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APPENDICES FOR THE
POLICY AND PROCEDURE FOR THE ADMINISTRATION OF
ELECTRO-CONVULSIVE THERAPY (ECT)
Authors
Dr Jane Shapleske
Dr Jorge Zimbron
Dr Tesema Taye
Sponsor
Medical Director
Responsible committee/individual
Clinical Executive Committee
Ratified by
Quality & Performance Committee
Date ratified
January 2014
Date issued
22 July 2013
Review date
December 2015
Version
3.0
If developed in partnership with
another agency, ratification details
of the relevant agency
N/A
Signed on behalf of the Trust:………………………………
Aidan Thomas, Chief Executive
Elizabeth House, Fulbourn Hospital, Fulbourn, Cambs CB21 5EF Phone: 01223 726789
Page 1 of 84
Version Control Sheet
Version
Date
Author
1.0
23.10.09
Luka Mhishi
Annalise Owen
Paul Collin
2.0
22.07.2013 Dr Jane
Shapleske,
Dr Jorge Zimbron,
and Dr Tesema
Taye
Comments
Policy ratified by Quality &
Healthcare Governance
Committee
Updated to reflect the new
Divisional structure of the Trust
and on the latest research
evidence found in the third
edition of the ECT Handbook by
the
Royal
College
of
Psychiatrists.
Page 2 of 84
Contents
Note: This is a separate document that supports the policy.
ECT Protocols / Appendices
Management of vulnerable patients
Appendix 1
ECT Facilities
Appendix 2
ECT Equipment specification
Appendix 3
Recommended Drug Stock list
Appendix 4
Staff and Responsibilities
Appendix 5
Unilateral versus bilateral ECT
Appendix 6
Discontinuation ECT
Appendix 7
Continuation/Maintenance ECT
Appendix 8
Emergency ECT
Appendix 9
Guidelines for Outpatient/Day Patient ECT
Appendix 10
Responsible Adult Information Leaflet
Appendix 11
Out patient ECT Information
Appendix 12
ECT Information Leaflet
Appendix 13
ECT Anaesthesia Information leaflet
Appendix 14
ECT and the MHA 2007 for adults over 18
Appendix 15
ECT and the MHA 2007 for under 18’s
Appendix 16
Consent Form 1
Appendix 17
Patients without capacity to consent (Form 4)
Appendix 18
Revised assessment of capacity Form
Appendix 19
Form T4
Appendix 20
Form T5
Appendix 21
Form T6
Appendix 22
Form CTO11
Appendix 23
Variance to Medication due to ECT and Medication Plan
Appendix 24
Guidelines for Routine Preoperative Tests
Appendix 25
Anaesthesia and ECT protocol
Appendix 26
Malignant Hyperthermia Management Protocol
Appendix 27
Dantrolene Protocol
Appendix 28
Management of Acute Anaphylaxis Protocol
Appendix 29
ECT Prescription form (example)
Appendix 31
Page 3 of 84
ECT Protocols / Appendices
Pre-ECT nursing checks (example)
Appendix 32
Stimulus Dosing Protocol (Thymathron IV and DGx)
Appendix 33

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Establishing treatment dose
Quality and timing of the seizure
When to re-stimulate after partial or missed seizure
Inadequate seizures
Prolonged seizures
Tardive seizures
Dose titration
Correcting impedance
Anaesthetic record (example)
Appendix 34
ECT record (example)
Appendix 35
Post ECT Nursing Observation Chart (example)
Appendix 36
Post ECT Monitoring Protocol
Appendix 37
Page 4 of 84
Appendix 1
PROTOCOL FOR MANAGEMENT OF VULNERABLE PATIENTS
ECT for Older patients
 Co-existing medical and surgical conditions should be assessed, stabilised and
treated
 Early referral for an Anaesthetic review is recommended
 Treating psychiatrist should be aware of the increased likelihood of higher seizure
thresholds for older patients
 Close monitoring of the older patient’s physical health and cognitive during a course
of ECT should be a priority
 Cognitive function should be assessed at least 24 hours after ECT to avoid
contamination of post-ictal effects
 Older people may be more susceptible to confusion after ECT thus you may need to
modify the ECT technique to minimise the cognitive side effects (e.g. unilateral ECT
or reduced frequency i.e. once a week and avoid substantially supra-threshold
electrical doses)
 The older patient may recover more slowly from ECT
 Patients with depression and dementia can be given ECT but they may be at
increased risk of post-ECT delirium. The symptoms include confusion, restlessness,
repetitive motor movements, poor response to simple commands, retrograde
amnesia. This may respond to benzodiazepines.
ECT for Younger patients
 Used with caution due to lack of evidence in RCT’s
 For a person under 16, two independent opinions should be sought from child and
adolescent psychiatrists. One opinion from a child and adolescent psychiatrist is
sufficient with 16-17 year olds, because there is more literature documenting the
safety and efficacy for this age group.
 Stop all non-essential medications used by patient due to reports of increased
length of seizures and post-ECT convulsions
 Stimulus dosing should take into account lower seizure thresholds in younger
people
 Where it is not possible to obtain informed consent, ECT should only be given when
the patient’s life is at risk from suicide/ depressive illness.
 Involve parents during consent process whenever possible.
ECT during pregnancy
 Obtain and obstetric and anaesthetic opinion before referral for ECT
 Routine foetal monitoring (after 1st trimester) before and after each treatment is
required
 Consider intubation because of increased risk of regurgitation particularly after 1st
trimester
 Probably needs to take place in main theatres.
ECT in patients with Intellectual Disability
 ECT is not contra indicated in patients with intellectual disability.
 Sever depressive disorder, lack of response to oral treatments or evidence of
previous good response to ECT may all indicate likely benefit from ECT.
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
Indications are similar as to those for other patient groups with an emphasis being
placed on achieving appropriate consent.
There being little of evidence from randomised controlled trials in patients with
intellectual disability it is appropriate to consider ECT only in carefully selected
cases
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Appendix 2
SPECIFICATION FOR ECT CLINIC FACILITIES
The ECT clinic facilities will comply with the ECTAS standards.
1. A separate comfortable quiet area with access to toilet facilities.
2. A treatment room with easy access to a telephone with up to date protocols on
cardiac arrest anaphylaxis and malignant hyperthermia are prominently displayed,
has a work surface and sink with hot and cold water and a clock with a second
hand, secure drug storage cupboard and a small drug fridge with a lock. Speech
cannot be heard from the waiting area. Staff in treatment room are able to speak
directly to staff in the recovery room. Good illumination and ventilation.
3. Recovery area Large enough to accommodate throughput of patients on
trolleys/beds with additional space top maneuver and has a doorway large enough
to take a trolley from the treatment room.
4. A post-ECT waiting area designed with a suitable, friendly and relaxed environment
with provision for refreshments for patients.
5. Office - there should also be an ECT office where staff and telephone conversations
cannot be overhead. It will have a telephone and computer and a filing cabinet.
Page 7 of 84
Appendix 3
SPECIFICATION FOR ECT CLINIC EQUIPMENT
The following equipment will be available in the ECT clinic in accordance with the
ECTAS standards:
Standard Equipment
 A tipping trolley with cot sides that can be padded or bed per patient position of
which can be adjusted.

Fully equipped emergency trolley.
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A Non-Invasive Blood Pressure (NIBP) monitoring machine or sphygmomanometer
and stethoscope to monitor blood pressure.
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An aural thermometer to measure temperature.
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Resuscitation equipment (including a defibrillator) in case of a cardiac arrest.

Positive pressure respiration: oxygen cylinder, mask and self-inflating bag and at
least one full spare cylinder in both the treatment and recovery areas.

At least one suction machine in treatment room.
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At least one suction machine with Yankauer ends and soft suction catheters in
recovery room. (If only one is available, treatment of a patient does not start until
the previously treated patient is conscious, as assessed by the recovery nurse or
anaesthetist).

A pulse oximeter pulse oximeter to determine oxygen saturation.
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A capnograph to measure end-tidal carbon dioxide levels in respired gases.

There is an ECG monitor.

Provision is made for assessing neuromuscular blockade, maintaining anaesthesia,
ventilation and monitoring in the event that transfer to a Critical Care Area is
needed.

Glucometer to test blood sugar concentration.

A moving and handling sheet to help turn patient.
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Weighing scales to weigh patients.
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Log-book of patients receiving ECT.
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Blank checklists.
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A system of resupply of disposables such as gloves, syringes, needles, cannulae,
tape, electrodes, airways and mouth guards should be established.

Approved containers for the safe disposal of contaminated material in accordance
with the Trust infection control policy.
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Containers for personal belongings.
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A secure drug storage cupboard and a small fridge.

A Bain or Waters circuit will be needed to support ventilation.

Airway circuits should be checked for function and patency before use.
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Reusable airway equipment should incorporate disposable filters.
Page 8 of 84
ECT Machine
 Two constant-current, brief-pulse ECT machines (one used as a backup) in each
clinic. The ECT machines should be capable of providing stimuli according to
current guidelines with settings that may be altered easily and quickly and has a
wide range of treatment settings (able to deliver a wide range of electrical dose 25
to 1000 mC).

Two channel EEG monitoring facility integrated into the ECT machine.
Emergency/resuscitation equipment
The emergency/resuscitation equipment should include the following:

A selection of airways, laryngoscopes, a range of endotracheal tubes and
connectors, a bougie and laryngeal masks.

Single-use ‘difficult airway’ boxes with equipment for managing respiratory
emergencies such as pneumothorax or upper-airway obstruction should be stocked.

A selection of intravenous (IV) fluids, giving sets, pressure infuser and drip stand
will be available.

Cardiac arrest and other emergency drugs will be supplied in single-use containers
as per locally agreed contents.

A defibrillator, which should be checked (and this recorded) before each session.

Resuscitation guidelines will be available in each ECT suite.

Periodic emergency-resuscitation ‘drills’ practised.
Page 9 of 84
Appendix 4
RECOMMENDED DRUG STOCK LIST


An anaesthetic induction agent: Thiopental, Propofol and alternatives
A muscle relaxant: Suxamethonium and alternative

Oxygen

There is a standard tray of drugs for use in the event of cardiac arrest

The emergency tray contains drugs and equipment agreed with the local pharmacy
or the Trust resuscitation committee

Dantrolene, plus sterile water. If not stored in the ECT clinic this should be stored
within 5 minutes of the clinic and there is a protocol in the clinic for where it is stored

Atropine, Glycopyrrolate, Midazolam as agreed with ECT Anaesthetist

A supply of drugs needed to treat other unwanted autonomic, cardiovascular,
respiratory or neurological effects is available as agreed with the ECT Anaesthetist.
Page 10 of 84
Appendix 5
STAFF AND RESPONSIBILITES
Role of the ECT Team Leader/Lead Nurse
 Contributing to ECT nursing policy and ensure that it is adhered to.

Be a Registered Mental Health Nurse.

Be responsible for running the department, recording information, managing the
patient booking system, equipment safety and maintenance, ordering and storing
medication, suite preparation prior to treatment and co coordinating the services of
the anaesthetist, recovery nurse, consultant psychiatrist and ward nursing staff.

Be responsible for all aspects of nursing care within the department.

Be supported by other nursing staff working within the ECT clinic who will take over
their duties when the team leader or lead nurse is on leave.

Ensure they are up to date with current and National policies, procedures and
Guidelines on ECT.

Represent the ECT nursing staff at any committees as required.

Be responsible for the training of nursing staff in relation to ECT and its provision.

Develop effective evidence based interventions.
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Act as a resource for patients, carers, staff and others in relation to ECT.

Supervise and manage junior staff as appropriate.

Will actively liaise with user and carer groups to enhance their knowledge and
awareness of the service.
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Deliver a cost effective service making optimum use of existing resources.
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Assist in the recruitment and induction of new staff as required.

Produce activity and outcome reports as required.
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Participate in Governance initiatives, including audit, research and evaluation of the
ECT service.
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Ensure clinical areas are maintained to the required standard.
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Participate in the management and investigation of incidents, accidents, complaints
and untoward incidents as required.
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Foster close relationships with wards and other relevant personnel

Ensure legal and ethical issues are adhered to correctly.
The ECT Nurse
 Is responsible for planning and co-ordinating the clinic session.

Undertakes the following equipment checks before each ECT clinic session:

Check emergency resuscitation equipment.
Page 11 of 84

Check emergency drugs tray for any out of date drugs and missing items and
replace them before each ECT clinic session.
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Check electrodes visually before each ECT clinic session.
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If the machine does not self-check, check the electrical safety of the ECT machine
and record prior to each ECT session, including the testing of delivery dose.

Plans the arrival times of patients by liaising with the wards and the outpatient
department to minimise waiting time and will ensure that the waiting time is no
longer than half an hour.

Checks that all the required documentation has accompanied patient including:
o The patient’s consent form.
o Mental Health Act documentation.
o A copy of any other supporting documentation relating to consent e.g. capacity
assessment or SOAD documentation.
o The patient’s pre ECT assessment including medical examination, drug history
and other investigations.
o ECT prescription form (Appendix 31).
o ECT file/booklet.

Checks that all pre ECT paperwork and documentation is correct.

Ensures that inpatients are escorted from the waiting room through ECT and
recovery and back to the ward by a registered nurse who is known to the patient
and is aware of the patient’s legal and consent status and has an understanding of
ECT.

Ensures that before ECT is administered, the patient is given any further information
they may need. The ECT nursing staff will explain the procedure to the patient
again, gives reassurance and spends time with relatives answering questions where
applicable.

Provides information about the safekeeping of valuables, location of toilets and
arrangements for further appointments.

Carries out and records health and safety checks before each treatment (Appendix
32). These include:
o The patient’s identity is checked and the patient wears an identity bracelet.
o The patient is asked when he or she last ate and last drank and this should
concord with the length of time required for 'fasting' agreed with the local
anaesthetic department.
o All metal objects are removed from the patients hair and the patient is asked if
he/ she is wearing any make up or nail polish, or whether he/ she has lacquer
or cream in his/ her hair.
o The patient will be asked to remove his/ her dentures which will be kept safe in
an individualized container.
o The patient’s record will be checked to confirm that he/ she is not allergic to
anything effecting the treatment or anaesthetic. The patient will also wear an
allergy bracelet if appropriate.
o The ECT nursing staff will take and record the patient’s blood pressure, pulse,
temperature and weight and the patient is encouraged to empty their bladder.

Checks that the referring psychiatrist prescribes no more than two treatments at a
time before reviewing and renewing the prescription.
Page 12 of 84
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Introduces the patient to the treating team.
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Keeps all treatment records up to date.
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Provides nursing care to patients during the ECT process.
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Recovers the patient and ensures that there is one more trained recovery nurse
than there are unconscious patients.
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Ensures activity logbook is completed.
The Treating Psychiatrist
Checks consent prior to ECT and whether patient requires any further information.
 Explains what he/ she is going to do and why.

Ensures there is adequate contact /impedance (Appendix 33) between the
electrodes and the scalp of the patient.

Checks anaesthetist is satisfied with anaesthetic level of patient before proceeding
with treatment.

Follows the guidelines in the stimulus dosing protocol (Appendix 33). These will be
displayed in the ECT suite.

Ensures that an adequate seizure is induced i.e. that the seizure induced is a
typical generalised tonic convulsion (Appendix 33).
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The duration is monitored by the direct observation of the resulting motor effects
and two-channel EEG monitoring.
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Completes Treatment Record (Appendix35) and retain the EEG tracing.
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Ensures that any recommendations are communicated with the clinical team.

Sign activity logbook.
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Remains in hospital until all patients fully recovered.
Anaesthetist
 Checks that there have been no problems with previous anaesthesia.

Checks consent, pre-ECT health and safety checks including fasting time.

Follows the ECT Anaesthesia protocol (Appendix 26) including:
o Cannulation of patient.
o Administration of induction agent and muscle relaxant.
o Hyperventilates patient.
o Inserts mouth guard.

Checks mouth after treatment to ensure all teeth and crowns still in situ and no
bites.
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Ensures patient fully conscious and maintaining airway.
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Completes anaesthetic record.
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Signs activity logbook.
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Remains immediately available until the last patient is fit for discharge.
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Duties of the ECT Recovery Nurse
 The recovery nurse must be trained in post anaesthesia recovery techniques,
airway maintenance and the use of emergency equipment. These skills should be
practised regularly and updated.
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Accepts patients from the treatment room.
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Provides reassurance to the patient.
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Ensures that an airway is maintained until the patient is fully conscious.

Monitors oxygenation, pulse, blood pressure and oxygen saturation (SO2) until
patient is stable.
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Administers oxygen as prescribed by the anaesthetist.

Performs oropharyngeal suction as required.

Follows any instructions which may be issued by the anaesthetist to maintain
patient safety.

Contacts the anaesthetist if the patients’ clinical condition is unsatisfactory in any
way.

Removes intravenous cannulae when the patient is adequately recovered.

Helps the recovered patient to the 2nd stage recovery areas so that they may
receive light refreshment.

Completes the orientation checklist and assists with orientating the patient to their
surroundings.

Completes the recovery checklist (Appendix 36).

Prior to each clinic checks the recovery trolley is stacked, checks monitoring
equipment and oxygen supply is in working order.

Ensures the patient is provided with an appropriate escort back to their ward or
home as appropriate.
Role of the Consultant with responsibility for ECT
 Ensures he/she keeps up to date with new developments in ECT and undertake
additional training as necessary.

Represents the Trust Medical staff on ECT matters.

Takes a key role in the planning and developments within the service.

Appraises medical colleagues of any developments within ECT services.

Ensures that a junior doctor is available to carry out every ECT session.

Ensures that medical colleagues are adequately trained in the appropriate use of
ECT.

Ensures that ECT equipment and medical procedures are kept up to date and are in
line with the Royal College of Psychiatrists recommendations.
Page 14 of 84
Role of the Responsible Clinician (RC)
 Ensures patients are given adequate information about ECT.

Considers NICE guidance on ECT. If patients have conditions which are not
supported by NICE guidelines then they will document the reason for variance in the
case notes and may consider an internal second opinion.

Decides if the patient can give informed consent.

Clearly documents capacity assessment.

Obtains informed consent from the patient.

Ensures junior medical staff under his/her supervision understand relevant
procedures for obtaining consent, carrying out physical examinations/ investigations
and administering treatment.

Ensures the correct procedures are followed for patients who are receiving
treatment under the Mental Health Act 1983.

Ensures the progress of the patient is reviewed after every ECT procedure and
prescribes no more than two treatments at a time on the treatment record. Capacity
to consent should be reviewed between each session for non-capacitous patients
being treated under the MCA. If the patient regains capacity they should be
consented.

Ensures the patients cognitive function is monitored prior to, during and after a
course of ECT.
Duties of the ward junior doctor
 Explains the reason for and the process of ECT to patients.

Carries out adequate physical examinations/investigations.

Informs the anaesthetist of any physical concerns about physical health of the
patient.
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Updates any physical examinations as necessary.

In consultation with the RMO reduces/discontinues any medications which are likely
to affect fit threshold.

Completes a medication pan and attaches to the drug chart.

Carries out regular mental state examinations of patients having ECT and records
these in patients’ notes after every treatment.
Duties of ward nursing staff
 Ensures that the patient has had nothing to eat or drink from midnight before
treatment.

Administers essential oral medication with minimal amount of water.

Checks medication plan for any variance to treatment and timing.

Completes the pre treatment memory assessment.

Escorts the patient to the treatment suite- This must be a registered nurse who is
familiar to the patient.
Page 15 of 84
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Ensures that staff do not escort more than one patient at a time.

Ensures that all relevant documentation has been completed and accompanies the
patient.

Ensures that the patient has used the toilet prior to treatment.

Ensures the patient has no hairspray, make up or nail varnish on.

Provides a comprehensive handover of information about the patient to the clinic
staff, raising any concerns if appropriate.

Remains with the patient during ECT and post ECT to offer support and
reassurance.

Assists the ECT nurse as necessary.

Liaises with the clinical team as to when the patient may leave the department.

Reports relevant observations to the nurse in charge of the ward.
Page 16 of 84
Appendix 6
UNILATERAL VERSUS BILATERAL ECT PROTOCOL
There is no ideal electrode placement for ECT.
Unilateral ECT
Unilateral (UL) ECT is preferred when minimising cognitive adverse effects takes
priority. When treatment is non-urgent an initial trial of UL ECT will significantly shift the
cost-benefit balance because of the substantial reduction in the risk of severe and
persistent retrograde amnesia.
UL ECT will also be preferred where:
 The rate of clinical improvement is not critical
 There is a history of recovery with UL ECT
When the initial course is UL ECT, review the prescription after 4 treatments. Lack of
satisfactory clinical improvement may lead to an increase in dose or to a switch to
bilateral electrode placement.
Right UL ECT is preferred for people who are consistently right handed.
In left handed people or where cerebral dominance is hard to decide:
 BL electrode placement might be preferred.
 Alternatively, and empirical trial may be made when the time to reorientation is
compared between right- and left sided treatment at consecutive treatment
sessions.
Position:
The position is described in the figure below and is called the temperoparietal – or d’Elia
position. The exact position on the parietal arc is not crucial. The aim is to maximise the
distance between the electrodes to reduce shunting of electrical current and to choose a
site on the arc where the electrode can be applied firmly and flat against the scalp.
Temporal position (left) and temporalparietal position (right)
Bilateral ECT
Bilateral (BL) ECT is preferred when rate or completeness of recovery has priority as
well as:
 Where the index episode of illness or an earlier episode of illness has not been
adequately treated by UL ECT.
 Where determining cerebral dominance is difficult.
 In the treatment of mania (probably preferable as optimum UL treatment in mania
not yet established).
Position:
The centre of the electrode should be 4 cm above, and perpendicular to, the midpoint of
a line between the lateral angle of the eye and the external auditory meatus. This
position is known as bi-temporal ECT.
Page 17 of 84
Appendix 7
DISCONTINUING ECT
The extent of clinical improvement over the first few treatments is closely correlated
with the extent of eventual improvement.
If no clinical improvement is seen after 6 adequate treatments, it is highly unlikely
that more treatment will bring about either significant clinical improvement or eventual
recovery and therefore treatment should stop. The consultant responsible for ECT
should discuss this with the referring consultant.
It may be reasonable to give up to 12 treatments to patients who display definite but
slight or temporary improvement over the first few treatments – a small but significant
minority of depressed patients respond fully to treatments beyond the eighth of a
course, having shown only modest improvements with earlier treatments.
A significant minority of severely depressed patients may require substantially more
than 12 treatments.
In patients who have switched from unsuccessful unilateral treatment to bilateral
ECT, it is reasonable to discount the previous UL treatments and to assess their
need for treatment afresh using the same principles as for BL ECT as there is some
evidence that those who recover subsequently with BL ECT require a similar number
of treatments to those initially treated with BL ECT from the out set.
Page 18 of 84
Appendix 8
CONTINUATION AND MAINTENANCE ECT
Definition:
Continuation ECT – prophylactic ECT to prevent relapse
Maintenance ECT – prophylactic ECT to prevent further episodes (outside NICE
guidelines)
Indication:
Continuation ECT should be considered for patients with relapsing or refractory
depression which has previously responded well to ECT but for who standard
pharmacological and psychological continuation treatment is ineffective or
inappropriate. Continuation ECT should be considered when:
 The index episode of illness responded well to ECT.
 There is early relapse despite adequate continuation drug treatment, or an inability
to tolerate continuation drug treatment.
 The patient’s attitude and circumstances are conducive to safe administration.
Before commencing continuation ECT:
 Ensure the diagnosis is correct.
 ECT has proven to have been of benefit.
 Alternative options have been adequately explored.
 It is good practice to seek a second opinion from a colleague, preferably from one
with experience in ECT.
 Full work-up as for acute ECT.
 Determine which symptoms would indicate a relapse – this information helps to
determine the frequency of treatment.
 Consider concurrent medications that may interfere with longer term treatment.
 Full baseline psychometric assessment should be carried out.
Example of continuation ECT regime:
 Give as acute ECT until clinical response is achieved.
 Reduce to weekly.
 Reduce to every 10 days.
 Reduce to every 2 weeks.
 Reduce to every 3 weeks.
 Reduce to monthly
Review:
 As for acute ECT plus.
 Monthly MMSE.
 Full anaesthetic review every 6 months.
 Full repeat of all psychometric tests every 12 months.
 Written consent should be renewed every 6 months
Stopping:
Since relapse is most likely in the first 12 months after recovery it may be wise to
continue for at least 1 year. If the goal had been to prevent relapse (continuation ECT),
it is reasonable to terminate the treatment at this stage. If the aim was to prevent further
episodes, the treatment should theoretically be continued indefinitely.
Page 19 of 84
Appendix 9
EMERGENCY ECT
Definition:
Any ECT which needs to be given outside the normal ECT sessions necessitating
extraordinary arrangements for delivery of the treatment.
The decision to treat a patient with ECT without delay will usually be taken by the
consultant responsible for the patient.
Procedure:
a) When a decision to treat a patient with ECT without delay has been made during
working hours, the junior doctor from the treating team will make the arrangements
listed below and if possible carry out the treatment. If the junior doctor from the
treating team is not able to carry out the treatment because of other clinical
commitments or outside working hours this will be the responsibility of the duty
doctor for psychiatry. The treating team should liaise with the duty doctor. If there is
any doubt about the competence, confidence or experience of the junior doctor, the
RMO should ensure that he/she is supervised by a clinician familiar with ECT.
b) The ECT Lead consultant needs to be informed of the arrangements by the treating
team at the earliest opportunity.
c) The junior doctor from the treating team or the duty doctor (where appropriate), will
need to liaise with the anaesthetic department and agree on a suitable time and
place for treatment to take place.
d) The junior doctor from the treating team or duty doctor (where appropriate) will
inform the ward of the arranged time.
e) The patient should be escorted by a nurse/nurses with an appropriate level of skills
and accountability.
Page 20 of 84
Appendix 10
OUT-PATIENT ECT
Definition of outpatient ECT
The patient having ECT will be returning home within 2-4 hours of receiving ECT.
Pre-ECT preparations
1. The decision to give OP ECT should be discussed with the Lead ECT
Consultant.
2. The ECT session including arrangements for transport and escorts should be
booked in the normal way.
3. Patients should be physically relatively fit and healthy.
4. Outpatient ECT is relatively contra-indicated in the following groups:
a.
b.
c.
d.
Grossly obese patients (30% of the recommended weight).
Patients with severe respiratory and cardiovascular disease.
Patients with imperfectly controlled diabetes.
Patients who are 75 years old or over.
If outpatient ECT is being considered in these patients, the patient must be seen
by the ECT anaesthetist before the first ECT session and the first session must
be as an inpatient. The ECT anaesthetist will decide on whether subsequent
sessions can be offered as an outpatient.
5. ALL patients should have had a full medical history and a full physical
examination in the week
BEFORE the first outpatient ECT session. All findings and treatment plans
should be documented in the ECT file, special investigations carried out and
results filed and consent forms completed. A brief admission to hospital prior to
the first treatment may be the best way of ensuring all of the above is done.
6. Blood tests, ECG and chest x-ray should be available as appropriate (refer to
Routine Pre-ECT Tests Protocol).
7. A letter should be sent to the GP informing him/her of the proposed treatment.
8. A responsible adult (see definition below) who will stay with the patient for 24
hours after treatment, needs to be identified. The responsible adult and patient
should be asked to sign a disclaimer form (page **) before each treatment to
confirm that they are aware of all the important information and accept this role.
9. The patient should be given an OP ECT information card and advised to bring
this with them to each treatment session.
10. The patient should be given fasting and medication advice.
11. The patient will be given an ECT a Medication Plan.
12. The patient should be advised to be at the clinic at the appointed time so that
consent can be checked, pre-ECT checklist can be completed and patient can be
prepared for the treatment.
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Post-ECT precautions
1. Discharge criteria used:
a) Stable vital signs
b) Tolerating oral fluids
c) Alert and oriented
d) Walking unaided
e) Responsible adult* accompanying the patient
f) No patient should be discharged less than 2 hours after ECT treatment
*A responsible adult is a person over the age of 17 years who understands and is
adequately informed of the potential problems with ECT, and is able to fully consent and
take responsibility for the care of the patient in the first 24 hours after ECT i.e. they must
be with the patient overnight following the treatment.
2. The patient should be seen by a doctor to establish whether the patient is medically
and mentally fit to leave and if so this should be recorded in the hospital records. If
the patient is not medically fit to leave but insists on doing so they need to sign an
‘against medical advice’ discharge form. If the patient is not mentally fit to be
discharged, compulsory admission under the MHA may be indicated.
3. Patients should have adequate housing conditions and indoor toilet facilities if they
are going home.
4. The patient and the responsible adult are informed and should agree that the
patient for 24 hours after the ECT will not:
a. Cook.
b. Drive (including cycling).
c. Operate any form of machinery (including electric kettles and microwaves).
d. Drink alcohol.
e. Sign important documents e.g. wills and cheques.
5. The patient should be reviewed by the treating team at least as regularly as
inpatients.
6. At the end of the course of treatment, a letter should again be sent to the GP
detailing the treatment, outcome and follow-up plans.
Page 22 of 84
Appendix 11
OUTPATIENT ECT – RESPONSIBLE ADULT INFORMATION LEAFLET
Definition:
A responsible adult is a person over the age of 17 years who Understands and is
adequately informed of the potential problems with ECT, and is able to fully consent and
take responsibility for the care of the patient in the first 24 hours after ECT i.e. they must
be with the patient overnight following the treatment.
Before ECT
The evening before their next treatment, the patient should not eat any food after
midnight, and take fluids and tablets or medicines only as agreed with their hospital
doctor according to the medication plan.
Medication Plan
The patient should be given an ECT Medication Plan that explains the variation to the
regular prescription that may be needed because of the ECT.
Day of ECT
The patient needs to arrive at …………………………..Ward by ……………..(fill in time).
After ECT
The patient will be discharged by a doctor when fully fit to leave the ward. The doctor is
required to sign the patient’s OP ECT information card. The responsible adult, patient
and MH worker are required to sign the responsible adult disclaimer form after every
treatment.
For 24 hours after ECT the patient should not:
 Cook
 Drive (including cycling)
 Operate any form of machinery (including electric kettles and microwaves)
 Drink alcohol
 Sign important document e.g. wills, cheques etc.
What to do if you are worried
If the patient suffers any serious side-effects, then contact their own general practitioner
in the first instance and pass on the information on their OP ECT information card.
If you, or the patient, have any concerns relating to the treatment or if the patient
develops a cold or physical illness, then the ward staff should be contacted. The
information will be passed on to their hospital doctor.
Contact number Ward:………………………………………..
Page 23 of 84
OUTPATIENT ECT RESPONSIBLE ADULT DISCLAIMER FORM
I understand and accept the role of responsible adult to ensure post ECT care for
(patient’s name)……………………………….. during the proposed course of Out patient
ECT for up to 12 sessions. This role has been fully explained to me by ………………
and an information leaflet has been given to me.
Date
Session
Patient
Responsible
Signature
Adult Signature
MH worker
1
2
3
4
5
6
7
8
9
10
11
12
This card needs to accompany patient to each treatment
At the end of the course a copy needs to be retained in the patient’s notes
Page 24 of 84
Appendix 12
OUTPATIENT ECT INFORMATION CARD (for patient)
Name:…………………………………………………Date:…………………………………..
Hospital Number:…………………………………….Ward:………………………………...
Consultant:……………………………………………Key worker:…………………………
Ward doctor:………………………………………….Ward tel. number:…………………..
You are currently receiving a course of electroconvulsive therapy which may be up to 12
sessions. Each treatment involves a general anaesthetic; therefore you should not do
any of the following for at least 24 hours after the treatment:
 Cook
 Drive (including cycling)
 Operate any form of machinery (including electric kettles and microwaves)
 Drink alcohol
 Sign important documents/ cheques
You should have another responsible adult to remain with you for the first 24 hours
after treatment. If you suffer any serious side-effects, then contact your own general
practitioner in the first instance and pass on the information on this sheet. If you have
any concerns relating to your treatment or develop a cold or physical illness, then
contact the ward. The information will be passed on to your hospital doctor.
The evening before your next treatment, please remember to not to eat any food after
midnight, and take fluids, tablets or medicines only as directed by
your hospital doctor.
Any specific instructions given:
…………………………………………………………………...…..……………………………
……………………………………………………………………………………………………
…………………………………………………………………………………
Session
Date
Discharging doctor’s signature
1
2
3
4
5
6
7
8
9
PLEASE bring this card with you each time you attend for treatment.
At the end of the course of ECT a copy needs to be retained in the patient’s notes
Page 25 of 84
Appendix 13
INFORMATION ON ECT (ELECTROCONVULSIVE THERAPY)
1.
INTRODUCTION
This leaflet is adapted from the Royal College of Psychiatrists information on ECT
for patients their relatives and staff who want to know more about ECT. It
discusses how ECT works, why it is used, its effects and side-effects, and
alternative treatments.
ECT remains a controversial treatment and some of the conflicting views about it
are described. If your questions are not answered in this leaflet, there are some
references and sources of further information at the end of the leaflet.
Where there are areas of uncertainty, other sources of information that you can
use are listed. Important concerns are the effectiveness and side-effects of ECT
and how it compares with other treatments.
2.
WHAT IS ECT?
ECT is a treatment for a small number of severe mental illnesses. It was originally
developed in the 1930s and was used widely during the 1950s and 1960s for a
variety of conditions. It is now clear that ECT should only be used in a smaller
number of more serious conditions.
ECT consists of passing an electrical current through the brain to produce an
epileptic fit – hence the name, electro-convulsive. The idea developed from the
observation that, in the days before there was any kind of effective medication,
some people with depression or schizophrenia, and who also had epilepsy,
seemed to feel better after having a fit. According to the Royal College of
Psychiatrists research suggests that the effect is due to the fit rather than the
electrical current.
3.
HOW OFTEN IS IT USED?
ECT is now used less often. Between 1985 and 2002 its use in England more than
halved, possibly because of better psychological and drug treatments for
depression.
4.
HOW DOES ECT WORK?
No-one is certain how ECT works, and there are a number of theories.
Many doctors believe that severe depression is caused by problems with certain
rain chemicals. It is thought that ECT causes the release of these chemicals and,
probably more importantly, makes the chemicals more likely to work and so help
recovery.
Recent research has suggested that ECT can stimulate the growth of new blood
vessels in certain areas of the brain.
Page 26 of 84
5.
DOES ECT REALLY WORK?
It has been suggested that ECT works not because of the fit, but because of all the
other things – like the extra attention and support and the anaesthetic – that
happen to someone having it.
Several studies have compared standard ECT with "sham" or placebo ECT. In
placebo ECT, the patient has exactly the same things done to them – including
going to the ECT rooms and having the anaesthetic and muscle relaxant – but no
electrical current is passed and there is no fit. In these studies, those patients who
had standard ECT were much more likely to recover, and did so more quickly than
those who had the placebo treatment.
Those who didn't have adequate fits did less well than those who did. Interestingly,
a number of the patients having "sham" treatment recovered too, even though they
were very unwell; it's clear that the extra support has an effect. However, ECT has
been shown to have an extra effect in severe depression – it seems, in the short
term, to be more helpful than medication.
6.
PROS & CONS OF ECT
6.1 Who is ECT likely to help?
The National Institute of Health and Clinical Excellence (NICE) have looked in
detail at the use of ECT and have said that it should be used only in severe
depression, severe mania or catatonia. ECT is most often used for severe
depression, usually only when other treatments have failed.
6.2 Who is ECT unlikely to help?
ECT is unlikely to help those with mild to moderate depression or most other
psychiatric conditions. It has no role in the general treatment of schizophrenia.
6.3 Why is it given when there are other treatments available?
It would normally be offered if:





several different medications have been tried but have not helped
the side-effects of antidepressants are too severe
you have found ECT helpful in the past
your life is in danger because you are not eating or drinking enough
you are trying to kill yourself
6.4 What are the side effects of ECT?
ECT is a major procedure involving, over a few weeks, several epileptic seizures
and several anaesthetics. It is used for people with severe illness who are very
unwell and whose life may be in danger. As with any treatment, ECT can cause a
number of side-effects. Some of these are mild and some are more severe.
Page 27 of 84
6.4.1 Short-term
Many people complain of a headache immediately after ECT and of aching in their
muscles. They may feel muzzy-headed and generally out of sorts, or even a bit
sick.
Some become distressed after the treatment and may be tearful or frightened
during recovery. For most people, however, these effects settle within a few
hours, particularly with help and support from nursing staff, simple pain killers and
some light refreshment.
There may be some temporary loss of memory for the time immediately before
and after the ECT.
Older people may be quite confused for two or three hours after a treatment. This
can be reduced by changing the way the ECT is given (such as passing the
current over only one side of the brain rather than across the whole brain).
There is a small physical risk from having a general anaesthetic – death or serious
injury occurs in about 1 in 50,000 treatments – less than the risks in childbirth.
6.4.2 Long-term
The greater concern is that of the long-term side effects, particularly memory
problems. Surveys conducted by scientists and clinical staff usually find a low level
of severe side-effects, maybe around 1 in 10. User-led surveys have found much
more, maybe in half of those having ECT. Some surveys conducted by those
strongly against ECT say there are severe side-effects in everyone.
Some difficulties with memory are probably present in everyone receiving ECT.
Some people – some would say many – also have problems with memory for past
events, even very significant ones such as the birth of a child. Most people find
these memories return when the course of ECT has finished and a few weeks
have passed. However, some people do complain that their memory has been
permanently affected, that their memories never come back. It is not clear how
much of this is due to the ECT and how much is due to the depressive illness or
other factors.
Some people have complained of more distressing experiences, such as feeling
that their personalities have changed, that they have lost skills or that they are no
longer the person they were before ECT. They say that they have never got over
the experience and feel permanently harmed.
What seems to be generally agreed is that the more ECT someone is given, the
more it is likely to affect their memory.
6.5 What if ECT is not given?
 You may take longer to recover.
 If you are very depressed and are not eating or drinking enough, you may
become physically ill or die.
 There is an increased risk of suicide if your depression is severe and has not
been helped by other treatments.
Page 28 of 84
7. WHAT ARE THE ALTERNATIVES?
If someone with severe depression refuses ECT there are a number of
possibilities. The medication may be changed, new medication added or intensive
psychotherapy offered, although this should already have been tried. Given time,
some episodes of severe depression will get better on their own, although being
severely depressed carries a significant risk of suicide.
8.
DECIDING TO HAVE (OR NOT TO HAVE) ECT
8.1 Giving consent to having ECT
Like any significant treatments in medicine or surgery, your doctor will ask you to
give consent, or permission for the ECT to be done.
The ECT treatment, the reasons for doing it and the possible benefits and sideeffects will be explained in a way that you can understand. If you decide to go
ahead, you then sign a consent form. It is a record that ECT has been explained to
you, that you understand what is going to happen, and that you give your consent
to it. However, you can withdraw your consent at any point, even before the first
treatment.
8.2 What if I really don’t want ECT?
If you have very strong feelings about ECT, you should make them known to the
doctors and nurses caring for you, but also friends, family or other advocates who
can speak for you.
Doctors must consider these views when they think about what to do.
If you have made it very clear that you do not wish to have ECT then you should
not receive it. It may be helpful to write an ‘advance directive’ to make clear how
you want to be treated if you become unwell again.
9.
CAN ECT BE GIVEN TO ME WITHOUT MY PERMISSION?
Most ECT treatments are given to people who have agreed to it. This means that
they have had:
 a full discussion of what ECT involves
 why it is being considered in their case.
 the advantages and disadvantages
 a discussion of side-effects.
It is the responsibility of the doctors and nurses involved to make sure that this
discussion has been had – and to document it.
Sometimes, however, people become so unwell that they are unable to take on
board all of the issues – perhaps because they are severely withdrawn or have
ideas about themselves that stop them fully understanding their position (e.g they
believe what is happening to them is a punishment they deserve).
Page 29 of 84
In these circumstances, it may be impossible for them to give proper agreement or
consent. When this happens, it is still possible to give ECT. The legal provisions
for this differ from country to country, even within the United Kingdom.
In England and Wales the patient must first be assessed by their own GP (family
doctor) and a social worker, and then must have a second opinion from an
independent specialist who is not directly involved in their care. The clinical team
should also speak to family and other carers, to consider their views and any
views the patient may have expressed before. So, if someone is judged to lack
the ability to give consent, it is possible to give them ECT even if they are refusing
it. In 2002 about 1
in 6 people who had ECT were judged to be not able to give consent to it, but it is
not clear how many of these were actively refusing.
10.
HOW IS ECT GIVEN?
ECT should only used to treat severe illnesses, so usually the person having it will
be in hospital, although a few people have found it helpful to have ECT as day
patients.
The seizure is made to happen by passing an electrical current across the
person’s brain in a carefully controlled way from a special ECT machine.
An anaesthetic and muscle relaxant are given so that:
 the patient is not conscious when the ECT is given;
 the muscle spasms that would normally be part of a fit – and which could
produce serious injuries - are reduced to small, rhythmic movements in the
arms, legs and body.
By adjusting the dose of electricity, the ECT team will try to cause a seizure
between 20 and 50 seconds long.
11. IS THERE ANY PREPARATION?
In the days before a course of ECT is started, your doctor will arrange for you to
have some tests to make sure it is safe for you to have a general anaesthetic.
These may include:
 a chest X-ray
 a record of your heart working (ECG)
 blood tests
You will be asked not to have anything to eat or drink for 6 hours before the ECT.
This is so that that the anaesthetic can be given safely.
12. WHERE IS ECT DONE?
Cambridge:
ECT is done in the Day surgery Unit at Addenbrooke’s Hospital.
Peterborough: ECT is done in the ECT Suite at the Cavell Centre
Page 30 of 84
There are separate rooms for people to wait, have their treatment, wake up fully
from the anaesthetic and then recover properly before leaving.
There are enough qualified staff in the clinic to look after the person all the time
they are in the clinic so that anyone confused or distressed can be helped.
13. WHAT HAPPENS DURING ECT?
The patient will arrive at the ECT suite with a trained nurse who is known to the
patient and who is able to explain what is happening. ECT suites are happy for
family members to be there. You will be met by a member of the ECT staff who
will carry out routine physical checks if these have not already been done. The
staff member will check that the patient is still willing to have ECT and if they have
any further questions.
When the patient is ready they will be accompanied into the treatment area and be
helped onto a trolley.
The anaesthetist and anaesthetic assistant will connect monitoring equipment to
check your heart rate, blood pressure, oxygen levels, etc. You may also be
connected to an EEG machine, to check the brain waves.
A needle will then be put into a vein normally at the back of your hand, through
which the anaesthetist will give the anaesthetic drug and, once you are asleep, a
muscle relaxant. While you are going off to sleep, the anaesthetist will also give
you oxygen to breathe.
Once you are asleep and fully relaxed a doctor will give the ECT treatment. The
muscle relaxant wears off quickly (within a couple of minutes) and, as soon as the
anaesthetist is happy that you are waking up, you will be taken through to the
recovery area where an experienced nurse will monitor you until you are fully
awake.
When you wake up, you will be in the recovery room with a nurse. He or she will
take your blood pressure and ask you simple questions to check on how awake
you are. There will be a small monitor on your finger to measure the oxygen in
your blood and you may wake up with an oxygen mask. You will probably take a
while to wake up and may not know quite where you are at first. You may feel a bit
sick. After half an hour or so, these effects should have worn off.
 The ECT units have a second area for light refreshments. The person will
leave the suite when their physical state is stable and they feel ready to do so.
 The whole process usually takes around half an hour.
14. WHAT ARE BILATERAL AND UNILATERAL ECT?
In bilateral ECT, the electrical current is passed across the whole brain; in
unilateral ECT, it is just passed across one side. Both of them cause a seizure in
the whole of the brain.
Bilateral ECT seems to work more quickly and effectively and it's probably the
most widely used in Britain; however, it seems to cause more side effects.
Page 31 of 84
Unilateral ECT has fewer side-effects, but may not be as effective; it is also more
difficult to do properly.
Sometimes ECT clinic will start a course of treatment with bilateral ECT and switch
to unilateral if the patient experiences side-effects. Alternatively they may start with
unilateral and switch to bilateral if the person isn’t getting better.
14. HOW OFTEN AND MANY TIMES IS ECT GIVEN?
ECT in the Trust is given twice per week on Mondays and Thursday, or Tuesday
and Friday. It is impossible to predict how many treatments someone will need.
However, in general, it will take 2 or 3 treatments before any effect is seen, and 4
to 5 treatments for noticeable improvement.
A course will, on average, be 6 to 8 treatments, although as many as 12 may be
needed. If someone has shown no response at all after 12 treatments it is unlikely
that ECT is going to help. A doctor will see the person after each treatment and
their consultant will see them after every two. ECT is stopped as soon as the
person has made a recovery or if they say they don't want to have it any more.
15. WHAT HAPPENS AFTER A COURSE OF ECT?
Even when someone finds it effective, ECT is only a part of recovering from
depression. Like antidepressants, it can help to ease problems so that the sufferer
is able to look at why they became unwell. Hopefully they can then take steps to
continue their recovery and perhaps find ways to make sure the situation doesn’t
happen again. Psychotherapy and counselling can help and many sufferers find
their own ways to help themselves. Certainly people who have ECT, and then do
not have other forms of help, are likely to quickly become unwell again.
16. THE ECT CONTROVERSY
There are many areas in which people disagree over ECT, including whether it
should even be done at all. People tend to have very strong feelings about ECT,
often based on their own experiences. The main areas of disagreement are over
whether it works, how it works and what the side effects are.
17. WHY IS ECT STILL BEING GIVEN?
ECT is now used much less and is mostly a treatment for severe depression. This
is almost certainly because modern treatments for depression like psychotherapy
(talking treatments), antidepressants and other psychological and social supports
are much more effective than they were in the past.
Even so, depression can for some people still be very severe and life-threatening,
with extreme withdrawal and reluctance, or inability to eat, drink or communicate
properly. Occasionally people may also develop strange ideas (delusions) about
themselves or others. If other treatments have not have worked, it may be worth
considering ECT.
Page 32 of 84
19.
WHAT DO PATIENTS THINK OF ECT?
A UK review of a number of studies in 2003 found that the proportion of people
who had had ECT and found it helpful ranged from a low of 30% to a high of over
80% in another. The authors commented that studies reporting lower satisfaction
tended to have been user-led, those reporting higher satisfaction tended to have
been doctor-led. In both user and doctor-led studies between 30% and 50%
complained of memory loss.
20. WHAT DO THOSE IN FAVOUR OF ECT SAY?
Many doctors will say that they have seen ECT relieve very severe depressive
illnesses when other treatments have failed. Bearing in mind that 15% of people
with severe depression will kill themselves, they feel that ECT has saved patients'
lives, and so that the overall benefits are greater than the risks. Some people who
have had ECT will agree and may even ask for it if they find themselves becoming
depressed again.
21. WHAT DO THOSE AGAINST ECT SAY?
There are many different views and many different reasons why people object to
ECT. Some say that ECT is an inhumane and degrading treatment, which belongs
to the past. They say that the side-effects are severe and that psychiatrists have
either accidentally or deliberately ignored how severe they can be. They say that
ECT permanently damages both the brain and the mind, and if it does work at all,
does so in a way that is ultimately harmful for the patient. Many would want to see
it banned.
22. WHAT HAPPENS IN OTHER COUNTRIES?
At the moment, ECT is part of standard psychiatric practice in Britain and the
majority of countries worldwide. Some countries (and some states in America also)
have restricted its use more than in the UK.
23. HOW DO I KNOW IF ECT IS DONE PROPERLY LOCALLY?
The Royal College of Psychiatrists has set up the ECT Accreditation Service
(ECTAS) to provide an independent assessment of the quality of ECT services.
ECTAS sets very high standards for ECT, and visits all the ECT units who have
registered with it. The visiting team involves psychiatrists, anaesthetists, nurses
and lay people. It publishes the results of its findings and also provides a forum
for sharing best clinical practice. All Trust ECT clinics have acquired ECTAS
accreditation.
24. WHERE CAN I GET MORE INFORMATION?
The Internet has many sites discussing ECT that are produced by professionals,
organisations, people who have had ECT, or others with particular opinions.
(Updated by January 2009).
Page 33 of 84
FURTHER INFORMATION
National Institute for Health and Clinical Excellence (NICE)
Electroconvulsive therapy (ECT): the clinical effectiveness and cost effectiveness of
electroconvulsive therapy (ECT) for depressive illness, schizophrenia, catatonia and
mania.
Electroconvulsive Therapy Accreditation Services (ECTAS)
Launched in May 2003, ECTAS aims to assure and improve the quality of the
administration of ECT; awards an accreditation rating to clinics that meet essential
standard.
www.rcpsych.ac.uk/crtu/centreforqualityimprovement/electroconvulsivetherapy.aspx.
REFERENCES PROVIDED BY THE ROYAL COLLEGE OF PSYCHIATRISTS
Ebmeier, K. et al (2006) Recent development and current controversies in depression.
Lancet, 367, 153-167
Eranti,S. V. & McLoughlin, D.M (2003) Electroconvulsive therapy - state of the art. the
British Journal of Psychiatry 182: 8-9
Rose, D., Fleischmann, P., Wykes, T., Leese, M. & Bindman, J. (2003) Patients'
perspectives on electroconvulsive therapy: systematic review, BMJ 2003;326;13631368
Scott A.I.F. (2004) The ECT Handbook (Second edition): The Third Report of the Royal
College of Psychiatrists’ Special Committee on ECT. Royal College of Psychiatrists:
London, UK ECT Review Group. (2003)
Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic
review and meta-analysis. Lancet 361: 799-808
Department of Health Statistical survey (2007) Electro Convulsive Therapy: Survey
covering the period from January 2002 to March 2002, England. DH: London
http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/StatisticalWorkAreas/Statisti
calhealthcare/DH_4000216
This leaflet was adapted from that produced by the Royal College of Psychiatrists'
Public Education Editorial Board. 7
Page 34 of 84
Appendix 14
ANAESTHESIA INFORMATION LEAFLET FOR ECT
All electro-convulsive therapy will be carried out under a General Anaesthetic. This
means that you will be in a state of controlled unconsciousness, during which you will
feel and remember nothing.
Technique
When you arrive in the procedure room, the pulse and blood pressure monitors will be
connected and you will be introduced to the anaesthetist.
Anaesthesia is usually started by an injection into the needle placed in a vein. You will
be kept unconscious for as long as the therapy takes.
At the end of the procedure, you will return to consciousness.
During the procedure, the anaesthetist will monitor your body’s reactions to the
anaesthetic and therapy and will make sure your breathing is satisfactory.
At the end of the therapy, you will be taken to the Recovery Ward, where the nursing
staff will take care of you until you are fully awake and comfortable.
After effects
Any residual dizziness or drowsiness will usually disappear within an hour of your
therapy. If you are feeling sick, please let the attending nurse know so they can give you
appropriate medication.
For a day or so after your therapy, you may find you tire easily, and your concentration
may not be as good as usual. You should not drive for at least 24 hours, and should
take great care with everyday things like cooking and crossing the road.
Risks and complications
Modern anaesthesia is extremely safe. Very rarely, life threatening complications such
as a serious allergy reaction to the drugs used, or equipment failures, or nerve damage,
can happen. There are about 5 deaths for every million anaesthetics given in the UK,
and are usually caused by a combination of several complications; people with chronic
ill health are at slightly higher risk. It is also very rare, but not unknown, for people to
regain consciousness before the therapy has ended. Damage to your teeth, lips or
tongue can occur, but only rarely.
Page 35 of 84
Appendix 15
ECT and the MHA 2007 for adults over 18 years
Patient considered for ECT
Aged 18 plus
Informal,
incapable of
consenting
Informal, capable
of consenting,
and patient
consents
Provisions of the
MCA are followed;
in best interest of
patient
Age less
than 18
Detained
and
Consenting
Clinician in
charge or
SOAD certifies
capable of
consent
Detained but not
capable of
consent
SOAD certifies not
capable of consent,
treatment appropriate, no
advance decision, and
not against wishes of
Donee or CoP
Form T6
Form T4
An informal patient
who has the capacity
to give informed
consent but who
declines ECT cannot
be given ECT against
their wishes
See flow diagram for
under 18 year olds
(Appendix16)
Give ECT
Section 62
IF NONE OF THE ABOVE
APPLY THEN ECT CANNOT
BE GIVEN
Detained patient over the age of 18
who is not consenting or capable of
giving consent where:Treatment immediately necessary to
save the patients life or
Immediately necessary to prevent
an immediate deterioration in patients
condition
And Clinician in charge certifies the
same and requests SOAD
Page 36 of 84
Appendix 16
ECT and the MHA 2007 flowchart for under 18s
Patient considered for ECT
Age less than 18
Consenting to the
treatment (whether
informal or detained)
SOAD certifies
capable of consent
and that treatment
is appropriate
Detained
patient lacks
capacity
Not detained
patient lacks
capacity
SOAD certifies lack of
capacity, that
treatment is
appropriate,
no refusal by deputy
or COP
ECT can be given
if SOAD
authorises it
Form T6
SOAD
completes
Form T6
SOAD
Completes
Form T5
Patient over 16
MCA
provisions
applied (best
interest
and IMCA if
needed)
Patient under
16
Court order,
Parental
responsibility
or other
authority in
place?
Give ECT
Section 62
Detained patient under the age of 18 who is not
consenting or capable of giving consent where:Treatment immediately necessary to save the
patients life or
Immediately necessary to prevent an immediate
deterioration in patients condition
And Clinician in charge certifies the same and
requests SOAD
Page 37 of 84
Appendix 17
CONSENT FORM 1
Patient Agreement to Electroconvulsive Therapy (ECT)
Patient details (or pre-printed label)
Patient’s surname/family name__________________________________
Patient’s first names__________________________________________
Date of birth ________________________________________________
Responsible health professional _________________________________
Job title_____________________________________________________
NHS number (or other identifier) ________________________________
Male
Female
Special requirements__________________________________________
(e.g. other language/other communication method)
Top copy of form accepted by patient: Yes/no (delete as appropriate)
1
Page 38 of 84
Patient Identifier/Label
A course of Bilateral/Unilateral (please delete as appropriate) Electro-convulsive
therapy up to a maximum of________treatments is prescribed.
(This section must be completed. If a number is not stated then treatment will not
be given)
STATEMENT OF CONSULTANT
I have explained the procedure to the patient. In particular, I have discussed:
The intended benefits and likelihood of success (describe)_________________
___________________________________________________________________
________________________________________________________________
Serious or frequently occurring risks associated with ECT and Anaesthesia including:
Tooth injury
Sore throat
Nausea and vomiting
Muscle pains +/ headache
Memory Problems
Small incidence of severe complications
________________________________________________________________
________________________________________________________________
I have also discussed what the procedure is likely to involve, the benefits and risks
of any available alternative treatments (including no treatment) and any particular
concerns of this patient (describe)
____________________________________________________________________
____________________________________________________________________
Top copy of form accepted by patient: Yes/no (delete as appropriate)
Page 39 of 84
Patient Identifier/Label
I have explained that this procedure will involve:
general anaesthesia
muscle relaxation
benzodiazepines
The following leaflet has been provided
ECT Factsheet
Signed______________________________Date________________________
Name (PRINT)____________________________________________________
Job title_________________________________________________________
STATEMENT OF INTERPRETER (where appropriate)
I have interpreted the information above to the patient to the best of my ability and in
a way in which I believe s/he can understand.
Signed__________________________Date ____________________________
Name (PRINT)____________________________________________________
Top copy of form accepted by patient: Yes/no (delete as appropriate)
Page 40 of 84
Patient Identifier/Label
STATEMENT OF PATIENT
Please read this form carefully. If your treatment has been planned in advance, you
should already have your own copy of page 2 which describes the benefits and risks of
the proposed treatment. If not, you will be offered a copy now. If you have any further
questions, do ask – we are here to help you. You have the right to change your mind
at any time, including after you have signed this form.
I agree to the procedure or course of treatment described on this form.
I understand that you cannot give me a guarantee that a particular person will perform
the procedure. The person will, however, have appropriate experience.
I understand that I will have the opportunity to discuss the details of anaesthesia with
an anaesthetist before the procedure, unless the urgency of my situation prevents this.
(This only applies to patients having general or regional anaesthesia.)
I understand that any procedure in addition to those described on this form will only
be carried out if it is necessary to save my life or to prevent serious harm to my health.
I have been told about additional procedures which may become necessary during
my treatment. I have listed below any procedures which I do not wish to be carried
out without further discussion.
Patient’s Signature _________________Date______________________
Name (PRINT) ______________________________________________
A witness should sign below if the patient is unable to sign but has indicated his
or her consent.
Young people/children may also like a parent to sign here.
Signed___________________________Date______________________
Name (PRINT) ______________________________________________
Top copy of form accepted by patient: Yes/no (delete as appropriate)
Page 41 of 84
Patient Identifier/Label
Confirmation/Withdrawal of Consent (Administering Psychiatrist to obtain consent
before each subsequent ECT treatment)
I have confirmed with the patient that she/he has no further questions and wishes ECT
to proceed. I have explained that she/he may withdraw consent at any time.
Treatment No 1
Signed__________________________Date __________________
Name (PRINT)____________________Job Title________________
Treatment No 2
Signed__________________________Date __________________
Name (PRINT)____________________Job Title________________
Treatment No 3
Signed__________________________Date __________________
Name (PRINT)____________________Job Title________________
Treatment No 4
Signed__________________________Date __________________
Name (PRINT)____________________Job Title________________
Treatment No 5
Signed__________________________Date __________________
Name (PRINT)____________________Job Title________________
Treatment No 6
Signed__________________________Date __________________
Name (PRINT)____________________Job Title________________
Page 42 of 84
On completion top copy of form accepted by patient: Yes/no (delete as
appropriate)
Treatment No 7
Signed__________________________Date ___________________
Name (PRINT)____________________Job Title________________
Treatment No 8
Signed__________________________Date __________________
Name (PRINT)____________________Job Title________________
Treatment No 9
Signed__________________________Date __________________
Name (PRINT)____________________Job Title________________
Treatment No 10
Signed__________________________Date __________________
Name (PRINT)____________________Job Title________________
Consent withdrawn:
Patient signature__________________Date___________________
On completion top copy of form accepted by patient: Yes/no (delete as
appropriate)
Page 43 of 84
Appendix 18
CONSENT FORM 4
Form for adults who are unable to consent to investigation or treatment
Patient details (or pre-printed label)
Patient’s surname/family name_____________________________________
Patient’s first names _____________________________________________
Date of birth ___________________________________________________
Responsible health professional ____________________________________
Job title_______________________________________________________
NHS number (or other identifier) ____________________________________
Male
Female
Special requirements_____________________________________________
(e.g. other language/other communication method)
Top copy of form accepted by patient: Yes/no (please delete as appropriate)
Page 44 of 84
Patient identifier/label
All sections to be completed by the Consultant proposing the procedure
A
Details of procedure or course of treatment proposed
(NB see guidance to health professionals overleaf for details of situations where court
approval must first be sought)
B
Assessment of patient’s capacity
I confirm that the patient lacks capacity to give or withhold consent to this procedure
or course of treatment because:
The patient is unable to comprehend and retain information material to the
decision; and/or
The patient is unable to use and weigh this information in the decision-making
process; or
The patient is unconscious
Further details (excluding where patient unconscious): for example how above judgements
reached; which colleagues consulted; what attempts made to assist the patient make his or
her own decision and why these were not successful.
Top copy of form accepted by patient: Yes/no (please delete as appropriate)
2
Page 45 of 84
Patient identifier/label
C
Assessment of patient’s best interests
To the best of my knowledge, the patient has not refused this procedure in a valid
advance directive. Where possible and appropriate, I have consulted with colleagues
and those close to the patient, and I believe the procedure to be in the patient’s best
interests because:
(Where incapacity is likely to be temporary, for example if patient unconscious, or where
patient has fluctuating capacity)
The treatment cannot wait until the patient recovers capacity because:
D
Involvement of the patient’s family and others close to the patient
The final responsibility for determining whether a procedure is in an incapacitated patient’s
best interests lies with the health professional performing the procedure. However, it is good
practice to consult with those close to the patient (e.g. spouse/partner, family and friends,
carer, supporter or advocate) unless you have good reason to believe that the patient would
not have wished particular individuals to be consulted, or unless the urgency of their situation
prevents this. “Best interests” go far wider than “best medical interests”, and include factors
such as the patient’s wishes and beliefs when competent, their current wishes, their general
well-being and their spiritual and religious welfare.
(To be signed by a person or persons close to the patient, if they wish)
I/We have been involved in a discussion with the relevant health professionals over the
treatment of
(patient’s name). I/We understand that he/she is unable
to give his/her own consent, based on the criteria set out in this form. I/We also
understand that treatment can lawfully be provided if it is in his/her best interests to
receive it.
Any other comments (including any concerns about decision)
Name _______________________ Relationship to patient _________________
Address (if not the same as patient)
___________________________________________________________
Signature _________________________Date_____________________________
If a person close to the patient was not available in person, has this matter been discussed in
any other way (e.g. over the telephone?)
Yes
No
Details:
Top copy of form accepted by patient: Yes/no (please delete as appropriate)
Page 46 of 84
Patient identifier/label
Signature of Consultant proposing treatment
The above procedure is, in my clinical judgement, in the best interests of the patient, who
lacks capacity to consent for himself or herself. Where possible and appropriate I have
discussed the patient’s condition with those close to him or her, and taken their knowledge of
the patient’s views and beliefs into account in determining his or her best interests.
I have/have not sought a second opinion.
Signature ____________________
Date__________________
Name (PRINT) ____________________ Job title ______________________
Where second opinion sought, s/he should sign below to confirm agreement:
Signature ________________________ Date__________________
Name (PRINT) ___________________ Job title ___________________
Top copy of form accepted by patient: Yes/no (please delete as appropriate)
4
Page 47 of 84
Appendix 19
ASSESSMENT OF CAPACITY FORM
Assessment of Capacity Form (Soc 1708 / CPA Part 8)
Mental Capacity Act: Capacity Assessment Form
Before completing this form check whether there are substitute decision making arrangements in place that would
make an assessment of capacity unnecessary ~ see guidance section 7
Part 1: Capacity Assessment
User of service:
Date of Birth
Details of decision required:
Decision Maker:
Name:
Role:
Contact:
Capacity Assessment : Stage 1 : Diagnostic Threshold : (Guidance Section 9)
Is there an impairment in or a disturbance of the functioning of the mind or brain?
No
Yes
If no, person cannot be
deemed to lack capacity
under the Mental Capacity
Act
Evidence recorded in:
Assessment is ended
Complete stage 2
Capacity Assessment : Stage 2 : Functional Test
Page 48 of 84
Can the person understand the information relevant to the decision?
Specify Support Given (Refer to Guidance 10.5-7):
Yes (Give reasons)
No (Give reasons)
Can the person retain the information for long enough to make the decision?
Specify Support Given (Refer to Guidance 10.8-9):
Yes (Give reasons)
No (Give reasons)
Can the person weigh the information as part of the decision making process?
Specify Support Given (Refer to Guidance 10.10-13):
Yes (Give reasons)
No (Give reasons)
Can the person communicate the decision?
Specify Support Given (Refer to Guidance 10.14-15):
Yes (Give reasons)
No (Give reasons)
Page 49 of 84
Conclusion : Does the person have capacity to make the decision?
YES : If ‘yes’ to ALL of the elements of Stage 2
NO : If ‘no’ to ANY of the elements of Stage 2
YES
NO Person lacks capacity (give reason)
Person has capacity to make decision.
Assessment process ended.
Complete Sections 2 & 3
Signature of Decision Maker :
Date:
Page 50 of 84
Appendix 20
FORM T4 Regulation 27(3)(b)
Mental Health Act 1983
Section 58A(3) – certificate of consent to treatment (patients at least 18 years old)
THIS FORM IS NOT TO BE USED FOR PATIENTS UNDER 18 YEARS OF AGE
I (PRINT full name and address)
the approved clinician in charge of the treatment described below / a registered medical
practitioner appointed for the purposes of Part 4 of the Act (a SOAD) (delete as appropriate)
certify that:
(PRINT full name and address of patient)
who has attained the age of 18 years.
a) is capable of understanding the nature, purpose and likely affects of: (Give description of
treatment or plan of treatment. Indicate clearly if the certificate is only to apply to any or all of
the treatment for a specific period).
AND
b) has consented to that treatment.
Signed
Date
1
Page 51 of 84
Appendix 21
FORM T5 Regulation 27(3)(b)
Mental Health Act 1983
Section 58A(4) – certificate of consent to treatment and second opinion (patients
under 18)
THIS FORM IS ONLY TO BE USED FOR PATIENTS UNDER 18 YEARS OF AGE
I (PRINT full name and address)
a registered medical practitioner appointed for the purposes of Part 4 of the Act (a SOAD)
certify that:
(PRINT full name and address of patient)
who has not yet attained the age of 18 years.
a) is capable of understanding the nature, purpose and likely affects of: (Give description of
treatment or plan of treatment. Indicate clearly if the certificate is only to apply to any or all of
the treatment for a specific period).
AND
b) has consented to that treatment.
In my opinion it is appropriate for that treatment to be given.
My reasons are as below / I will provide a statement of my reasons separately. (Delete as
appropriate).
(When giving reasons please indicate if, in your opinion, disclosure of the reasons to the
patient would be likely to cause serious harm to the physical or mental health of the patient, or
to that of any other person).
Signed
Date
Page 52 of 84
Appendix 22
FORM T6 Regulation 27(3)(b)
Mental Health Act 1983
Section 58A(5) – certificate of second opinion (patients who are not capable of
understanding the nature, purpose and likely effects of the treatment).
I (PRINT full name and address)
a registered medical practitioner appointed for the purposes of Part 4 of the Act (a SOAD),
have consulted:
(PRINT full name of nurse)
a nurse and
(PRINT full name and profession)
who have been professionally concerned with the medical treatment of
(PRINT full name and address of patient)
I certify that the patient is not capable of understanding the nature, purpose and likely effects
of:
(Give description of treatment or plan of treatment. Indicate clearly if the certificate is only to
apply to any or all of the treatment for a specific period.
But that it is appropriate for the treatment to be given.
My reasons are as below / I will provide a statement of my reasons separately. (Delete as
appropriate)
(When giving reasons please indicate if, in your opinion, disclosure of the reasons to the
patient would be likely to cause serious harm to the physical or mental health of the patient or
to that of any other person).
I further certify that giving the treatment described above to the patient would not conflict with
i)
any decision of an attorney appointed under a Lasting Power of Attorney or deputy
(appointed by the Court of Protection) of the patient as provided for by the Mental
Capacity Act 2005
ii)
any decision of the Court of Protection, or
iii)
any advance decision to refuse treatment that is valid and applicable under the
Mental Capacity Act 2005.
Signed
Date
Page 53 of 84
Appendix 23
FORM CTO11 Regulation 28(1)
Mental Health Act 1983
Section 64C(4) – certificate of appropriateness of treatment to be given to community
patient
(Part 4A certificate)
I (PRINT full name and address)
am a registered medical practitioner appointed for the purposes of Part 4 of the Act (a SOAD).
I have consulted (PRINT full name and profession)
and (full name and profession)
who have been professionally concerned with the medical treatment of
(PRINT full name and address of patient)
who is subject to a community treatment order.
I certify that it is appropriate for the following treatment to be given to this patient while the
patient is not recalled to hospital, subject to any conditions specified below. The treatment is:
(Give description of treatment or plan of treatment).
I specify the following conditions (if any) to apply:
(Conditions may include time limits on the approval of any or all of the treatment).
I certify that it is appropriate for the following treatment (if any) to be given to this patient
following any recall to hospital under section 17E of the Act, subject to any conditions
specified below. The treatment is:
(Give description of treatment or plan of treatment).
I specify the following conditions (if any) to apply to the treatment which may be given to the
patient following any recall to hospital under section 17E:
(Conditions may include time limits on the approval of any or all of the treatment).
My reasons are as below / I will provide a statement of my reasons separately. (Delete as
appropriate)(When giving reasons please indicate if, in your opinion, disclosure of the reasons
to the patient would be likely to cause serious harm to the physical or mental health of the
patient, or to that of any other person).
Signed
Date
Page 54 of 84
Appendix 24
VARIANCE TO MEDICATION DUE TO ECT
Consider carefully those patients taking benzodiazepines and anti-epileptics.
Remember to omit benzodiazepines the night before if possible.
Please note that SSRI’s, Lithium and Clozapine lower seizure threshold and
Benzodiazepines and Anticonvulsants increase the seizure threshold.
Caffeine is unlikely to augment the therapeutic effects of ECT and is no longer
recommended.
Patients should receive their antihypertensive medication and those with symptomatic
gastric reflux should receive their routine antacid medication on the morning of ECT.
For those with COPD/Asthma, ensure that they bring their inhalers to the ECT suite with
them.
Diabetic patients should NOT receive anti-diabetic drugs, on the morning of ECT
until the first substantial meal after ECT.
Devise a medication plan (see below) and staple to the drug chart.
Inform the patient’s key worker of these changes.
Give the medication plan to outpatients and inform their Carer’s of the changes.
Page 55 of 84
ECT MEDICATION PLAN
Please indicate below the steps to be taken regarding patients medication on ECT
treatment days. Please note that this is NOT a prescription chart.
Patient
name:……………………………………HN:………………..DOB:……………………..
Ward:…………………..Doctor name/signature:…………………………………………..
Present medication
Continue throughout ECT?
Yes
or
No
Yes
or
No
Yes
or
No
Yes
or
No
Yes
or
No
Yes
or
No
Yes
or
No
Yes
or
No
Variance to usual prescription
Page 56 of 84
Appendix 25
ROUTINE PRE-ECT TESTS PROTOCOL
The following guidelines apply:
 All patients should have:
o FBC
o Urine test to check for glucose, protein, blood
 As per indication below, patients should also have the following: U+E, ECG, CXR, Sicklecell test (SCT), Hep B, LFT, Blood sugar.
AGE
U+E
Male >45 Female >55
Either sex >70
HEART AND CVS
Cardiovascular disease, known or
suspected, including hypertension
History signs or symptoms of cardiac
Disease
Clinical or radiographic cardiomegaly
Significant heart murmur, esp with
signs of left ventricular hypertrophy
Hyperlipidaemia
On vaso-active or cardiac drugs
OTHER MEDICAL PROBLEMS
Chronic pulmonary disease, but not
asthma
Chest infection
Diabetes
Renal impairment, acute or chronic
Diuretic therapy
Lithium therapy
Steroid therapy
Cerebral or peripheral vascular
disease
Malignancy
Dehydration ± iv therapy already
needed
Haematological disease
Coagulation defect
Suspected anaemia
Patients with cachexia
OTHER
Patients who abuse drugs
History of alcoholism
Recent drug overdose
Afro-Caribbean, Middle Eastern,
Asian, Eastern Mediterranean patients
ECG
CXR
SCT
LFT
Hep
B
Blood
sugar
Echo
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Page 57 of 84
Echocardiography
In patients with known or suspected serious cardiac disease (e.g. poorly controlled or
unstable angina, poorly controlled atrial fibrillation, history of heart failure, clinical LV
hypertrophy or cardiomegaly, aortic stenosis) preoperative management should be
discussed with the Anaesthetist, before 1st ECT session if possible, who may advise
cardiology referral and/or echocardiography.
Please also note that:
The indications given above are intended as a guide and are not comprehensive.
Other preoperative tests (e.g. coagulation screen, thyroid function tests) may be
required in some clinical circumstances. If in doubt, the anaesthetist responsible for
the patient’s peri-operative care should be consulted.
Page 58 of 84
Appendix 26
ANAESTHESIA FOR ECT PROTOCOL
ECT is administered modified with a small dose of muscle relaxant and an anaesthetic
Pre-ECT evaluation
The goal of the evaluation is to ensure the patient’s safety by identifying risks of
anaesthesia and recommending appropriate modifications, tests, and consultations.
The evaluation should include the medical history, physical examination, previous
anaesthetic history, allergies and current medications. Patients whose condition or
results give cause of concern should be referred for specific anaesthetic assessment.
Potential problems with anaesthesia include:
 Angina
 Recent myocardial infarction
 Cerebrovascular accident
 Diabetes
 Hypertension
 Hiatus Hernia
 Known drug allergies
 Adverse reactions to previous anaesthetics
Contraindications to ECT:
 Uncontrolled cardiac failure
 Deep venous thrombosis- until anticoagulated
 Acute respiratory infection
 Recent myocardial infarction (within 3 months)
 Recent CVA (within 1 month)
 Raised intracranial pressure
 Unstable major fracture
 Untreated phaeochromocytoma.
Conduct of anaesthesia
A WHO standard Pre-Procedure briefing is performed at the start of the session. A
WHO standard “time-out” is performed before each patient.
A pre-anaesthetic assessment of the patient is performed by the anaesthetist and all
equipment, drugs and assistance are checked.
Monitoring is established following standard UK guidance (Reff: recommendations for
standards of monitoring during anaesthesia and recovery 4th Edit AAGBI March 2007)
 Pulse Oximetry
 ECG
 Non Invasive BP
 Respiratory Gases CO2 and O2
 EEG
Other monitors that must be available:
 Nerve stimulator
 Thermometer
IV access is established, Preoxygenation and pre-treatment EEG trace obtained.
Page 59 of 84
After induction the patient is hyperventilated with O 2 (Hypocapnia promotes and
hypercapnia suppresses seizure activity).
Usual drugs:


Propofol (guide dose 0.75 – 1.5mg/kg)
Suxamethonium (guide dose 0.5 – 1.0mg/kg)
Alternative drugs:

Etomidate (guide dose 0.15 – 3mg/kg)
When Propofol contraindicated, also may be used when patient becoming
resistant to ECT stimulus as Etomidate is less anticonvulsant. Recovery may
include more agitation.

Rocuronium (guide dose 0.15mg/kg) reversed at end of procedure with
Sugammedex (guide dose 1.5 – 2.0mg/kg)
When Suxamethonium contraindicated
Recovery
Recovery with O2 administered and monitored according to normal UK standards
without undue stimulation or excitement.
Position according to anaesthetist’s
preference, but lateral position is usually appropriate. Recovery is often slow and
should not be hurried. The anaesthetist must be available until the patient has
recovered sufficiently to allow return to a ward. (This is not necessarily the same as
until the patient has actually been discharged from the unit. But the anaesthetist must
be contactable until the patient has left the unit.)
Special circumstances
Repeated stimuli may be required, especially during the first session when the seizure
threshold is being established. A second (increased) stimulus should not be given until
60 seconds after first. Oxygen should be administered, a further dose of Propofol and
Suxamethonium (potential bradycardia may be prevented with Atropine) should be
considered.
A third stimulus would certainly require further Propofol and
suxamethonium.
Prolonged seizure, greater than 120 seconds, should be terminated with Midazolam or
Propofol. Preparation to treat a prolonged seizure should be made after 60 seconds.
Page 60 of 84
Appendix 27
MALIGNANT HYPERPYREXIA MANAGEMENT PROTOCOL
Replace this with AAGBI Guidance
Malignant Hyperthermia Crisis
AAGBI Safety Guideline
Successful management of malignant hyperthermia depends upon early
diagnosis and treatment; onset can be within minutes of induction or may be
insidious. The standard operating procedure below is intended to ease the
burden of managing this rare but life threatening emergency.
1. Recognition
 Unexplained increase in ETCO2 AND
 Unexplained tachycardia AND
 Unexplained increase in oxygen requirement
(Previous uneventful anaesthesia does not rule out MH)
 Temperature changes are a late sign
2. Immediate management






STOP all trigger agents
CALL FOR HELP. Allocate specific tasks (action plan in MH kit)
Install clean breathing system and HYPERVENTILATE with 100% O2 high flow
Maintain anaesthesia with intravenous agent
ABANDON/FINISH ECT as soon as possible
Muscle relaxation with non-depolarising neuromuscular blocking drug
Your nearest MH kit is stored Peterborough – Treatment Room.
Your nearest MH kit is stored Cambridge Prep room theatre 41/42
3. Monitoring & treatment










Give dantrolene (see below)
Initiate active cooling avoiding vasoconstriction
TREAT:
Hyperkalaemia: calcium chloride, glucose/insulin, NaHCO3¯
Arrhythmias: magnesium/amiodarone/metoprolol
AVOID calcium channel blockers - interaction with dantrolene
Metabolic acidosis: hyperventilate, NaHCO3¯
Myoglobinaemia: forced alkaline diuresis (mannitol/furosemide + NaHCO3¯);
may require
renal replacement therapy later
DIC: FFP, cryoprecipitiate, platelets
Check plasma CK as soon as able
Page 61 of 84
DANTROLENE
2.5mg/kg immediate iv bolus.
Repeat 1mg/kg boluses as required to max 10mg/kg
For a 70kg adult
 Initial bolus: 9 vials dantrolene 20mg (each vial mixed with 60ml sterile water)
 Further boluses of 4 vials dantrolene 20mg repeated up to 7 times.
Continuous monitoring
Core & peripheral temperature
ETCO2
SpO2
ECG
Invasive blood pressure
CVP
Repeated bloods
ABG
U&Es (potassium)
FBC (haematocrit/platelets)
Coagulation




Continue monitoring on ICU, repeat dantrolene as necessary
Monitor for acute kidney injury and compartment syndrome
Repeat CK
Consider alternative diagnoses (sepsis, phaeochromocytoma, thyroid storm,
myopathy)
 Counsel patient & family members
 Refer to MH unit (see contact details below)
4. Follow-up
The UK MH Investigation Unit, Academic Unit of Anaesthesia, Clinical Sciences
Building, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF. Direct line: 0113 206
5270. Fax: 0113 206 4140. Emergency Hotline: 07947 609601 (usually available
outside office hours). Alternatively, contact Prof P Hopkins, Dr E Watkins or Dr P
Gupta through hospital switchboard: 0113 243 3144.
© The Association of Anaesthetists of Great Britain & Ireland 2011
Page 62 of 84
Appendix 28
Malignant Hyperpyrexia Protocol – Local Variation
eterborough
Dantrolene is kept on site.
Management of malignant hyperpyrexia will be carried out initially on site by the
consultant Anaesthetist conducting ECT anaesthesia.
Immeditely call for Help.
999 call for transfer of collapsed patient to PCH A &E.
Consultant intensivist should be contacted via PCH switchboard to assist further
management before during and after transfer.
Cambridge
Dantrolene is kept in the Malignant Hyperpyrexia Emergency Box (Pink in Colour) that
is kept in the Prep Room between Theatres 41 and 42 in the Eye Day Surgery Unit
where ECT treatment takes place. The ODP is the designated person to fetch the
medication and prepare it for use. More Dantrolene is kept in the Neuro and Main
Theatres should this be required. The ODP is the designated person to obtain this
from the Neuro and Main Theatres.
ICU Anaesthetic consultant should be Bleeped immediately
Page 63 of 84
Appendix 29
ACUTE ANAPHYLAXIS MANAGEMENT PROTOCOL
Management of a Patient with Suspected
Anaphylaxis During Anaesthesia
Immediate management
Use the ABC approach (Airway, Breathing, and Circulation). Team-working enables
several tasks to be accomplished simultaneously.
Remove all potential causative agents and maintain anaesthesia
∙ CALL FOR HELP and note the time.
Peterborough - 999 Call plus ITU consultant via PCH switchboard.
Cambridge – Call ITU consultant
Maintain the airway and administer oxygen 100%. Intubate the trachea if necessary
and ventilate the lungs with oxygen.
Elevate the patient’s legs if there is hypotension.
If appropriate, start cardiopulmonary resuscitation immediately according to Advanced
Life Support Guidelines.
Give adrenaline i.v.
◦◦ Adult dose: 50 μg (0.5 ml of 1:10 000 solution).
◦◦ Child dose: 1.0 μg.kg-1 (0.1 ml.kg-1 1:100 000 solution).
Several doses may be required if there is severe hypotension or bronchospasm. If
several doses of adrenaline are required, consider starting an intravenous infusion of
adrenaline.
Give saline 0.9% or lactated Ringer’s solution at a high rate via an intravenous cannula
of an appropriate gauge (large volumes, 1000ml or more, may be required).
Plan transfer of the patient to an appropriate Critical Care area.
Secondary management
Give chlorphenamine i.v. Adult: 10 mg
Give hydrocortisone i.v. Adult: 200 mg
Page 64 of 84
If the blood pressure does not recover despite an adrenaline infusion, consider the
administration of an alternative i.v. vasopressor according to the training and
experience of the anaesthetist, e.g. metaraminol.
Treat persistent bronchospasm with an i.v. infusion of salbutamol. If a suitable
breathing system connector is available, a metered-dose inhaler may be appropriate.
Consider giving i.v. aminophylline or magnesium sulphate.
Investigation
Take blood samples (5 - 10 ml clotted blood) for mast cell tryptase:
 Initial sample as soon as feasible after resuscitation has started – do not delay
resuscitation to take the sample.
 Second sample at 1 - 2 h after the start of symptoms.
 Third sample either at 24 h or in convalescence
 Ensure that the samples are labelled with the time and date.
 Liaise with the hospital laboratory about analysis of samples.
Later investigations to identify the causative agent
The anaesthetist who gave the anaesthetic or the supervising consultant anaesthetist
is responsible for ensuring:
that the reaction is investigated. The patient should be referred to a specialist Allergy
or Immunology Centre (see www.aagbi.org for details).
© The Association of Anaesthetists of Great Britain & Ireland 2009
Page 65 of 84
Appendix 30
SCOLINE APNOEA MANAGEMENT PROTOCOL
Evaluation and Management
Immediate Care





Airway - maintain a clear airway and give oxygen, intubate if indicated.
Breathing - ensure adequate respiration. Monitor SpO2.
Circulation – Resuscitate as indicated.
Review the history, investigations, and perioperative management.
Assess for persisting neuromuscular blockade, using a nerve stimulator. If the
patient is still paralysed they should be sedated or kept anaesthetised, and
ventilated, transfer to ITU will be required.
1
Page 66 of 84
Appendix 31
Patient Label
OR
Patient Name
Patient DOB
Electroconvulsive Therapy Record
Version 7 July 2013
ICD 10 Diagnosis:
ICD 10 Code:
Status: Inpatient □ Outpatient □
If detained, Section
If inpatient: Voluntary □ Detained □
Previous ECT :
Outcome : Much improved □ Minimally improved □ No change □
Date:
Minimally worse □ Much worse □ N/A □
Gender:
Ethnicity:
White British □ Asian or Asian British – Pakistani
□
Black or White African □ White or
Black Caribbean □
White Irish □ Asian or Asian British – Indian
□
Mixed White & African □ Mixed White &
Caribbean □
White Other □ Asian or Asian British – Bangladeshi □ Not Known
□
Other Ethnic
Group
□
Indications within NICE guidelines?
If no, has patient been informed?
No
Please annotate in hospital
notes
Patient information booklet given/explained
Carer/Family consulted regarding decision to treat patient with
ECT
Risk/Benefit of ECT considered by Medical Team
Patient has capacity to give informed consent
Consent Procedure/Paperwork Completed
Proposed Number of ECT Treatments: ……………..
Referring Consultant:
Ward/Location:
No
No
No
□
□
□
□
Yes
Yes
Yes
Yes
□
□
□
□
N/A □
No □ Yes □
No □ Yes □
No □ Yes □
Unilateral/Bilateral ………………
Responsible Doctor:
Signed:
Date:
ECT PRESCRIPTION
All prescriptions only valid for 14 days
Prescription
Date
No.
UL/BL
Administration
Consent/Capacity
Status
Sign Prescriber
Date
No.
Signed ECT Dr
Page 67 of 84
Medical Team – Pre Treatment Assessment
Current Medication
Medication liable to affect seizure efficacy:
Anticonvulsants
No □
□
Yes
Please complete ECT Medication
Plan and staple to the Drug Chart
Benzodiazepines
Antidepressants
□
□
No
No
Factors that alter seizure threshold
□ > 65 □ Male
□ Baldness
□
□
Yes
Yes
□ ECT in last month
No □ Yes □
Patient reminded of DVLA restriction on driving
Current Mini Mental State Score: ________________ Date Conducted: ___________________
Weight: ___________ kg
Previous Anaesthetic problems
Family History of anaesthetic
problems
Smoker
No
No
□
□
Yes
Yes
□
□
No
□
Yes
□
Alcohol (> 10 units per week)
Taking Warfarin/MAOIs
No
No
□
□
Yes
Yes
□
□
Number per day
_______________________
Allergies:
Drugs
No □
Yes
Food
No □
Yes
Latex
No □
Yes
Other, specify: ________________________________
Cardiac:
BP (diastolic > 90 mmHg, systolic >
180)
Angina
Cardiac failure
H/o fainting, blackouts
Recent MI – If yes, patient for ECG
Pacemaker in situ – If yes, patient
for ECG
Palpitations – If yes, patient for ECG
Airway:
Obvious abnormal face, mouth,
chin, neck
Limited head/neck movements
Limited mouth opening
Crowns/bridges, broken/loose
teeth
□
□
□
No
□
Yes
□
No
No
No
No
No
□
□
□
□
□
Yes
Yes
Yes
Yes
Yes
□
□
□
□
□
No
□
Yes
□
No
□
Yes
□
No
No
No
□
□
□
Yes
Yes
Yes
□
□
□
Describe
______________________________
Page 68 of 84
Pre Treatment Medical Assessment (cont’d)
Respiratory:
Known respiratory condition
COPD
Asthma
Neurological:
H/o fits/seizures
Recent CVA/TIA
Recent neurosurgery
Intracranial Mass lesion
Haematological/Infectious:
H/o blood disorder
No
H/o DVT or PE
No
H/o bruising/bleeding
No
MRSA +ve, active TB, Hepatitis
No
or HIV
Special Needs
Physical special needs
No
Learning difficulties
No
Other Systems:
Kidney disease
Liver disease
Stomach/duodenal ulcers
Reflux or Hiatus Hernia
Insulin dependent Diabetes
Non Insulin dependent Diabetes
Phaeochromocytoma
Morbidly Obese (BMI >35)
Previous fractures
Glaucoma
Retinal detachment
Severe Osteoporosis
Other, specify:
No
No
No
□
□
□
Yes
Yes
Yes
□
□
□
No
No
No
No
□
□
□
□
Yes
Yes
Yes
Yes
□
□
□
□
Investigations
U&E □
FBP
□
CXR
□
TFT
□
ECG
□
□
□
□
Yes
Yes
Yes
Yes
□
□
□
□
□
Yes
□
□
Yes
□
No
No
No
No
No
No
No
No
No
No
No
No
No
□
□
□
□
□
□
□
□
□
□
□
□
□
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
□
Other, specify
_____________________________
Urinalysis: □
_________________________
Pregnancy Test: □
Physical Examination:
□
□
□
□
□
□
□
□
□
□
□
□
□
CVS:
Pulse:
Blood Pressure:
RS:
HS:
GI:
NS:
Clinical Summary and Reason for ECT:
Directions prior to first ECT session:
Page 69 of 84
MINI MENTAL STATE EXAMINATION (MMSE)
(To be completed before 1stand after 4th, 8th & 12th treatments and at end of course)
DATE
ONE POINT FOR EACH ANSWER
ORIENTATION
Year Month Day Date Time
Country Town District Hospital
Ward
REGISTRATION
Examiner names 3 objects (eg
apple, table, penny) Patient asked
to repeat (1 point for each correct).
THEN patient to learn the 3 names
repeating until correct.
ATTENTION AND CALCULATION
Subtract 7 from 100, then repeat
from result.
Continue 5 times: 100 93 86 79 65
Alternative: spell “WORLD”
backwards – dlrow
RECALL
Ask for names of 3 objects learned
earlier.
LANGUAGE
Name a pencil and watch
Repeat “No ifs, ands, or buts”.
Give a 3 stage command. Score 1
for each stage. Eg. “Place index
finger of right hand on your nose
and then on your left ear”.
Ask patient to read and obey a
written command on a piece of
paper stating “Close your eyes”.
Ask the patient to write a sentence.
Score if it is sensible and has a
subject and a verb.
____/5
____/5
____/5
____/5
____/5
____/5
____/5
____/5
____/3
____/3
____/3
____/3
____/5
____/5
____/5
____/5
____/3
____/3
____/3
____/3
____/2
____/2
____/2
____/2
____/1
____/1
____/1
____/1
____/3
____/3
____/3
____/3
____/1
____/1
____/1
____/1
____/1
____/1
____/1
____/1
____/1
____/1
____/1
____/1
COPYING
Ask the patient to copy a pair of
intersecting pentagons:
TOTAL
____/30 ____/30 ____/30 ____/30
Page 70 of 84
CONFIRMATION OF CONSENT
(Mandatory before each treatment)
Session
Capacity
Form T4/T5/T6
Section 62
I have confirmed that he/she has no further questions and wishes the procedure to go ahead.
Signature
Session
Date
Capacity
Name
Form T4/T5/T6
Job Title
Section 62
I have confirmed that he/she has no further questions and wishes the procedure to go ahead.
Signature
Session
Date
Capacity
Name
Form T4/T5/T6
Job Title
Section 62
I have confirmed that he/she has no further questions and wishes the procedure to go ahead.
Signature
Session
Date
Capacity
Name
Form T4/T5/T6
Job Title
Section 62
I have confirmed that he/she has no further questions and wishes the procedure to go ahead.
Signature
Session
Date
Capacity
Name
Form T4/T5/T6
Job Title
Section 62
I have confirmed that he/she has no further questions and wishes the procedure to go ahead.
Signature
Session
Date
Capacity
Name
Form T4/T5/T6
Job Title
Section 62
I have confirmed that he/she has no further questions and wishes the procedure to go ahead.
Signature
Session
Date
Capacity
Name
Form T4/T5/T6
Job Title
Section 62
I have confirmed that he/she has no further questions and wishes the procedure to go ahead.
Signature
Date
Name
Job Title
Page 71 of 84
Communications From ECT Team to Ward
For each seizure:- Position/Dose mC/Gen-Part-None/Duration-Visual/Duration-EEG
For each Session:-Comments & recommendations for next session
Points of concern or medication queries
Session
Date
Session
Date
Session
Date
Session
Date
Session
Date
Session
Date
Page 72 of 84
Comments/Recommendations from Ward/Community Teams
Include: symptomatic response, objective and subjective side effects after every session
Also : Changes in drug therapy or Consent/capacity
A Mini Mental State Score should be documented after every 4th session.
Session
Date:
Treatment to continue/stop
Signature
Treatment to continue/stop
Signature
Treatment to continue/stop
Signature
Treatment to continue/stop
Signature
Treatment to continue/stop
Signature
Treatment to continue/stop
Signature
Session
Date:
Session
Date:
Session
Date:
Session
Date:
Session
Date:
Page 73 of 84
OUTPATIENT ECT RESPONSIBLE ADULT DISCLAIMER FORM
I understand and accept the role of responsible adult to ensure post ECT care
for
(patient name)……………………………….. during the proposed course of Out patient
ECT
This role has been fully explained to me by ………………and an information leaflet has
been given to me.
Date/Session
Patient Signature
Responsible Adult Signature
MH worker
ECT - Pre-Anaesthetic
Assessment
Weight:
Date:
BMI:
ASA:
MEDICAL / ANAESTHETIC
HISTORY
Unit No.
Surname
Other Name
D.O.B.
Gender
Ward:
EXAMINATION
Drugs:
Hydration:
P:
BP:
Allergies:
AIRWAY:
Reflux:
Anaesthetic Plan:
Further Preparation:
Smoking:
Alcohol:
Substance abuse:
Signed:
Relevant Investigations:
The following were discussed with the patient:
Pre anaesthetic fast
Monitoring
IV induction
Anaesthetist present
Recovery room
Postoperative oxygen
FBC:
U&E:
CXR:
ECG:
Recovery Chart Grades
Sedation
Agitation
N&V
A= Awake
0= Unconscious
0 = None
Tooth injury
Sore throat
Nausea & vomiting
Sux. Pains
Small incidence of
Severe complications
Orientation Score up to 10/10
Indicate time of first correct answer
What is your first name?
What year were you born?
V=Responds to
verbal
command
1 = Quiet
Co-operative
1 = Mild
P=Responds to
Pain
2 = Concerned
2 = Moderate
U=Unresponsive
3 = Distressed
co-operative
3 = Severe
4 = V. Distressed
Non co-operative
What city do we live in?
What month is it?
What day is it today?
F
B
T
M
D
Appendix 32
PRE-ECT NURSING CHECKLIST
Patient Label
OR
Patient Name
Patient DOB
PreTreatment Checklist
Session:
Date:
Changes in medical condition
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Correct Patient (fit ID label or name band)
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Correct case notes & prescription record
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Anaesthetist aware of medical changes
No solids/fluids previous 6 hours
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
ECT Nurse informed of abnormalities
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Patient allergies documented
Patient micturated before treatment
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
N/A
Yes / No
Property stored
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Electrode sites prepared
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Orientation score documented
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Consent form completed
Possibility of Pregnancy
Jewellery/make up/piercings
Hair gel/cream/lacquer removed
Hair shampooed night before, no lacquer
Dentures removed
Spectacles/Contacts/hearing aid removed
Restrictive clothing/Prosthesis removed
Previous night’s sedation omitted
Lithium omitted
X-Rays/bloods/ECG accompany patient
Weight, Kg
Urinalysis
Blood Sugar
Temperature
B/P
Respirations
Pulse
SaO2
Patient details verified - Ward Nurse
Signature
Patient details verified - ECT Lead
Nurse Signature
Appendix 33
STIMULUS DOSING PROTOCOL
Aim
Initially the aim is to determine the “seizure threshold “ (ST) in all patients having ECT,
using an empirical titration method and then to establish the “treatment dose” (TD).
Definition of Seizure Threshold
The seizure threshold is the dose which will induce an “adequate seizure” i.e. polyspike
activity followed by slower spike and wave complexes typically 3 Hz/3 cycles per second
on EEG.
Such EEG activity 10 seconds usually results in a visible generalised tonic-clonic
convulsion (observed bilateral motor activity). The length of the generalised seizure is not
as important as the presence of EEG polyspike followed by 3 Hz spike and wave activity.
Factors increasing seizure threshold
↑ age
M>F
anticonvulsants including benzodiazepines and anaesthetics
baldness
recent ECT course in last month
high blood CO2
bilateral > unilateral
Factors reducing seizure threshold
low blood CO2
caffeine (although no longer recommended)
Establishing Treatment Dose
Once the ST is established the “treatment dose” can be determined for use at
subsequent sessions. The TD should be 1.5 to 2 (max 2.5) times higher charge than the
seizure threshold (ST) for bilateral ECT and 4 to maximum 6 times higher than ST for
unilateral ECT.
The treatment dose is one level higher than the ST level for bilateral, and 3 levels for
unilateral ECT at the next treatment session.
If the patient is very ill and needs treatment urgently he/she should be re-stimulated as
soon as ST has been established at the TD otherwise commence with TD at the next
session.
Inadequate seizures
The patient must be re-stimulated at the next level (of the dose titration chart) if a given
stimulation results in:
 A ‘missed seizure’ i.e. no seizure
 A ‘partial seizure’ – focal peripheral activity and/or absence of generalised EEG
activity
A minimum of 30 seconds must elapse between stimulations. If there has been a partial
seizure then wait 90 seconds between stimulations.
Prolonged seizures
Seizures lasting 2 minutes or longer on EEG must be identified by the psychiatrist,
communicated to the anaesthetist and terminated with intravenous diazepam
5-20mg given over 30-60 seconds by the anaesthetist. The prescribing consultant should
be informed and the event should be discussed with the patient.
Tardive Seizure
This is the late return of seizure activity. This could be a delayed complication of the
ECT. The recovery nurse should be aware of this phenomenon and able to implement
immediate management. This should include oxygenation by mask. The psychiatrist and
anaesthetist should be called. EEG monitoring should be recommenced and the
anaesthetist should be prepared to administer a further does of Propofol or intravenous
Diazepam. The prescribing consultant needs to be informed. The patient should be fully
informed of the event and any action required at further ECT sessions.
Dose Titration Chart for Thymatron IV/ Thymatron DGx ECT Machine
 For adults begin at level one for UL and level 2 for BL ECT. Start one level higher if
patient male or currently on benzodiazepines/ anti-convulsants or the patient has had
ECT within the last month or the patient is over the age of 65.
 Increase by one level until seizure is produced.
 If no seizure after two attempts consider increase by two levels for the third attempt.
 No more than three attempts per ECT session.
 Once ST determined, increase by three levels for UL and one level for UL ECT for
subsequent treatments and maintain this dose = Treatment Dose (TD).
 Increase by one more level if seizure length reduces by more than 25% in
subsequent treatments or patient not improving clinically.
 Decrease by one level if cognitive side-effects are troublesome or reduce frequency
of sessions.
 Terminate seizures lasting >120 seconds on EEG.
 If no seizure at 200% consider reducing pulse width. (discuss with supervisor).
Level
1 (low 0.5 programme)
2
3
4
5
6
7
8 (2X programme)
9
10
11
12
mC
25
50
76
126
176
277
378
479
604
756
907
1008
%
5
10
15
25
35
55
75
100
120
150
180
200
Correcting Impedance
Checking the static impedance tests the quality of the skin-to-electrode contact.
The static impedance should be between 100 and 3000 ohm before treatment is
administered.
An impedance below 100 ohm suggests the possibility of a short circuit, probably in the
recording cable.
An impedance of 3000 ohms should be reduced by the following steps:
 Press firmly on the ECT treatment pads – for unilateral ECT make sure scalp and
hair under vertex are moistened with saline-soaked pad.
 Test impedance again.
 If this is not successful, reposition ECT pads to minimise amount of hair underneath.
 Do not use alcohol swabs (this may dissolve the glue and contact will be less
efficient) to clean skin, rather use soap and water. Dry with paper or gauze.
 Electrode paddles instead of ECT pads may be used if impedance still above
3000ohm – Conductive gel needs to be applied to the paddle before application.
 One pad (temple) and one paddle (vertex) could be used for unilateral
 ECT if poor contact due to excessive hair.
Appendix 34
Anaesthesia &
Recovery Record
ANAESTHETIC RECORD (example)
Name:
Number:
Anaesthetist:
Psychiatrist:
Date:
Session:
ECT Nurse:
Recovery Nurse:
Anaesthetic Assessment:
ASA:
Nil by mouth:
Consent:
(refer to part1)
No Change:
Or Changes:
Induction Anaesthesia
Time:
Scores:
Recovery
0
Time:
Real time:
15
30
45
Medication
Orientation
Etomidate:
Propofol:
Suxamethonium:
Atropine:
Scores:
Reorientation
Agitation
Sedation
N&V
SaO2
FiO2
Resp
SaO2
FiO2
Resp
200
200
180
180
160
160
140
140
120
120
100
100
80
80
60
60
40
40
20
20
00
00
IV access:
Airway:
Position:
Biteguard:
Machine
check
Problems:
None
Moderate
Severe
Signature:
Comments:
Problems: None//Moderate//Severe
Comments:
Fit for discharge/transfer to: Signature:
Name:
Time:
Dischg
Appendix 35
ECT RECORD (example)
Patient Name: ……………………..HN:……………………
Age/DOB :…………………………RMO:………………………...
SESSION
Date:
Stimulation
1
Electrode Placement
Dose Setting
Impedance
Seizure Pattern/
Adequate
PSI/Coherence
Peak BP
Max Pulse
Seizure
Duration
Visual
EEG
Seizure Threshold
Comments and
Recommendations
ST Dr Signature
ECT Supervisor’s
Signature
2
SESSION
Date:
Stimulation
3
1
2
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Appendix 36
POST ECT NURSING OBSERVATION CHART (example)
Identification Details:
Surname:………………………First Name(s):……………..….………DOB:……/…..../……..
Ethnic group:………………… HN:……………………..Male / Female
Ward:……………………
OP/ IP
RMO:………………..… Date………………...
Session………Name of escorting nurse:……….. Signature:……………
Physical Observations
Before
ECT
10 mins
30 mins
2 hours
3 hours
6 hours
Before
ECT
10 mins
30 mins
2 hours
3 hours
6 hours
(Please fill in answers – Stop as soon as patient reorientated)
Before
5 mins
10 mins
15 mins
20 mins
ECT
25mins
Temperature
Blood Pressure
Pulse
SO2
Routine Questions (yes / no / N/a)
Do you have a headache?
Do you feel like being sick/
wanting to vomit?
Do your muscles feel sore?
Is patient agitated?
Have you reported any
abnormalities to ward doctor?
Any other immediate side effects?
Time of Treatment =
Time to reorientation
What is your first name?
What is your last name?
How old are you?
What year were you born?
What country do we live in?
What city do we live in?
What is the name of the hospital?
What year is it now?
What month is it?
What day is it today?
If not reorientated after 25 minutes continue assessing at 5 minute intervals until fully
reorientated. Total time to reorientation = __________Total time to recovery = _______
Initials
Outpatients:
Patient assessed by Psychiatrist
Valuables returned
N/A □
Prosthesis returned
N/A □
Instruction leaflet given
Date of next treatment given
Patient told re adult carer for next 24 hours
Patient told not to operate machinery for
24 hrs, (incl electric kettles and
microwaves)
Initials
Patient told re adult escort home (not
taxi driver)
Patient told re transport home (not taxi
driver)
Patient given telephone number for
Ward
Patient told not to drink alcohol for next
24 hours
Patient told not to sign legal documents
Patient told not to drive for 24 hours
(including cycle)
Patient told not to cook
ECT Lead Nurse Signature: ………………………………………………
Appendix 37
POST ECT MONITORING PROTOCOL
Day after treatment – by RMO/ Deputy:
This should preferably take place after every treatment but at least after every 2
treatments
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Assess and record clinical status and symptomatic response
Assess and record any objective cognitive and non cognitive side effects especially
autobiographical memory
Record patient’s subjective experience of treatment side effects
Decide whether treatment should continue or stop
MMSE after 1st session and after sessions 4, 8, 12 etc.
At the end of the course - RMO/ Deputy:
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
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Repeat MMSE
Summarise treatment and response
Include reason for stopping treatment
Plan follow-up and ongoing monitoring of memory