • Used only in poor response to medication • Schizo with positive & affective symptoms predict good response to ECT • In catatonia, benzodiazepine is the tx of choice • If not respond to benzodiazepine within 48-72 hrs • ECT should consider JMJ 4
- 5. Indications for ECT • Safe in pregnant patients • Take precausions to ensure proper hydration • Prevent use of unnecessary treatment JMJ 5
- 6. Indications for ECT • Severe depression with risk to life due to high suicidal risk or poor food and fluid intake • Poor response to antidepressants • Depression with psychotic features • Inability to tolerate antidepressants (especially in the elderly) • Puerperal psychosis • Catatonia • Neuroleptic malignant syndrome • Mania with poor response to medication JMJ 6
- 7. Contraindications for ECT • ECT is a safe treatment • According to the American Psychiatric Association guidelines • Mortality 1/10 000 • American Society of Anesthesiologists • Categorizes patients into 5 subgroups • By preoperative physical fitness JMJ 7
- 8. Contraindications for ECT • Pre ECT physical status evaluation recommended in • Unstable angina • Heart failure • Chronic obstructive airway disease • Asthma • Diabetes • Other physical illness JMJ 8
- 9. Contraindications for ECT • These patients may consider unfit for anesthesia if they have • Uncontrolled hypertension • Cardiac failure • Arrythmias • Respiratory tract infections JMJ 9
- 10. Contraindications for ECT • ECT contraindicated in patients who have had, • Myocardial infarction during the past 6 months • Raised inctracaranial pressure • Aneurysms • Recent cerebral infarction • ECT safe in • Pregnancy • Elderly • ECT rarely used in children and young people below the age of 18 JMJ 10
- 11. Pre ECT evaluation • Evaluation of physical condition • History, examination • Evaluate oral condition • Use of denature • If any condition detected, need specialized opinion JMJ 11
- 12. Pre ECT evaluation • Investigations • ECG • Chest Xray • Full blood count • Serum electrolytes • Fasting blood sugar (If diabetic) • Echo cardiogram in elderly & those with cardiac problems JMJ 12
- 13. Pre ECT evaluation • Evaluation by anesthetist • All patients should be assessed • MSE and scales to monitor progress • Baseline MSE needed prior ECT • Help in monitoring the patient • For more objective assessment use • Hamilton Rating Scales for depression • Brief Psychiatric Rating Scales JMJ 13
- 14. Pre ECT evaluation • Obtain written informed consent • ECT – an invasive procedure • For consent to be valid several criteria must be fulfilled JMJ 14
- 15. Pre ECT evaluation • History • Physical examination • Appropriate investigations • Other investigations depending on the physical status • Mental state examination • Scales to monitor progress • Evaluation by the anaesthetist • Obtaining written informed consent JMJ 15
- 16. Pre ECT preparation • Patient should have a bath previous day • Jewelry, hair accessories, contact lens, glasses, hearing aids, dentures • Should be removed • Hair should be clean • Keep the patient nil orally from 10 pm – previous night • Patient should not eat and drink prior ECT JMJ 16
- 17. Pre ECT preparation • Omit benzodiazepine on previous day • As it can increase the threshold level • Patients with HPT • May require morning medication • Which can be given 1 hour before ECT with a sip of water • Empty bladder and bowel before ECT JMJ 17
- 18. Facilities for ECT • Administer in a separate room with facilities for resuscitation • Patients awaiting ECT • Kept in a separate room JMJ 18
- 19. Electrode placement • Site of electrode placement • Must be cleaned well using alcohol-shocked gauze squares • If parietal side is used for unilateral ECT • Hair can be parted and cleaned • Conductive ECT gel is applied on to electrode • Electrodes must be firmly pressed against the skull to minimize impedance JMJ 19
- 20. Electrode placement • Bilateral (Bitemporal) placement • More commonly • The midpoint of the electrode is placed 1 inch above the midpoint • on an imaginary line drawn • between the external canthus of the eye, • and the tragus of the ear JMJ 20
- 21. Electrode placement • Unilateral placement • Electrode placed over the non-dominant hemisphere (generally the right) • Advantages • Less memory loss and confusion • May be less effective • In d’Elia placement • One electrode in the frontotemporal position on the R side • Other – over the parietal cortex JMJ 21
- 22. Administration of ECT • Short acting general anesthesia – IV • Propofol is preferred • Rapid recovery • Less hangover effect • Thiopental sodium – can also be used • Once the patient is unconscious • a muscle relaxant is administered • Common – succinylcholine • It dampens the tonic clonic movement of the seizure • Reduce the risk of musculoskeletal injury JMJ 22
- 23. Administration of ECT • Stimulant dose is calculated • Based on seizure threshold • Seizure threshold can be depend on • Age, gender, medication & previous ECT • During administration • Monitor Heart rate, BP, ECG, Oxygen saturation JMJ 23
- 24. Administration of ECT • Seizure should be monitored • Seizure duration should also be monitored • Seizure duration of 20 seconds is adequate for good clinical effect JMJ 24
- 25. Post ECT monitoring • Once seizure terminates • Continuous monitoring – needed • Patient’s vital signs are monitored every 15 minutes until stable • Most patients will require 6-8 ECTs • ECT can administer 2-3 times aweek JMJ 25
- 26. Post ECT monitoring • Adverse effects • Cardiac complications (arrhythmias) • Post ictal delirium following ECT • This causes disorientation & agitation • Risk factors – bilateral electrode placement, high intensity stimulation, pre-existing cerebral impairment • Patients recover within 45 minutes • Memory impairment –common • Muscle stiffness • Headache • Nausea JMJ 26