Download Electroconvulsive Therapy Protocols

Document name:
Electroconvulsive Therapy Policy and protocols.
Staff group to whom it
applies:
Designated ECT medical and nursing staff
Line managers of medical and nursing staff
Ward managers
Referring consultants and treatment teams
Distribution:
Designated ECT medical and nursing staff
Line managers of medical and nursing staff
Ward managers
Referring consultants and treatment teams
Issue date:
Reviewed
Next review:
May 2009
December 2011
June 2015
May 2017
Approved by:
Executive Management Team
Developed by:
Dr Clive Cruickshank and the ECT Subgroup on
behalf of the Drugs & Therapeutics Sub
Committee
Wakefield and Dewsbury - 01924 327439
Contacts for advice or
information:
Calderdale and Huddersfield – 01422 222815
Contents
1
Operational guidelines ...................................................................................... 1
1.1 Rationale .................................................................................................. 1
1.2 Description of the services provided ..................................................... 1
1.3 Key objectives of the service ................................................................. 1
1.4 Basic principles ....................................................................................... 1
1.5 Child/adolescent ECT .............................................................................. 3
1.6 Duties ....................................................................................................... 3
1.7
Implementation and compliance – Responsibilities of staff ............... 3
1.8
Training ................................................................................................... 3
1.9 Referral procedures and other information........................................... 4
1.10 Fasting and ECT ...................................................................................... 4
1.11 Monitoring ................................................................................................ 4
1.12 Patient valuables/property ...................................................................... 5
2 ECT Prescription ............................................................................................... 6
2.1 Consent .................................................................................................... 5
2.2 Prescription.............................................................................................. 6
2.3 Electrode placement ............................................................................... 7
2.4 Frequency of treatments ......................................................................... 7
2.5 Emergency ECT ....................................................................................... 7
2.6 Dosage of ECT ......................................................................................... 8
2.7 Monitoring during a course of ECT ........................................................ 8
3 Discontinuation/number of treatments ........................................................... 9
4 Driving and ECT ................................................................................................ 10
5 Special groups and ECT ................................................................................... 10
5.1 Children and adolescents ....................................................................... 10
5.2 Elderly service users ............................................................................... 11
5.3 Pregnant service users ........................................................................... 11
5.4 Learning disability ................................................................................... 12
5.5 Cardiac pacemakers/Implanted devices…………………………………..12
6 Continuation and maintenance ECT ................................................................ 13
7 ECT and co-prescribed medicines................................................................... 15
7.1 Medicines which are not normally given on an empty stomach ......... 15
7.2 Oral hypoglycaemics .............................................................................. 15
7.3 Insulin dependent .................................................................................... 15
7.4 Drugs for oesophageal reflux ................................................................. 15
7.5 Proton pump inhibitors ........................................................................... 16
7.6 Beta-adrenoceptor antagonists.............................................................. 16
7.7 H2 receptor antagonists ......................................................................... 16
7.8 Benzodiazepines ..................................................................................... 17
7.9 Hypnotics ................................................................................................. 17
7.10 Lithium ..................................................................................................... 17
7.11 Antipsychotics ......................................................................................... 17
7.12 Antidepressants ...................................................................................... 18
7.13 Antiepileptics…………………………………………………………………...18
8 Day Case ECT .................................................................................................... 20
9 Patients proceeding on a period of leave ....................................................... 22
10 Stimulus Dosing ................................................................................................ 23
10.1 ECT Machine ............................................................................................ 23
10.2 Electrode placement ............................................................................... 23
10.3 Stimulus dosing....................................................................................... 23
ii
11
12
13
14
15
16
17
18
19
20
21
22
23
10.4 Dosing strategy ....................................................................................... 23
10.5 Dose adjustments during the course of treatment ............................... 24
10.6 Missed seizures ....................................................................................... 24
10.7 Monitoring seizure activity ..................................................................... 24
10.8 Methods of monitoring ............................................................................ 25
10.9 General aims of stimulus dosing ........................................................... 25
10.10 Estimation of seizure threshold for Thymatron system 4 .................... 25
10.11 Failure to induce convulsion .................................................................. 26
10.12 Termination of prolonged convulsion ................................................... 27
10.13 Tardive seizures ..................................................................................... 27
10.14 Factors that influence seizure threshold .............................................. 27
Measuring time to reorientation post ECT ...................................................... 29
Escorting a service user undergoing ECT from an onsite ward ................... 30
Escorting a service user undergoing ECT from an offsite ward ................... 31
Securing “Out of hours” ECT services ........................................................... 33
Obtaining back up ECT apparatus ................................................................... 35
Induction of anaesthesia .................................................................................. 36
Management of Suxamethonium (Scoline) Apnoea ....................................... 38
Management of malignant hyperthermia ........................................................ 39
Dantrolene reconstitution for use in malignant hyperthermia – Fieldhead –
ECT Department ................................................................................................ 41
Anaphylaxis management ................................................................................ 43
Management of ECT in pregnancy................................................................... 45
Cardio pulmonary resuscitation (CPR) ........................................................... 48
Management of failed intubation ..................................................................... 49
Appendix 1: Equality Impact Assessment Tool ................................................... 50
Appendix 2: Checklist for the Review and Approval of Procedural Document 51
Appendix 3: Version Control Sheet ...................................................................... 53
Abbreviations used in this document
AAGBI
AC
ASA
BNF
CMHT
CPR
CQC
D&T
DDH
ECT
MCA
MH
MHA
MHRA
NICE
ODP
RCP
SOAD
ST
Association of Anaesthetists of Great Britain and Ireland
Approved Clinician
American Society of Anaesthesiologists
British National Formulary
Community Mental Health Team
Cardio Pulmonary Resuscitation
Care Quality Commission
Drug and Therapeutic Sub Committee
Dewsbury District Hospital
Electro convulsive therapy
Mental Capacity Act
Malignant Hyperthermia
Mental Health Act
Medicine and Healthcare Products Regulatory Agency
National Institution for Clinical Excellence
Operating department practitioner
Royal College of Physicians
Second Opinion Appointed Doctor
Seizure threshold
iii
Electroconvulsive Therapy Protocols
1.
Operational guidelines
1.1
Rationale
There is substantial evidence that electro-convulsive therapy (ECT) is an effective
treatment of symptoms in some psychiatric illnesses such as severe depressive
illness, a prolonged or severe manic episode, and catatonia.
1.2
Description of the services provided
ECT is provided at two locations within South West Yorkshire Partnership NHS
Foundation Trust. For Wakefield and North Kirklees and Barnsley, the ECT suite
(Briarfields) is annexed to the Priory Unit within the campus of Fieldhead. For
Calderdale and South Kirklees the ECT suite is located in the Day Case (theatre)
Unit within the Calderdale Royal Hospital. In both locations the service is provided for
both in-patients and day cases.
There is a lead consultant psychiatrist with clinical responsibility for ECT, in each of
the Trust’s 2 areas. There is also a lead nurse with responsibility to supervise and
manage the service. There is a named consultant anaesthetist and a core team of
ECT designated operating department practitioners (ODP’s). The service is provided
twice per week, but there is provision for additional sessions in an emergency
situation. See “Out of hours“ protocol.
1.3

Key objectives of the service
The provision of safe, effective, flexible service that causes least disruption to
service users and their carers.

Full compliance with the requirements of the Mental Health Act 1983
(amended 2007) and its associated Code of Practice; promotion of the legal
rights of the service users with regard to their treatment.

Full compliance with the terms of the Mental Capacity Act, 2005.

The support and education of service users, their carers and significant others.
ECT will be carried out following the best available evidence.

The ECT team is a resource for the provision of information to other
professionals.
1.4

Basic principles
ECT is used to achieve a rapid response and a significant improvement of
severe symptoms when an intensive trial of other treatment options has
proven ineffective or the condition is potentially life threatening.

All decisions to treat must be made on an individual service user basis and be
based on documented assessment of the risks and potential benefits to the
individual. Risks and benefits of alternative treatments, or not treating must
also be assessed.
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
ASA grades 1 & 2
The service users that are anaesthetically assessed as ASA 1&2 will receive their
treatment in the Fieldhead site or Calderdale Royal Hospital site as appropriate.

ASA grades 3 & 4
Generally those service users assessed as ASA grades 3&4 will have their
treatment administered in the Calderdale Royal Hospital on the acute Trust site.
Rarely, service users assessed as ASA 3 and whose physical condition is stable
may be treated at Briarfields. This decision must be made by a Consultant
Anaesthetist and the reasons documented.
Consideration must be given to the service user’s fitness to travel; therefore,
liaison between the appropriate consultants of the two hospitals may be required
to determine if it is more appropriate to transfer the service user to care of
consultant in Calderdale.
Those who require gaseous anaesthesia induction (irrespective of their ASA
level) will have their treatments administered at Calderdale Royal Hospital. In
exceptional circumstances treatment may be carried out in another local general
hospital (Pinderfields or Dewsbury District Hospital).

Following each treatment there should be a documented assessment of the
service user’s clinical status and cognitive function. Treatment should be
stopped when a clinical response has been achieved or if the service user has
not responded after an adequate trial.

Previous response to ECT should always be taken into account prior to further
courses of ECT being administered.
ECT treatment can be provided on an in-patient basis, or day case basis, if the
service user has been screened as being appropriate and has a responsible adult
available to stay with him for 24 hours. The care pathway for day case treatment
must be completed (located in treatment record).
ECT must only be carried out by professionals trained in its delivery and in the
anaesthesia techniques required, and who maintain an appropriate level of skill
through regular clinical practice and continuing professional development.
All professionals administering ECT must be trained in the use of the equipment.
Arrangements must be made for junior medical staff to be trained to an acceptable
level of competency and to have access to supervision.
There will be a dedicated team of staff as defined by the Royal College of
Psychiatrists that includes medical staff, nurses, and operating department
practitioners.
All equipment used in ECT treatment and anaesthetic equipment must be checked
prior to use in accordance with manufacturers’ instructions.
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All equipment must be maintained and serviced as required by the manufacturers.
There will be procedures for operational management of ECT in the department.
ECT will be audited on a twelve monthly basis and will include treatment criteria, age,
and pre and post ECT mental health assessment.
1.5
Child/adolescent ECT
When ECT is being considered for a person under the age of 18, reference should be
made to the protocol “Special groups and ECT”.
1.6

Duties
Mental Health organisations have an obligation to provide a safe and effective
ECT service to their patients and appropriate training for their staff. A suitable
infrastructure is required to establish and continue support for these activities.

The Chief Executive is responsible for ensuring that resources and
mechanisms are in place for the overall implementation, monitoring and
review of this policy.

The Medical Director together with D&T, in particular the ECT sub-group is
responsible for ensuring that this policy is approved, reviewed and monitored.

The Executive Management Team will provide policy approval and ratification.

The Drug & Therapeutic Trust Action Group will consider the monitoring
evidence put before them and request actions as appropriate.

Assistant Directors are responsible for ensuring the disseminating and
implementing of the policy occurs within their own area of responsibility. In
addition, they are responsible for providing relevant support for the training
required around ECT in section 1.8.
1.7
Implementation and compliance - Responsibilities of staff
All staff involved in ECT must adhere to these guidelines. Managers at all levels are
responsible for ensuring that the staff for whom they are responsible are aware of
and adhere to this policy.
1.8 Training
The Medical Director will work with the Human Resources / Workforce Development
to ensure that training and education in ECT is available to those staff that require it.
Each Consultant Psychiatrist is responsible for ensuring that his/her junior doctors
have received the appropriate training.
If ECT activity falls below 50 individual treatments a year and/or there is more than a
3 month gap between treatment sessions all relevant staff will attend the opposite
unit within the Trust in order to maintain skills and knowledge by continuing their ECT
practice.
Education on the subject of ECT will be provided at two levels. One for clinicians
who are involved in administering or prescribing ECT, and another for any other
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member of staff or service user/carer who is interested in the subject. The aim of the
latter course is to reduce any misunderstanding around the use of ECT.
The Trust is committed to supporting training of clinicians involved in ECT and will
support attendance and participation at related conferences and national groups.
1.9
Referral procedures and other information
Verbal referrals to the unit’s nursing staff are accepted from the referring consultant
or his/her nominated deputies. In-patients are assessed by their care teams, day
cases by the consultant or his/her deputy, and are supported by Community Mental
Health Teams and/ or intensive home based treatment teams.
All prospective ECT patients will have a documented assessment, including a clear
statement as to why ECT is being prescribed. A detailed medical history and physical
examination (including cardiovascular, respiratory, DVT assessment, VTE risk
assessment and neurological systems) will be documented. All fields should be
completed on the ‘Trusts physical’ document. The anaesthetic risk should be
assessed and recorded, and any subsequent changes in ASA grade recorded and
the ECT department informed. Medication, allergies, previous problems related to
anaesthesia, or other drug problem should be recorded. Mental state examination,
including assessment of memory and orientation should be recorded. A full capacity
assessment should be carried out for all patients and recorded in the treatment
record.
All patients should have FBC, U&E’s and ECG. Other investigations as appropriate.
All women of child bearing potential should have a pregnancy test. Significant
abnormalities/results should be discussed with the anaesthetist.
Issues of non-compliance with assessments and monitoring will be addressed with
the referring team on each occasion. Sustained non-compliance will be addressed
through Datix.
Transferring a service user in order to facilitate ECT
If any patient is to be transferred for the purpose of ECT it is essential that
communication takes place between the two consultants involved, the appropriate
ECT staff, and the Anaesthetist if necessary.
1.10 Fasting and ECT
Patients should not eat or, in general, drink from 1 am on the day of ECT. However, a glass
of water (up to 500mls approx) up to 6 am may be taken.
If they have had any other drinks, any solid food, a drink after 6am or chewed gum, the ECT
Anaesthetist must be informed. This may result in their treatment being cancelled or
postponed.
1.11 Monitoring
The ECT sub-group of the Drugs & Therapeutics Trust Action Group monitors the
Units’ provision of ECT services and is particularly concerned with good practice and
correct implementation of the Royal College of Psychiatrists’ standards as laid down
in its publication, the “ECT Handbook”.
Regular audit will be undertaken.
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There is a named consultant psychiatrist who has lead responsibility for ECT
administration. This consultant provides initial training and ongoing personal
supervision for junior medical staff until he/she feels they are able to administer the
treatment competently.
Nursing staff undergo initial and then subsequent yearly refresher training in post
anaesthesia airway management, CPR/immediate life support, and legislative
matters pertaining to ECT.
Anaesthetists and Operating Department Practitioners are subject to supervision and
training as required by their own regulatory bodies and employing Trust.
1.12 Patient valuables/property
It is advised that patient’s do not bring valuables and property to the department on
the morning of treatment. In preparation for ECT excess jewellery will be removed.
Clinics have individual protocol for dealing with valuables and property as per trust
policy.
2.
ECT Prescription
All service users, without exception, must have a full capacity assessment
completed, located in the Treatment Record. This must be carried out by the
responsible Consultant Psychiatrist only.
For those with capacity then the initial assessment of capacity only is required (in
addition to the consent process) but close attention must be paid to any change in
presentation that does not concur with the initial assessment. A further capacity
assessment may be required at this point.
For those lacking capacity there must be an ongoing review of capacity prior to every
treatment and this can only be undertaken by the responsible Consultant
Psychiatrist.
2.1 Consent
Consent must be obtained by the responsible Consultant Psychiatrist and only the
referring consultant must sign the consent form. This task cannot be delegated to
other medical or non medical personnel. The decision to prescribe ECT must be an
informed decision enabled by appropriate information. The written and verbal
information must emphasise the service user’s right to withdraw his consent at any
time.
For informal patients
Valid consent must be obtained wherever possible (see the Trust Consent Policy for
further information). For patients with capacity in relation to ECT, form 1 and 2 (in the
treatment record) must be completed. For incapacitous patients form 4 (DH) in
addition to form 1 in the treatment record should be completed. The consultant
psychiatrist must make reasonable enquiries to determine that the service user has
not made an advance decision refusing ECT.
When the service user is compliant but:

does not have capacity,

is not subject to treatment under a section of the Mental Health Act and
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
there is no advance decision refusing ECT,
the procedure under the Mental Capacity Act 2005 may be followed (see policy Mental Capacity Act). Assuming that these processes find the service user not to
have mental capacity, a record of the assessment of capacity must be completed and
the (DH) form 4 in addition to form 1 of the treatment record to be completed.
In rare cases, where the service user is consenting to treatment but is physically
unable to sign the consent form himself, his compliance with the proposed treatment
should be recorded on the general consent Form 1 and witnessed, preferably by an
independent professional, e.g. a social worker.
For detained patients
For service users detained under an appropriate section of the Mental Health Act
1983 (amended 2007). (Sections 2, 3, 17a, 36, 37, 38, 45a, 47, 48).
Following the implementation of the Mental Health Act 1983 (amended 2007) there
have been significant changes in the use of ECT. The following refers to service
users over 18 years of age. (The rules are different for those under 18 years of agesee under child / adolescent).
For the detained, capacitous patient

if consenting, Approved Clinician completes form T4.

if refusing, ECT cannot be given except in an emergency under S62 – this
should be very rare.
For the detained, incapacitous patient

The CQC must be contacted to request a SOAD visit. If the SOAD agrees that
ECT is the appropriate treatment, a form T6 will be completed giving
authorisation for ECT treatment.

In an emergency ECT can be started under S62 prior to the SOAD visit.
The AC should determine that there is no valid and applicable advanced decision to
refuse ECT, nor conflict with a Court of Protection ruling or refusal of consent by a
deputy or attorney (as detailed in the Mental Capacity Act).
If any of these are present, ECT cannot be given, except in an emergency under
S62. Legal advice should be obtained.
For those receiving ECT under S62, a new S62 form must be completed for each
treatment.
For those assessed as incapacitous, capacity must be reviewed in the 24 hours prior
to each treatment and recorded in the case notes and Treatment Record Booklet. If
the patient regains capacity and refuses ECT, then treatment cannot be given
(except in an emergency).
The maximum number of treatments (maximum 12) planned in the course are stated
on the consent form and a copy provided to the service user. If more than 12
treatments are considered a new consent form must be completed in addition to a
new Treatment Record Booklet and a further routine blood sample and a 12 lead
ECG need to be carried out.
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2.2
Prescription
The referring team is responsible for the selection of electrode-placement, and
prescription of frequency, total number, and duration of treatment. Factors that may
influence these decisions are summarised below. More information can be found in the
ECT handbook (third edition) Royal College of Psychiatrists’ 2013. The majority of
recommendations refer to the use of ECT in depressive disorder, as there is little
evidence about ECT technique in the treatment of mania, schizophrenia and
neuropsychiatric conditions. The referring team is also responsible for the monitoring of
service users during the course of treatment, including clinical review, and cognitive
assessment.
Special groups
Child /adolescence, Elderly, Pregnant, and Learning difficulty service users.
See additional advice within the protocol ‘Special Groups & ECT’ and ‘Pregnancy and
ECT’.
2.3
Electrode placement
The choice between unilateral and bilateral electrode-placement remains controversial.
On balance, where speed of recovery (for example marked suicidality, life threatening
reduction in food, and/or fluid intake), and/or completeness of recovery have priority, the
bilateral placement is preferred. If the urgency of response is not critical, unilateral
electrode-placement should be considered in order to minimise possible cognitive
impairment as a side effect. Bilateral electrode-placement may be preferred when the
current episode of illness or an earlier episode of illness was not treated adequately by
unilateral ECT, if there is difficulty in determination of cerebral dominance, and in the
treatment of mania where optimal techniques of the use of unilateral ECT has not been
established. Unilateral electrode-placement may be preferred where there is a history of
previous recovery with unilateral ECT. Right unilateral ECT is preferred in individuals
who are consistently right handed. In left handed people, or where cerebral dominance
is hard to decide, bilateral electrode-placement may be preferred.
2.4
Frequency of treatments
In bilateral ECT the optimal treatment is twice per week. This could be reduced to
weekly in the management of treatment emergent cognitive side effects. Administration
of bilateral ECT three times per week leads to a more rapid reduction in depressive
symptoms over a course of treatment, but at the cost of more pronounced cognitive side
effects. It does not increase the likelihood of eventual recovery. Administration three
times per week would, therefore, be unjustified except possibly in the early treatment of
severe and life threatening illness and should always be discussed with the ECT
Consultant.
For unilateral ECT the optimal frequency is probably twice per week. For practical
reasons ECT is virtually always administered twice per week.
2.5
Emergency ECT
In the case of service users requiring emergency ECT outside the usual treatment times,
the responsible medical team should liaise directly with the ECT Department.
If however, the department is closed and accessing a member of the ECT team is not
possible then the protocol “Out of hours ECT” should be followed.
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2.6
Dosage of ECT
This will initially be determined by medical staff at the ECT Unit, according to protocol.
Subsequent dosage adjustments will depend on a number of factors, and clinical
improvement is important in this respect. It is, therefore, vital that the ECT Outcome
Monitoring form is completed and available to the ECT staff for each treatment, in
addition to the clinical entries in the notes.
2.7
Monitoring during a course of ECT
It is the responsibility of the referring team to ensure;
a.
clinical review between each treatment
b.
consultant review and re prescription on a weekly basis
c.
orientation – to complement ECT nursing team assessments of cognition and
memory that will be carried out at regular intervals throughout the course of
treatment, on completion of treatment and 2 months post treatment.
Issues of non-compliance with assessments and monitoring will be addressed with
the referring team on each occasion. Sustained non-compliance will be addressed
through Datix.
Reference documents
Waite.J and Easton.A (Ed), The Royal College of Psychiatrists (2013) The ECT
Handbook: the forth report of the special committee on ECT and related treatments.
National Institute for Clinical Excellence 2003. Guidance on the use of
electroconvulsive therapy Technological Appraisal 59
National Institute for Clinical Excellence 2007. Depression: Management of
Depression in primary and secondary care Clinical guidelines 23 (amended).
Royal College of Psychiatrists ECT Accreditation Service Ed. H Caird, A Worrall Dec
2003. Standards for the Administration of ECT.
South West Yorkshire Mental Health Trust ECT Department Nursing Guidelines.
South West Yorkshire Mental Health Trust. Guidelines for Obtaining Consent to
Examination, Treatment or Clinical Intervention (does not apply to treatment
prescription under the Mental Health Act 1983).
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3.
Discontinuation/number of treatments
A set course of treatments should not be prescribed.
The need for ongoing treatment should be assessed after each individual treatment.

If there has been no improvement at all after six properly given bilateral treatments,
clinicians may wish to reassess the need for ECT and consult with the service user
(based on a predicted decreased response rate with subsequent treatments).

If there has been no improvement after 12 treatments, there is unlikely to be a
sustained response.

For service users who have not responded to unilateral ECT, it is worth considering
switching to bilateral ECT, and in this case the ineffective unilateral treatments
should be disregarded in relation to the number of ECT treatments given.

Unless there is a medical entry indicating reasons for a pause in treatment the
consent process will need to be repeated after a delay of more than 2 weeks from
the last treatment
Other reasons to consider discontinuation include

Deterioration in physical health that substantially raises the anaesthetic risk.

Significant side effects unacceptable to the service user.

Withdrawal of consent
Reference documents
Waite.J and Easton.A (Ed), The Royal College of Psychiatrists (2013) The ECT
Handbook: the forth report of the special committee on ECT and related treatments.
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4
Driving and ECT
The DVLA give specific advice on driving both during and following an episode of
mental illness, and in particular, depressive disorder. Patients receiving ECT should be
advised by the referring consultant not to drive during the acute course of ECT, and
should not resume driving until advised that they are able to do so. In general it is the
nature of depression, rather than the ECT that is the concern. How long after a course
of ECT a patient is considered fit to drive is a matter of clinical judgment. There may
be occasions when a moderately depressed patient has had ECT, improved and is
considered fit to drive when referring consultant advises they are able to do so. Side
effects of medication should be considered. Patients should not drive during a course
of ECT (particularly of relevance to those taking leave, or receiving ECT as a day case
/ out patient), unless explicitly advised by the responsible Consultant. Under no
circumstances should a patient drive within 24 hours of ECT.
The rules are more stringent for professional drivers and those with a HGV license.
It is important that you discuss return to driving with your patient.
Patients should be advised to inform the DVLA about their circumstances.
If there is evidence that a patient is driving during or shortly after a course of ECT
against clear advice the referring Consultant and/ or the lead ECT Consultant should
consider, if it is appropriate, breaching confidentiality and should inform the DVLA
directly.
Maintenance ECT: Patients receiving maintenance ECT may have mild, or no
depressive symptoms.
The decision when, after each maintenance treatment, a patient is fit to drive has to
remain a matter of clinical judgment. Advice to refrain from driving for 24 hours
following each ECT treatment is appropriate as well as individual advice about driving
whilst they are undergoing maintenance treatment.
The DVLA rules differ depending on the severity of the depression and the type of
license held. The rules for driving and mental disorder are periodically updated. It is
important that the referring Consultant treats every patient as an individual case, and
should refer to specific, current DVLA guidance prior to advising the service.
5
Special groups and ECT
(Children, adolescents, elderly, pregnant and learning disabled service users)
5.1
Children and adolescents
The use of ECT in children and adolescents remains controversial. The following have
been recommended.

ECT should be used with caution in young people because of lack of evidence
from randomised control trials.
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
First line use in persons under the age of 18 should be very rare.

For all patients under 18 years of age a request for a SOAD visit must be made,
irrespective of legal status, capacity and compliance.

Treatment under S62 is possible in an emergency, but another opinion from a
consultant in child and adolescent psychiatry should be obtained prior to
treatment.

There have been reports of increased length of seizures and post ECT
convulsions, and clinicians are advised to stop all non essential medications
used by the service user at the time of the course of ECT.

Stimulus dosing should take into account the lower seizure threshold in young
people.

Consent requires specific attention. Parents and child should be involved
whenever possible.

The ECT session must be organised so that persons under the age of 18 years
are treated separately to any adults attending for treatment.
5.2

Elderly service users
Elderly people may suffer from more physical illnesses, and must be
appropriately screened prior to treatment. See section 7.

All co-existing medical or surgical conditions should be assessed and, where
possible optimised, stabilised, or treated prior to ECT. There should be
discussion with the anaesthetist if there are particular health concerns.

Older service users may be more susceptible to confusion after ECT, as may
those with pre-existing dementia. The responsible consultant should give
consideration to the choice of electrode placement.

Regular assessments of cognitive function for at least twenty four hours after the
administration of ECT should be undertaken.
5.3

Pregnant service users
An obstetric consultation with full MDT should occur before referral for ECT.

Advice should be gained regarding the need for routine foetal heart monitoring.
CTG pre ECT and post ECT depending on gestation at antenatal day unit.

Advice should also be obtained as to whether the ECT Department is
appropriate in case an obstetric or foetal complication should arise.

A pre-anaesthetic assessment should be obtained. A case by case
consideration of intubation is necessary because of the risk of regurgitation.
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
Pregnancy more than 18 weeks - treatment to be carried out at the Calderdale
Royal Hospital.

Pregnancy less than 18 weeks - treatment to be carried out at Fieldhead or
Calderdale Royal Hospital as appropriate.
Refer to Pregnancy Management (Section 21) for further advice
5.4
Learning disability
The management of service users with learning disabilities requiring treatment with
ECT will, in general, proceed in line as with other adult service users.
Issues of capacity and consent will need special consideration. Refer to “Mental Capacity
Act 2005”.
5.5 Cardiac pacemakers/Implanted devices.
Service users with implanted cardiac pacemakers can be safely treated with ECT.ECT
team to contact the local pacemaker clinic for advice. Service users with implanted
cardiac pacemakers can be safely treated with ECT. The device should be checked by
an appropriately trained technician to ensure correct functioning prior to a course of
ECT; if it is, no special cautions are required. Otherwise, or if a person has an
implanted cardiac defibrillator, a cardiology technician must be present in the ECT suite
to inactivate the device prior to treatment, and restart it once treatment is complete.
It may be appropriate to consider transfer of the service user to Calderdale for
treatment.
Reference documents
Waite.J and Easton.A (Ed), The Royal College of Psychiatrists (2013) The ECT
Handbook: the forth report of the special committee on ECT and related treatments.
.
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6.
Continuation and maintenance ECT
Following the successful treatment of depressive symptoms by ECT, relapse is
common. Usual clinical practice is to offer prophylactic treatment – usually
pharmacological and psychological. Some service users will relapse despite such
measures. Continuation ECT has been defined as prophylactic treatment during the
six months following remission. Maintenance ECT is given beyond this to prevent
recurrent episodes.
Continuation/maintenance ECT was not recommended by N.I.C.E. 2003 (TA59).
In the updated depression guidelines N.I.C.E. 2009 (CG90) this guidance was
removed.
The ECT Handbook states continuation ECT should be considered for service users
who have a relapsing or refractory depression that has previously responded well to
ECT, but for whom standard pharmacological and psychological continuation
treatment is ineffective or inappropriate. The following should be considered:
o Good past response to ECT.
o There is (repeated) early (0-6months) post ECT relapse, or later
recurrence (6-12months) not controlled by medication.
o There is an inability to tolerate continuation drug treatment, as poor
treatment adherence leads to repeated relapse.
o Service user requests continuation ECT.
If prescribing continuation/maintenance ECT, adherence to the following
protocol is required:

Before commencement, there should be a full case review, including
consideration of the diagnosis, past response to ECT, and alternative
therapies provided. Discuss pharmacological options with the pharmacist.

The referring consultant should record in the service user’s notes the reason
for proposing continuation/maintenance ECT as opposed to alternative
treatments. Risks and benefits should be recorded.

The decision should be discussed fully with the service user and his family, or
carers.

A second opinion should be sought from a consultant colleague for informal
service users.

For service users detained under the Mental Health Act, who refuse, or lack
capacity a formal Second Opinion is needed from the Mental Health Act
Commission. The Second Opinion Doctor should be informed that the
treatment proposal is for continuation/maintenance ECT.
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
The decision to recommend continuation/maintenance ECT should be
discussed with the local ECT Consultant. If you are to proceed discuss with
medical director, and submit a clinical query form. The D&T committee should
be updated on progress every 3 months.

A statement of capacity must be recorded prior to commencement.

A consent form should be completed. Written consent should be gained every
six months, or every twelve treatments, whichever is sooner.

Service users should undergo the usual clinical check up prior to ECT,
repeated every six months, or as clinically appropriate, including laboratory
tests as necessary.

Following clinical recovery the aim is to gradually reduce the frequency of ECT
to the minimum required to maintain clinical response, for example, following
initial recovery:





Reduce to weekly.
Reduce to every ten days.
Reduce to every two weeks.
Reduce to every three weeks
Reduce to monthly.

Clinical progress should be assessed and reviewed following each individual
administration of treatment. A full review should take place before each
change in frequency of treatment.

Cognitive function and side effects should be assessed at regular

Relapse of depressive disorder is more likely in the twelve months after
recovery. It would be appropriate to consider continuation / maintenance ECT
(to prevent relapse) for at least one year. After one year there should be a full
review, with consideration of either terminating continuation ECT, or
continuing with maintenance ECT (to prevent future episodes).
intervals.
Reference documents
Waite.J and Easton.A (Ed), The Royal College of Psychiatrists (2013) The ECT
Handbook: the forth report of the special committee on ECT and related treatments.
.
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14
7.
ECT and co-prescribed medicines
Generally, immediately prior to ECT, all medicines prescribed for a physical condition
are continued unless it is specifically requested that they are omitted by the
anaesthetist.
Note:
Ensure that the morning dose of medication on the day of treatment is given with up
to 100mls of water.
Ensure that any changes to the individual’s drug therapy are clearly documented on
the prescription chart and that the anaesthetist is made aware of them.
The decision on whether to continue with medication should be based on risk/benefit
analysis for each individual.
The management regime of an individual with a physical condition that may or may
not require medication may need to be discussed with the anaesthetist.
Information on prescribed medicines is available in the current edition of the BNF
(also available on line www.bnf.org).
7.1
Medicines which are not normally given on an empty stomach
e.g. aspirin and non steroidal anti-inflammatory drugs are omitted on the morning of
ECT.
7.2
Oral hypoglycaemics
These are usually omitted on the morning of ECT and only given in combination with
food and fluids, after recovery from anaesthesia. However if the diabetes is unstable,
this should be discussed first, with the anaesthetist.
Common
Less common
Rare
Gliclazide (Diamicron)
Metformin (Glucophage)
Glibenclamide (Euglocon)
Glimepiride (Amaryl)
Chlorpropamide
Glipizide
(Glibenese,Minodiab)
Pioglitazone (Actos)
Rosiglitazone (Avandia)
Metformin
and
Rosiglitazone
(Avandamet)
Acarbose (Glucobay)
Repaglinide (Pradin)
Tolbutamide
Nateglinide (Starlix)
NB – Glibenclamide and chlorpropamide have a very long duration of action.
7.3
Insulin dependent
Service users are discussed with the anaesthetist prior to ECT as they will require an
individual treatment plan.
7.4
Drugs for oesophageal reflux
Drugs such as Gaviscon, Peptac should not be administered prior to ECT.
Lansoprazole should be considered. (see 7.5).
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7.5
Proton pump inhibitors
These should be administered the night before or at least 6 hours before treatment.
Common
Lansoprazole (Zoton)
Omeprazole (Losec, Mepraclec))
Less common
Rare
Rabeprazole (Pariet)
Esomeprazole (Nexium)
Pantoprazole (Protium)
7.6
Beta-adrenoceptor antagonists
Limited studies suggest that these may increase seizure threshold and reduced
seizure duration.
Common
Less common
Rare
Atenolol
(Tenormin, Kalten (also contains
diuretics), Tenoret 50 (also
contains diuretic), Tenoretic (also
contains diuretic), Beta-Adalat (also
contains calcium channel blocker),
Tenif (also contains calcium
channel blocker))
Propranolol
(Inderal)
Acebutolol
(Sectral)
Bisoprolol (Cardicor, Emcor)
Carvedilol (Eucardic)
Labetolol (Trandate)
Sotalol (Beta-Cardone, Sotacor)
Nebivolol (Nebilet)
Oxprenolol (Trasicor,
Trasidrex
(also
contains diuretic))
Metoprolol (Betaloc, Lopresor, CoBetaloc (also contains diuretic))
Timolol (Betim, Moducren (also
contains diuretic), Prestim
(also
contains diuretic), Timoptol (eye drop),
Nyogel (eye gel), Combigan (eye drop
with brimonidine), Xalacom (eye drop
with latanoprost), Cosopt(eye drop with
dorzolamide
Pindolol
(Visken,
Viskaldix
also
contains diuretic)
Betaxolol (Betoptic
eye drop)
Carteolol
(Teoptic
eye drop)
Levobunolol
(Betagan eye drop)
Metipranolol
(eye
drop)
7.7
H2 receptor antagonists
These can be administered on the morning of ECT.
Common
Less common
Rare
Ranitidine
(Zantac)
Cimetidine
(Tagamet, Dyspamet)
Famotidine
(Pepcid)
Nizatidine
(Axid)
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7.8
Benzodiazepines
Long established benzodiazepine drug use should not be stopped suddenly just
before a course of ECT because there is the risk of a dramatic lowering of seizure
threshold. If the dose cannot be gradually reduced and stopped before the
administration of ECT, it may be better to continue the drug during ECT, perhaps in a
reduced dosage.
7.9 Hypnotics
Zopiclone can reduce seizure length when used the night prior to treatment. If it is
difficult to produce adequate seizures in patients taking this medication, it should be
stopped.
7.10
Lithium
Recommendations in the literature vary. The following guidance may be considered:
o If Lithium is having no benefit, stop before ECT commences,
o If Lithium is expected to continue during ECT, monitor for signs of
adverse effects (eg delirium, confusion) and maintain on the lowest
effective lithium level.
o If there are concerns about using Lithium during ECT, then consider a
switch to an alternative mood stabiliser, such as an antipsychotic, if the
risks outweigh the benefits of continuing Lithium.
7.11
Antipsychotics
Generally no special precautions required however clozapine may lower seizure
threshold so it may be prudent to start treatment at a lower electrical dose for the first
treatment. The manufacturers suggest that the drug is withheld for 12 hours prior to
each anaesthetic / ECT session and that the patient has their next dose after
treatment at the usual time if physically able.
7.12
Antidepressants
a)
SSRIs
A number of reports suggest that SSRIs taken during ECT may be related to
prolonged seizure activity, however, because of their long half life stopping them
immediately prior to ECT has no benefit.
-Young women with low fit thresholds may be more at risk.
-Prolonged seizure activity of 2-3 minutes has been reported with fluoxetine,
paroxetine and sertraline.
Because these problems have been reported in service users on SSRIs, and also
when they have recently been withdrawn, stopping drugs with shorter half lives such
as paroxetine (half life approx 24 hours) and sertraline (half life approx 26 hours) is
only recommended if a washout period of two weeks can be achieved. Fluoxetine
has a much longer half life (2 to 3 days), and a 3–5 week washout would be required.
In most clinical situations where ECT is being considered, such a long wait would not
be good or safe clinical practice. It is therefore recommended for service users premedicated with SSRIs that:
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-SSRIs should not be discontinued before starting ECT, unless a full washout, as
above can be achieved.
Treatment dose should be started with a low stimulus. Ensure all staff are aware of
the potential for prolonged seizure activity, and ensure that there is an agreed
decision on when the seizure should be terminated with the use of an intravenous
benzodiazepine.
Common
Less common
Citalopram (Cipramil) SSRI
Paroxetine (Seroxat) SSRI
Escitalopram (Cipralex) SSRI
Fluvoxamine (Faverin) SSRI
Fluoxetine (Prozac, Oxactin) SSRI
Sertraline (Lustral) SSRI
b)
Monoamine oxidase inhibitors (MAOIs)
o Phenelzine (Nardil), tranylcypromine (Parnate),
Do not need to be discontinued prior to ECT, but the treating doctor and
anaesthetist must be made aware due to potential interactions with
medicines used.
o Moclobemide -reversible inhibitor of MAO-A (Manerix)
It is recommended that Moclobemide is stopped 24hours before ECT.
c)
L- tryptophan may shorten seizures.
7.13
Antiepileptics
Are commonly used as mood stabilisers. They may raise seizure threshold, and
shorten seizure duration. The initial dose titration protocol is adjusted to allow for this.
If the antiepileptic drug is being used as a treatment for epilepsy, the dose titration
schedule is not adjusted. If antiepileptics are used for mood stabilisation, it is
probably best to continue then during ECT.
Antiepileptic drugs used for mood stabilisation
Common
Carbamazepine (Tegretol)
Phenytoin (Epanutin)
Sodium valproate (Epilim
Depakote)
Less common
Lamotrigine (Lamictal)
Rare
Gabapentin (Neurantin)
Levetiracetam (Keppra)
Oxcarbazepine (Trileptol)
Tiagabine (Gabitril)
Topiramate (Topamax)
References
Waite.J and Easton.A (Ed), The Royal College of Psychiatrists (2013) The ECT
Handbook: the forth report of the special committee on ECT and related treatments.
South West Yorkshire Partnership NHS Foundation Trust
Electroconvulsive Therapy Protocols
18
Bazire S., Healthcomm UK Ltd. Psychotropic drug directory 2007
Taylor D, Paton C, Kerwin R (Ed), Informa Healthcare. The Maudsley Prescribing
Guidelines 9th Edition
Clozaril Patient Monitoring Service (2010) Clozaril and General Anaesthesia
Factsheet. CPMS
Tobiansky, R.I (1991) Effect of the cyclopyrrolone hypnotic zopiclone on ECT seizure
duration. Journal of psychopharmacology, 5, 268-269
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8.
Day Case ECT
Service users requiring ECT as day cases require similar preparation as those having
ECT as in-patients (see 1.9). However, additional special requirements apply. The
liaison that normally takes place between the nursing, medical and ECT team is
significantly affected, it is therefore essential that effective communication between the
referring doctor, service user’s consultant and the ECT team takes place.
Factors to consider before referring patients for Day Case ECT.








Suicide risk.
Past History
Substance /alcohol abuse
Physical fitness to undergo and recover from a general anaesthetic.
Ability to retain information about their treatment and fulfil the safety requirements
pre- and post-treatment.
Social support network, i.e. a responsible adult who can remain with them posttreatment, transport to and from sessions with a responsible adult as the escort.
Input of care professionals, e.g. CMHT.
Compliance with the treatment plan, i.e. agreed attendance at the ECT clinic and
medical reviews.
In addition to the pre anaesthetic assessment that is located within the Treatment
Record a full physical assessment must be carried out as identified in the Trusts
Physical Health Policy, Appendix 1 (including VTE assessment). These can be found in
the ECT treatment record.
http://www.southwestyorkshire.nhs.uk/documents/430.pdf
It is essential that the referring doctor ensures a member of the ECT clinical team is
informed of all new service users requiring treatment, it is desirable that at least 48
hours notice is given. If the service user wishes to meet the ECT nursing staff or visit
the ECT suite the clinical staff are able to facilitate this as long as they are given
sufficient notice.
Service users for day case ECT must be ASA grades 1 or 2 physical status, and have
adequate social and professional support in place prior to treatment commencing. It is
the responsibility of the referring consultant to obtain consent and to ensure that
completion of day case documentation in line with Trust policy has been carried out.
The referring doctor must provide a copy of the Trust’s “Information for service user’s
documentation” in respect of ECT and Anaesthesia. The service user should be
advised to pay particular attention to the section on day case ECT.
The referring doctor must provide both written and verbal information about the special
requirements for day case ECT and both service user and doctor must sign the
consent forms. The service user must also sign the service user agreement form found
in the ECT record booklet.
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The referring doctor must identify the escorting responsible adult and the named
responsible adult that will remain with the service user for 24 hours following treatment.
The named responsible adult must sign the appropriate form found in ECT record
booklet.
The referring doctor together with the community mental health care worker is required
to complete the out-patient care plan found in ECT record booklet.
Service users requiring ECT as a day case must have full pre-treatment investigations.
All investigations must be carried out in time for the results to be available for the first
treatment sessions.
The medical assessment checklist must be completed by the referring doctor and be
available to the treatment team prior to the administering of the first ECT.
Service users receiving ECT as a day case must be physically fit to return home after
treatment has been administered, any doubts about physical fitness must be discussed
with the anaesthetist responsible for the ECT, as these service users may require inpatient provision in order to ensure adequate care/supervision can be provided.
It is essential that the service users are made aware of the importance of fasting prior
to anaesthesia.
Service users should be advised that they will need to remain in hospital for a minimum
of 2 hours post treatment and will be allowed to leave when the clinical team are sure
that they have recovered sufficiently from the effects of the treatment.
The service user must be advised that it is necessary that he is accompanied by the
responsible adult to and from the ECT department and have appropriate direct
supervision by a responsible adult for the 24 hour period following treatment, and that
he should not sign legal documents, travel alone, be in sole charge of children or
operate machinery/ power tools / appliances (including cookers, kettles & fires) which
may cause injury. Also alcohol should not be drunk for at least 24 hours following
treatment. The care pathway for out patient treatment must be followed (located in the
Treatment Record Booklet).
The service user must be given advice regarding driving.
See Driving and ECT protocol.
If transport to and from the ECT Clinic is required the treatment team nurse must be
contacted to make the necessary arrangements.
Pre treatment nursing checks are the same as required as a hospital in-patient but will
be undertaken by the ECT team.
Day patients are then escorted from the waiting room through ECT and recovery by a
ECT nurse.
Service users receiving ECT as a day case must have provision for assessment by the
medical team on a weekly basis. Clear written information with regard to clinical
response so far, changes in physical status, changes in medication, cognitive and or
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any other side effects should be recorded in the case notes as well as any treatment
recommendations/instructions for the ECT team.
It is good practice for the referring doctor to ensure that the service user’s GP has
been informed that the treatment is to be provided on a day case basis.
The ECT nursing team must be informed by a member of the medical team when the
service user has completed his course of treatment.
9.
Patients proceeding on a period of leave.
(Within the 24 hour period after receiving ECT)
Service users proceeding on a period of leave from hospital within 24 hours of
receiving an administration of ECT require the same preparation and aftercare as
patients receiving ECT as a day case.

The referring doctor must provide both written and verbal information about the
special requirements for proceeding on leave after ECT and both service user
and doctor must sign the service user agreement form found in the ECT record
booklet.

The referring doctor must provide a copy of the Trust’s “Information for service
user’s documentation” in respect of ECT and Anaesthesia. The service user
should be advised to pay particular attention to the section on day case ECT.

The referring doctor must identify the responsible adult that will remain with the
service user for 24 hours following treatment, and the responsible adult must
sign the appropriate form found in ECT record booklet.

Service users should be advised that they will need to remain in hospital for a
minimum of 2 hours post treatment and will be allowed to leave when the clinical
team are sure that they have recovered sufficiently from the effects of the
treatment.

The service user must be advised that it is necessary that he is accompanied
home, and have appropriate direct supervision by a responsible adult for 24
hour period following treatment and that he should not sign legal documents,
travel alone, be in sole charge of children or operate machinery/ power tools /
appliances (including cookers, kettles & fires) which may cause injury and
should not drink alcohol for at least 24 hours following treatment. The care
pathway for out patient treatment must be followed (located in the Treatment
Record Booklet).

The service user must be given advice regarding driving.
See Driving and ECT protocol.

Service users proceeding on a period of leave must be physically fit to return
home after treatment has been administered, any doubts about physical fitness
must be discussed with the anaesthetist responsible for the ECT.

Service users returning from leave on the morning of their next treatment must
be advised of the requirement for pre ECT fasting.
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10.
Stimulus Dosing
10.1 ECT Machine
ECT is administered by a constant-current, brief pulse ECT machine that is able to
deliver a range of dose from 25 mC to 1000 mC. The Thymatron System IV ECT
machine is used across the Trust. It should be used in the low – 0.5 or 2x programme.
10.2
Electrode placement
In bilateral ECT, the recommended position of the electrodes is the
bi-temporal positioning. See RCP handbook.
In unilateral ECT, the recommended position of the electrodes is the temporo-parietal or
d’Elia positioning, on the non dominant hemisphere. See RCP handbook.
10.3
Stimulus dosing
The most important decision taken by the ECT practitioner in the ECT clinic is the
selection of the electrical dose for the individual service user.

The selection of electrical dose for an individual service user (stimulus dosing) is
contingent upon the service user’s seizure threshold.

The initial seizure threshold cannot be reliably predicted for individual service
users based on demographic or clinical features. Empirical measurement is the
best available means of establishing the initial seizure threshold, by using a low
electrical dose (25-50 mC) as the first stimulation at the first treatment.

Exception may be in the management of life-threatening illness, where the rate
of
clinical improvement is critical. Here it would be better to estimate the
seizure threshold and calculate the treatment dose as per the dosing strategy.

The use of a fixed or standard electrical dose is no longer acceptable in nonurgent treatments.
10.4
Dosing strategy
Bilateral ECT:

The initial electrical dose should be at least 50% above (i.e. one-and-half times)
the seizure threshold.

Where emergency treatment is required to save life, the initial electrical dose
should be at least 50-100% above (i.e. 1.5 – 2.0 times) the seizure threshold.

If clinical improvement is inadequate after 4 treatments, doses up to 100%
above (i.e. 2.0 times) the seizure threshold are indicated. If after 3 more
treatments there is still no improvement then the dose is to be increased
further up to 150% above (ie 2.5 times) the seizure threshold.
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Unilateral ECT:

The initial electrical dose should be 400% above (i.e. 5 times) the seizure
threshold.

If clinical improvement is not satisfactory after 4 treatments, doses up to 700%
above (i.e. 8 times) the seizure threshold are indicated.
10.5
Dose adjustments during the course of treatment:
The seizure threshold may rise during the course of treatment. Unfortunately there is
only a modest correlation between the change in seizure duration and the change in
seizure threshold. Therefore clinical monitoring is the best guide to decide what, if any,
adjustment to the electrical dose is required during the course of treatment: lack of or
inadequate clinical improvement indicates a need for higher electrical dose, while the
emergence of significant adverse cognitive effects indicates that lower electrical dose
should be used.

Clinical monitoring may also affect the choice of electrode placement.
10.6

Missed seizures
If the necessary cerebral seizure activity has not been induced, the service user
should be re-stimulated with a higher electrical dose while still unconscious. Up to
three stimuli can be given in one session.

The extent to which the dose is increased will depend upon whether its purpose is
to establish a new, higher threshold or whether the re-stimulation is given to
maximize the clinical improvement.

The occurrence of a missed seizure should prompt a review of ECT and
anaesthetic technique as well as concomitant psychotropic drug treatment, to
identify any factors that may be modified to ease the induction of cerebral
seizure at the next treatment session.
10.7
Monitoring seizure activity
The aim of ECT is to induce a modified generalised cerebral seizure activity
characterized by tonic-clonic or grand mal convulsion; after the initial tonic contraction of
the muscles, there is a longer, clonic phase of rhythmic alternating contraction and
relaxation of muscles of the limbs on both sides of the body.
The modified seizure is characterized on the EEG by widespread high-frequency spikes
(polyspike activity) followed by slower spike and wave complexes, typically around 3
cycles per second, or Hertz (Hz). The modified generalized cerebral seizure is followed
by a phase of relative or complete suppression of electrical activity (postictal
suppression).
In the absence of EEG monitoring or if it is not reliable, the aim is to induce grand mal
convulsive activity on both sides of the body.
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10.8

Methods of monitoring
Timing of convulsion:
It is the responsibility of the treating doctor to see that the length of the generalized
convulsion is properly timed. The stopwatch should be started at the end of electrical
stimulation and stopped at the end of generalized (i.e. bilateral) clonic activity. This time
should be recorded on the prescription sheet of the ECT booklet. If isolated clonic
activity in a limb continues beyond generalized activity, this time should also be
recorded.
EEG monitoring:

EEG monitoring will be used routinely for all treatments. At least two-channel
(one channel from each side of the head) EEG monitoring is needed.
Prolonged seizure activity is a recognised adverse effect of ECT; it increases the risk of
adverse cognitive effects without any commensurate increase in efficacy. These are
treatable, if detected. (see termination of prolonged convulsion 10.12)
The risk of prolonged cerebral seizure activity is probably greatest at the first treatment.
Prolonged cerebral seizure activity may occur in the absence of prolonged convulsion.
Therefore, the appropriate method to detect prolonged seizure activity is EEG
monitoring.
Cuff technique:

This should be regarded as supplementary to EEG monitoring and when EEG
evidence is not conclusive.

This may be useful in the assessment of brief or apparently absent convulsions.
10.9

General aims of stimulus dosing
The seizure threshold i.e. the minimum amount of electrical charge (in mC)
required to induce a classical generalized tonic-clonic convulsion, is routinely
measured by an empirical titration method.

The aim is for the dose of electrical charge in subsequent treatments to be
clearly supra threshold and yet to avoid grossly supra-threshold doses, so as
to maximize efficacy while minimizing the adverse cognitive effects.

The only exception is where treatment is started in an emergency to save life.
It may be desirable to estimate the seizure threshold and treat with a suprathreshold dose to maximise the therapeutic effect.
10.10

Estimation of seizure threshold for Thymatron system 4
First treatment session:
The aim is to estimate the seizure, and ensure an adequate seizure. See
stimulus dosing schedule.
1st stimulation
Exceptions -
bilateral 50mC
unilateral 25mC
10%
5%
level 2
level 1
< 18 years – use lowest dose available
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- > 65 years – up 1 level
- service users on anti epileptic drugs as mood stabilisers, or regular
benzodiazepines - up 1 level
If no response (observation & EEG) , re-stimulate after 30 seconds
2nd stimulation bilateral 76mC 15% level 3
unilateral 50mC 10% level 2
If no response (observation & EEG), re-stimulate after 30 seconds
3rd stimulation
bilateral 151mC 30%
unilateral 353 mC 70%
level 5
level 7
If a partial seizure occurs (eg unilateral, focal) count as no response. Wait 1 minute
before re-stimulating and ensure adequate oxygenation of the service user.

2nd treatment session
If the seizure threshold has been identified in the first treatment session then the
treatment dose is:
bilateral ECT approx 50% higher – up 1 level
unilateral ECT approx 400% higher – up 4 levels
If at the first session no seizure had occurred the dose titration continues starting with
the next higher dose in order to identify the seizure threshold.
If seizure activity occurred at the 3rd stimulation then the seizure threshold is not
clearly identified and the 1st stimulation should be
bilateral ECT - 101MC - 20% - level 4
unilateral ECT - 76MC - 15% - level 3
in an effort to more clearly identify the seizure threshold and treatment dose.

3rd and subsequent treatments
The dose continues at previously identified supra threshold levels.
The seizure duration may reduce, which may suggest a raising of the seizure
threshold. This alone does not warrant an increase in dose. The best guideline is
clinical improvement. If clinical improvement is not satisfactory then the dose should
be increased.
If the initial dosing strategy brings about only slight or no clinical improvement after 4
treatments then doses up to 2.5 times the seizure threshold in bilateral ECT and up
to 8 times the threshold in unilateral ECT may be indicated.
Significant treatment-emergent cognitive adverse effects such as prolonged
disorientation after treatment may be an indication to reduce the electrical dose. The
management of such adverse effects should be discussed with the supervising
consultant.
10.11 Failure to induce convulsion:
The protocol has already covered how to proceed during dose titration.
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Stimulation may fail to induce a convulsion later on in a course of treatment if there
has been a marked increase in the seizure threshold (because of the ECT) or
because of a change in another variable e.g. prescription of an antiepileptic drug or
change in anaesthetic technique.
It is essential to re-stimulate with a higher dose. A small (25-50 mC) increase will be
appropriate if the idea is to establish the new higher threshold. But if the service user
is severely ill, it is better to assume (estimate) that the new threshold is 25-50 mC
higher than the failed stimulus and calculate the dose for re-stimulation as per the
dosing strategy.
10.12 Termination of prolonged convulsion:
A prolonged convulsion is one that lasts120 seconds (2 minutes) or more, and should
be terminated immediately, either by additional dose of induction (anaesthetic) agent
or by intravenous administration of a benzodiazepine drug in consultation with the
anaesthetist. Once a convulsion of about 90 seconds has been observed, then it
would be wise for the treating psychiatrist and anaesthetist to decide how the
convulsion is going to be terminated.
10.13 Tardive seizures
The late return of seizure activity may occur in the recovery room and the
anaesthetist should be alerted immediately. In this instance the EEG monitoring
should be reinstituted as soon as it is practical to do so. The tardive seizure should
be terminated by slow intravenous administration of a benzodiazepine drug given by
the anaesthetist.
10.14






Factors that influence seizure threshold
Age – increasing age is associated with increasing seizure threshold,
particularly in men.
Sex – seizure threshold is higher in men.
Electrode placement – seizure threshold is higher in bilateral ECT than in
unilateral.
Previous ECT – seizure threshold may rise during a course of ECT,
particularly bilateral ECT.
Anaesthetic drugs – excessive induction agent shortens seizures.
Pronounced effect with Propofol.
Concomitant drug treatment – Benzodiazepines, Antiepileptics, LTryptophan and centrally acting beta blockers may shorten seizures.
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Stimulus dosing schedule for Thymatron system 4
Refers to pre-set and x 2 programs only. No other programs should be used).
Suggested starting
points
Unilateral
Level
%
MC
1
5
25
Bilateral
2
10
50
3
15
76
4
20
101
5
30
151
6
50
252
7
70
353
8
100
504
9
150
756
10
200
1008
In over 65 years of age, start one level higher.
For service users on antiepileptics (as mood stabilisers) or regular benzodiazepines,
start one level higher.
For service users under 18 years start at the lowest dose.
Practical aspects of using the Thymatron 4 will be covered in the induction session.
Also, practical written information on using the Thymatron 4 can be found in the
Resource Folder located in the department. (ECT department nursing guidelines) or
in the Thymatron instruction manual(located in the department).
Reference documents
Waite.J and Easton.A (Ed), The Royal College of Psychiatrists (2013) The ECT
Handbook: the forth report of the special committee on ECT and related treatments.
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11.
Measuring time to reorientation post ECT
There may be a relationship between time to reorientation post ECT and later
memory impairments.

The time to reorientation is measured from when the patient enters the
recovery area.

The recovery nurse will ask the questions (as below) regarding orientation
when the patient is alert enough to be able to respond appropriately.

Questions are repeated every 5-10 minutes until reorientation, the time to
reorientation is documented in the patient’s Treatment Booklet.
Reorientation questions

Age

Day

Month

Place

Person (recognition of nurse or doctor)
A score of 1 is given for a correct answer. A score of 4 is taken as reorientation.
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12.
Escorting a service user undergoing ECT from an onsite ward
This protocol (where relevant) should be read in conjunction with the Trust’s policy on
Mental Health Act 1983 (amended 2007) section 17 leave, and the Observation
policy.
The level of escort is determined as per the Trust’s policy - Access and Escorts
Limits set under section 17 Mental Health Act 1983 (amended 2007) always take
precedence.
The person conducting the escort to and throughout the unit should wherever
possible, be a registered nurse. However, following a risk assessment, this duty may
be delegated to a suitably experienced health care worker. If this duty is delegated,
the registered nurse accountable for the decision continues to be responsible for the
escort process.
Staff acting as escort should be prepared to deal with queries raised by service users
in respect of clinical care, consent or Mental Health Act issues. Where the escort
feels he/she is unable to answer questions adequately, the escorting member of staff
must ensure that they are communicated to the treatment team on arrival at the unit.
As the escort back to the ward carries more risks, this duty is always led by a
registered nurse. If additional escorts are required these need not be registered
nurses, but must be suitably experienced and have received basic life support
training.
If the escort requires the use of motor transport, there must be a minimum of one
qualified nurse in each vehicle. The escorting staff in each vehicle must have access
to a mobile telephone.
Generally each service user should have an individual escort and it is desirable that
the escort knows the patient.
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13.
Escorting a service user undergoing ECT from an offsite ward
This protocol relates to the escort of patients from Dewsbury and Barnsley
Hospitals to Fieldhead and from any offsite ward to the Calderdale Royal,
Halifax for the purpose of undergoing ECT.
This procedure (where relevant) should be read in conjunction with the Trust’s policy
on Mental Health Act, 1983 (amended 2007) s17 leave
http://nww.swyt.nhs.uk/policies/mentalhealth/mha%20s.17.doc, and the Observation
policy. (http://nww.swyt.nhs.uk/Policies/Docstore/details.aspx?docid=289
Depending on the number of service users being transported it may be possible for
the number of escorts to be reduced (e.g. three patients / two escorts), but this would
be dependant on good communication between the referring wards and an
appropriate risk assessment.
At the point when a patient has been accepted for ECT at either the Fieldhead or
Calderdale ECT departments, the service user’s consultant psychiatrist (or a doctor
nominated by him/her) and a qualified nurse with direct responsibility for the patient,
determines the required escort. Limits set under s17 Mental Health Act 1983
(amended 2007) always take precedence.
This decision is recorded in the service user’s case notes, and a plan of care is
constructed which sets out clearly the escort requirements and any other relevant
information.
In determining the level of escort required, the service user’s history, presenting
behaviour and level of risk must be taken into account. Additionally, consideration is
given to the level of experience and confidence of those undertaking the escort and
also the relationship between the service user and member(s) of staff. Where
possible the patient is fully involved in this process.
Where more than one service user is being escorted for treatment e.g. patients
travelling from Dewsbury and Barnsley Hospitals or St Lukes Hospital, circumstances
may arise where one service user is an in-patient on the working age adult ward, and
another, an in-patient on the older people’s ward. On these occasions it may not be
necessary for each service user to have a qualified nurse escort from his/her
respective care area or indeed for both members of staff to have basic life support
training – just one may suffice.
Specific areas to consider:

The sex of the patient

Cultural/ethnicity issues

Is more than one escort needed? Consider carefully why this is a requirement,
what is the exact purpose of having a multiple escort?

Is this duty suitable for;
- pool staff
- student nurses
Care planning
In most circumstances the service user will be transported to Fieldhead or Calderdale
Hospital in a taxi and the care plan should reflect this. If this mode of transport is not
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suitable, then the care plan must indicate specifically what type of transport should
be used and why.
The level of observation prescribed, as per the observation policy, is taken into
account when determining the need for escort levels etc.
At the time of leaving the ward, all the staff involved in escort duties must be clear
about the responsibilities of undertaking the escort, and understand any conditions
which may apply. Importantly, the escorts must understand what is expected of them
in case of a psychiatric/medical crisis, or if the service user attempts to leave the
escorting staff.
Mental Health Act 1983 (amended 2007) considerations
For any detained patient, a current s17 leave form must be visually checked by a
registered nurse prior to the patient leaving his/her unit.
General notes
Nursing staff from each area should discuss escort requirements and determine the
level of escort required. It will not be generally necessary for each patient to have an
individual escort although it is desirable that the escort knows the patient. The
number of escorts required is a risk determined factor, and should be negotiated
between the in-patient wards as required.
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14.
Securing “Out of hours” ECT services
ECT treatment normally takes place on Tuesdays and Fridays 9am to 12.30pm at
Fieldhead and Mondays and Thursdays 9am to 1.30pm at Calderdale Royal Hospital.
In an emergency the first consideration should be liaising with the sister unit.
Otherwise it may be possible to arrange treatment on other days including weekends
and public holidays.
It should be borne in mind that this takes great organisational effort and should
not be initiated other than in cases of emergency.
ECT will only be carried out if an experienced team of practitioners are present for
the procedure.
The need for emergency ECT must be determined by a consultant psychiatrist.
He/she must be satisfied that the health of the service user will be severely
compromised if he has to wait until the next scheduled session. The referring
consultant should ideally discuss the case with a lead consultant for ECT.
Physical examination, appropriate investigations and valid consent / correct
MHA / MCA documentation, must be in place before arranging emergency ECT. If
the medical team have any concerns about the physical health or abnormal test
results of the service user, these should be discussed with the anaesthetist prior to
organising the treatment as service users assessed as ASA grades 4 and most ASA
3 are not treated in Fieldhead site but at Calderdale Royal Hospital. ASA levels 1, 2
and stable 3 only are considered for treatment on the Fieldhead site.
When the ECT clinic is open (see chart below) contact with the clinic staff is made
giving full details. The clinic staff will make the appropriate arrangements. The
referrer must ensure the clinic staff have there contact details as the anaesthetist or
ECT psychiatrist may need to discuss the service user’s clinical needs.
Fieldhead ECT clinic hours
01924 327439 / 327440
Mobile 07786666842
Monday
6.50am to 2.45pm
Calderdale clinic hours
Mobile 07795540264
Office 01422 222815
Monday 7.30am to 1.30pm
Tuesday
6.50am to 2.45pm
Thu
Thursday
6.50am to 2.45pm
Friday
6.50am to 2.45pm
7.30am to 1.30pm
When the clinic is not open, the senior nurse on duty from the referring area should
first consider contacting the sister unit, if open. If not, the senior nurse should attempt
to contact the most senior ECT nurse available via switchboard from the identified
locality. The ECT nurse will take details, and liaise with other team members
(anaesthetist, senior psychiatrist) if available, and will then advise the referring senior
nurse of treatment options.
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It is the responsibility of the referrer to organise transport and qualified staff escort to
the designated ECT unit.
One person from each column below MUST be available from the treating
locality. If this is not possible then the treatment cannot be provided, and
arrangements made for a different time, or for the next planned treatment
session
Definition. A “suitably trained psychiatrist” has completed parts 1, 2 and 3a of
the Royal College ECT Competencies and has been signed off as competent by
a supervising ECT doctor
Anaesthetists & ODP
Dr Paddy Oconnor
Dr Edwina Offori
Dr Noel Dwyer
Dr Piers Lesser
Dr Karen Bartholomew
Wakefield Locality
Nursing
Psychiatrists
Clare
SHO – Suitably trained (see note
Charles
above)
Helene
Dr Clive Cruickshank
Haughton
Amy Saville- Dr Vinod Shukla
Scott
Calderdale Locality
Angela
SHO – Suitably trained (see note
Brown
above)
Dr Uday Joshi
Anaesthetist – Suitably
trained
Dr R Badshah
The anaesthetist will liaise with the Acute Trust to ascertain the availability of an
Operating Department Person (ODP).
Plan the treatment for the next organised treatment session
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15.
Obtaining back up ECT apparatus
Each unit has a back up Thymatron system IV apparatus.
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16.
Induction of anaesthesia
Anaesthesia for ECT is a consultant led service and the following represents best
clinical practice.
1
Establish intravenous access.
2
Baseline monitoring, BP, Sp02, 3 lead ECG.
3
Pre oxygenate, unless service user is uncooperative.
4
Administer a sleep dose of intravenous induction agent, Propofol or
Thiopentone.
The dose of induction agent is decided by the anaesthetist having regard for
the service user’s physical fitness.
Because of the different effects on seizure threshold the same induction agent
should be used throughout a course of treatment, or changed only following
discussion with the psychiatrist.
At present Propofol is the induction agent of choice unless there is a
contraindication to it being so. At least two different anaesthetic agents are
stocked in clinic.
4
Administer Suxamethonium (initially 0.5mgs/kg) although the dose may need
to be adjusted on subsequent treatments depending on response.
5
Hyperventilate with 100% oxygen by bag and mask, using Guedal airway if
necessary until Suxamethonium takes effect.
6
Place the bite block between the service user’s teeth whilst treatment is
administered.
7
Re-insert Guedel airway if necessary and ventilate with 100% oxygen until
adequate respiration resumes.
8
Pulse oximeter is routinely used during anaesthesia.
9
ECG monitoring is routinely used during anaesthesia.

If more than two stimuli are required during the titration phase it may be
necessary to administer a further dose of Propofol and Suxamethonium
(typically half induction dose). It may be necessary to treat bradycardia with
Atropine or Glycopyrronium bromide (Glycopyrrolate) if a second dose of
Suxamethonium was required.

If a service user cannot receive Suxamethonium it is possible to use a small
dose of Vecuronium (0.05mg/kg) or Mivacurium 0.2mg/kg. However the
paralysis will last longer than the anaesthesia produced by a single dose of
induction agent and increments or an infusion will be required. Reversal of
relaxants may be needed. Neither Suxamethonium or Mivacurium must not
be used in patients known to have “ scoline apnoea”
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.
This regimen should only be used after full discussion between the members
of the treatment team.

If vascular access is not possible, then gaseous induction with Sevoflurane
provides acceptable anaesthesia for ECT. A second anaesthetist should
ideally be present to assist with I.V access in cases of known difficulty with airway
or difficult I.V access.
There are no facilities for this at Fieldhead and service users needing gaseous
induction should have their treatment transferred to the Royal
Calderdale Hospital.
Minimum monitoring and full resuscitation equipment must be available during
anaesthesia in accordance with AAGBI guidelines.
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17.
Management of Suxamethonium Apnœa
1
If service user remains apnœic after 5 minutes use the nerve stimulator to
assess neuromuscular block.
2
If twitch pattern is suggestive of prolonged action of Suxamethonium then
maintain the sedation of the service user by boluses of sedative, e.g. Propofol,
or set up Propofol infusion, or use a volatile agent.
3
Use appropriate airway device (LMA or ET tube).
For Briarfields.
4
Ring Pinderfields Hospital Critical care Unit (CCU) as first choice 01924 541985
then Dewsbury ICU 01924 816101 as second choice to ascertain whether they
have an ICU bed. If neither have a bed available ask Dewsbury ICU for the
Critical Care Network telephone number details.
5
Cancel remainder of ECT session service users.
6
Once location of an ICU bed has been identified the call 9/999 for paramedic
ambulance to transfer the service user.
After transfer continue management in accordance with Mid Yorkshire Hospitals
Suxamethonium Apnoea protocol.
Contact the ICU to which the service user has been transferred, to test for
abnormal pseudocholinesterase deficiency genetic makeup.
For CRH.
In the case of Calderdale and South Kirklees, ECT is undertaken in the Calderdale
Royal Hospital, an acute District General Hospital, therefore the acute trust policy
will be followed.
Documentation / communications
Complete first responder scheme/service user report form and give to paramedic
team. (Located on the Emergency trolley).
Complete Adverse Incident form and send to Clinical Risk Management
Team. (Located in Health & Safety file).
Inform service user’s consultant and GP and service user’s family (if appropriate) of
transfer.
Inform line manager.
Anaesthetic entry to be made in service user’s file.
Nursing entry to be made in service user’s file.
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18.
Management of malignant hyperthermia
For Wakefield and North Kirklees
Although malignant hyperthermia is rare it has a high mortality if untreated.
Successful treatment of a malignant hyperthermia (MH) crisis depends on early
diagnosis and aggressive treatment. The onset of a reaction can be within minutes
of administration of SUXAMETHONIUM (or volatile agent) or more insidious.
Previous uneventful anaesthesia does not exclude MH. Temperature rise may be a
late sign.
Consider MH if:
1 Unexplained increase in end-tidal CO2 despite adequate ventilation together
with
2 Unexplained tachycardia, together with:with
3 Unexplained increase in oxygen consumption.
OR
4 An unexplained increase on body temperature of 2OC per hour.
The facilities for the successful management of an MH crisis at Fieldhead are
limited. Therefore urgent arrangements must be made to transfer the service
user to Pinderfields A&E by 9/999 ambulance.
Initial Management – Use AAGBI MH Protocol.
Cooling measures; ie ice/cool packs to femoral and axillary areas.







Re-anaesthetise if necessary and continue anaesthesia with propofol by
infusion.
Ventilate with high flow 100% oxygen. (As volatile agents are never used at
Fieldhead there is no need to change circuits).
Paralyse with a suitable dose of vecuronium and intubate the trachea.
Establish large bore IV access if possible.
Mix and administer dantrolene 2.5mg/kg IV.
Continue or re establish full monitoring and treat arrhythmias as appropriate.
U&E’s for potassium level and ABG’s.
Contact Pinderfields A&E to alert them.
Tel no’s:
Major base 01924 541765
Minor base 01924 541754
Reception
01924 541740
Co- ordinator 01924 541756
Contact Pinderfields CCU 01924 541985/541990 Ask for assistance either on
site or in A&E.
Ring 9/999 for paramedic transfer
Documentation / Communications
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






Complete first responder scheme / service user report form and give to
paramedic team. (Located with the AED machine).
Complete adverse incident form and send to Clinical Risk Management team
(Located in Health and safety file).
Inform referring Consultant, GP and service user’s family of transfer
Inform line manager.
Anaesthetic entry to be made in service users file.
Nursing entry to be made in service user’s file.
After transfer, management will be continued in accordance with Mid
Yorkshire Hospitals MH protocol.
For Calderdale and South Kirklees
The Calderdale Royal Hospital Acute Trust protocol will be followed.
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19.
Dantrolene reconstitution for use in malignant hyperthermia - Fieldhead
ECT Department
Stock located in drug cupboard in store room

Dantrolene sodium 20mg vial for reconstitution x 12.

Water for Injections 100ml for mixing x 12.
Note: as dantrolene is poorly soluble in cold water, the water for injection
must be stored at room temperature.

50 ml Syringes.
Reconstitution: Each vial of Dantrolene should be reconstituted by adding 60ml of
room temperature water. Shaking well until the solution is clear.
Dosage and administration: As soon as the MH is recognised all known
anaesthetic trigger agents should be stopped, but propofol can be used to continue
anaesthesia if necessary, with NDMR (non-depolarising muscle relaxant).
An initial dose of Dantrolene 1mg/kg should be given rapidly directly into the vein. It
must not be mixed with other intravenous infusions.
If the symptoms persist or reappear this dose should be repeated up to a cumulative
dose of 10mg/kg.
Clinical experience to date has shown that the average dose of intravenous
Dantrolene to reverse the manifestations of MH has been 2.5mg/kg. If a relapse or
reoccurrence occurs, intravenous Dantrolene should be re administered at the last
effective dose.
Calderdale Royal Hospital
ECT Department Day Case Procedure Unit
In the event of a malignant hyperthermia crisis
12 ampoules of Dantrolene are kept within the recovery area of main theatres.
An agreement has been reached with both the Elland Independent and the
Huddersfield Royal Infirmary to provide further supplies.
As soon as a malignant hyperthermia crisis is identified immediate contact with both
hospitals must be made to provide further supplies.
If this occurs within normal working hours contact pharmacy who will organise
delivery.
If outside working hours contact both hospitals direct.
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The dantrolene will be dispatched immediately, a member of staff must be identified
to meet the carriers and bring the supply to the ECT department.
The telephone numbers are
Elland Independent 01422 324700
Huddersfield Royal Infirmary 01484 342000
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20.
Anaphylaxis management
For Calderdale and South Kirklees
The Acute Trust protocol will be followed
Fieldhead ECT Department
a) Recognition and management by doctors and nurses
Recognition

Profound hypotension. Pulse weak and fast, or very slow

Pallor, limpness, apnoea, collapse

Acute urticaria and itch

Hoarseness and stridor resulting from swelling of epiglottis and larynx

Tight chest, shortage of breath, audible wheeze.
Management
1.
Call for immediate assistance. Dial 9-999 and inform operator of the nature of
condition, age of service user and location.
2.
Secure the airway, attempt to restore blood pressure by lying the service user
flat and raising the feet. If unconscious, insert airway if competent to do so.
3.
Give1 in 1,000 (1mg in 1ml) Adrenaline (500micrograms/0.5ml to be given
intramuscularly) Check the time.
4.
The dose of adrenaline is repeated if necessary at five minute intervals
according to blood pressure, pulse and respiratory function.
5.
Oxygen administration is also of primary importance.
6.
Chlorphenamine maleate (Piriton) 10 - 20 mg may be given by slow
intravenous injection in a dose of 10-20mg by appropriately trained
individuals, it is a useful adjunctive treatment, given after adrenaline
injection and continued for 24 -48
hours to prevent relapse. Service
users receiving beta blockers or those receiving anti-depressants require
special consideration (please refer to British National Formulary).
7.
Continuing deterioration requires further treatment, including intravenous
fluids, intravenous Aminophylline or a nebulised beta 2 agonist (such as
Salbutamol or Terbutaline (refer to BNF), in addition to oxygen, assisted
respiration and possibly emergency tracheotomy may be necessary.
8.
An intravenous corticosteroid, e.g. Hydrocortisone (sodium succinate) in a
dose of 100 – 300 mg is of secondary value in the initial management of
anaphylactic shock, because the onset of action is delayed for several hours,
but should be given to prevent further deterioration in severely affected service
users.
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9.
When a service user is so ill that there is doubt as to the adequacy of the
circulation, the initial injection of adrenaline may need to be given as a dilute
solution by the intravenous route, for details of cautions, dose and strength,
please refer to the BNF and package insert.
NOTE: A maximum of 3 doses of intramuscular Adrenaline may be given. All
cases should be admitted to a general hospital for observation.
Important points to remember:
1.
Correct route for administering Adrenaline is intramuscularly.
2.
The Adrenaline should be injected into the arm or leg opposite the site of the
injection which led to the reaction and the limb massaged gently.
3.
Take care not to inject the adrenaline into a blood vessel as the service user
could suffer from the severe cardiac effects of the Adrenaline.
4.
Administering IM Adrenaline should not do any harm if the nurse has made an
incorrect diagnosis, although very few conditions can be mistaken for
anaphylactic shock.
The nurse should always commence treatment for anaphylactic shock and not
wait for help to arrive.
Continued observation should be carried out therefore transfer to Pinderfields
General Hospital to be arranged using paramedic ambulance.
Tel 9/999.
Documentation/communications
Complete first responder scheme / service user report form and give to paramedic
team (located with the AED machine).
The reaction should be reported to the Medicine and Healthcare Products Regulatory
Agency (MHRA) using the yellow card system. Located in BNF.
Complete adverse incident form and send to Clinical Risk Management team
(located in Health and safety file.)
Inform referring consultant and GP and service user’s family of transfer.
Inform line manager.
Anaesthetic entry to be made in service user’s file.
Nursing entry to be made in service user’s file.
After transfer management will be continued in accordance with Mid Yorkshire
Hospitals Anaphylaxis protocol.
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21.
Management of ECT in pregnancy
There is little research on the use of Electroconvulsive Therapy (ECT) during
pregnancy.
Benefits of ECT include avoidance of risk of psychotropic drugs especially during the
first trimester of pregnancy.
Adverse effects of ECT include:

Induction of premature labour with contractions and bleeding
Reason
Oxytocin is released by ECT seizures resulting in increased uterine tone, stimulation
of contractions and induction of labour.
Management
Obstetrician to review, who may suggest ritodrine (beta agonist).

Foetal distress (bradycardia)
Reason
ECT activates both parasympathetic and sympathetic systems with release of
acetylcholine and catecholamines. The catecholamines cause vasoconstriction
decreasing the blood flow to the uterus and placenta with potential hypoxemia of
foetus.

Maternal hypoxaemia
Reason
The pregnant woman has decreased functional residual capacity due to the enlarged
uterus, she will also have increased oxygen requirements.
Some pregnant women (1%) have reduced pseudocholinesterase activity resulting in
prolonged action of suxamethonium (succinylcholine).
Management Plan for pregnant women
In Calderdale and South Kirklees
The Acute Trust protocol will be followed.
In Wakefield and North Kirklees
The general rule for treating pregnant service users at Fieldhead is:

Pregnancy less than 18 weeks will be considered for treatment at Fieldhead
site.

Pregnancy more than 18 weeks would be considered for treatment on the
Calderdale Royal site.

As well as the usual routine pre-operative assessments required for all ECT
service users, an obstetric assessment must be carried out prior to the
treatment commencing. The anaesthetist must be informed the day before the
first treatment in order to finalise arrangements.
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
The referring psychiatrist must ensure that the service user is booked in under
the care of a consultant obstetrician. A review of the service user must be
carried out in order to determine whether she is considered to be a low or
high risk pregnant service user with regard to receiving both an anaesthetic
and an ECT treatment and a MDT meeting should take place.

Following MDT meeting if she is deemed to be a high risk (or more than 18
weeks pregnant) service user from the obstetric point of view, she will be
offered ECT at the Calderdale
Royal Hospital as there are onsite maternity
and obstetric facilities available.

Discussion between consultant psychiatrists from both areas must take place
regarding whether the service user’s care is transferred to the Calderdale
Royal Hospital or carried out as a day case, whilst still an in-patient at
Fieldhead.

Following MDT meeting if the service user is thought to be a low risk and
(less than 18 weeks pregnant) she will be offered ECT at Fieldhead with a
clear individual management plan as directed by the consultant obstetrician.

Wherever possible the case should be the first on the ECT list.
If treatment is given on the Fieldhead site, and an obstetric problem arises,
then immediate contact should be made with the triage midwife at Pinderfields
Hospital and transfer across.
On Calderdale Royal site contact to be made with the on call obstetrician.
Premedication
Acid aspiration prophylaxis (routine after first trimester)

Ranitidine 150mg night before at 22:00 and morning of treatment at 07:00.

Lansoprazole on morning of treatment at 07:00.

Sodium citrate 0.3M 30mls given in the ECT prep room about 15 minutes prior
to administration of anaesthetic.

The anticholinergic of choice prior to ECT to protect against bradyarrhythmia
and limit respiratory secretions is glycopyrronium bromide (glycopyrrolate).

Consider using a wedge to displace the uterus laterally to decrease the
incidence of supine hypotensive syndrome from about 16thth week of
pregnancy onwards.

Preoxygenate for at least three minutes prior to induction of anaesthesia and
hyperventilate in order to prevent hypercapnia.

Consider LMA airway for women 13-18 weeks pregnant.

Second generation LMA igel to be considered.
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
Consider endotracheal intubation in women in second trimester of pregnancy
(or above 16 weeks).
Further information regarding the Early Pregnancy Unit at Pinderfields Hospital can
be found in the leaflet “Early pregnancy information for referral criteria” produced by
the Mid Yorks Acute Trust. This leaflet should be located in the policy/protocols file
within the Fieldhead department.
Documentation/communications should be completed if there is an incident
with the service user that requires transfer from Fieldhead to Pinderfields
Hospital.
Complete first responder scheme / service user report form and give to paramedic
team (located with the AED machine).
Complete adverse incident form and send to Clinical Risk Management team
(located in Health and safety file).
Inform service user’s consultant, GP and service users’ family of transfer.
Inform line manager.
Anaesthetic entry to be made in service user’s file
Nursing entry to be made in service user’s file
References
Gen hospital psychiatry 1994 16(5) 348-53
NICE clinical guideline 45
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22.
Cardio pulmonary resuscitation (CPR)
The South West Yorkshire Mental Health Trust policy for CPR will be followed as per
the locality specific appendices.
1.
Check for any risk to you, the service user, or any others.
2.
Service user assessed as unresponsive.
3.
Establish absence of normal breathing.
4.
Shout for help or trigger personal alarm.
5.
Ask for 9/999 or 112 call to be made.
6.
Maintain CPR at ratio of 30:2 (30 compressions: 2 rescue breaths).
7.
Connect to ECG monitor.
8.
Ask for AED to be brought to service user, attach pads and switch on.
9.
Follow the AED voice prompts.
10.
Ensure that no one touches the service user whilst the rhythm is being analysed.
11.
Continue as directed with voice prompts until paramedic help arrives.
Documentation/Communications
Complete first responder scheme/service user report form and give to paramedic team.
(Located with the AED machine).
Complete CPR record.
Copy to be sent to Clinical Risk Management team and a copy filed in service user’s file.
(Located in Health and safety file).
Complete adverse incident form and send to Clinical Risk Management team.
(Located in Health and safety file).
Inform service users consultant, GP and service user’s family of transfer.
Inform line manager.
Anaesthetic entry to be made in service user’s file.
Nursing entry to be made in service user’s file.
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23.
Management of failed intubation
For Calderdale and South Kirklees
The Calderdale Royal hospital acute trust policy and algorithm should be followed.
Fieldhead ECT unit.
Endotracheal intubation is not normally undertaken as part of anaesthesia for ECT in
this unit. If the anaesthetist feels that the service user should be electively intubated,
e.g. in the presence of severe reflux, or pregnancy after the first trimester, he/she
should be transferred to the Calderdale Royal Hospital where treatment can be
undertaken in a fully equipped theatre suite.
At Fieldhead, intubation is only likely to be necessary in an emergency situation such
as cardio-respiratory collapse, suxamethonium apnoea or malignant hyperthermia.
The extreme rarity of these events in the ECT unit at Fieldhead makes it unrealistic to
stock all the equipment required by Difficult Airway Protocol.
In the event of failed endotracheal intubation –
1. Maintain oxygenation if possible using a bag and mask and a Guedel or
nasopharyngeal airway.
2. Repeat laryngoscopy after attention to head position, using a smaller tube, stylet
or bougie as appropriate.
3. If 1&2 are unsuccessful either
a. Attempt to ventilate using a Laryngeal Mask Airway.
b. Attempt to ventilate using a Frova bougie and Rapi-fit connector.
4. If all the above are unsuccessful proceed immediately to Cricothyrotomy using a Melker Catheter.
In all cases consider urgent transfer to Pinderfields General Hospital by ringing
9/999 for a paramedic ambulance
Documentation/communications
Complete first responder scheme / service user report form and give to paramedic
team. (Located with the AED machine).
Complete adverse incident form and send to Clinical Risk Management team
(Located in Health and safety file).
Inform service user’s consultant, GP and service user’s family of transfer.
Inform line manager.
Anaesthetic and nursing entry to be made in service user’s file.
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Appendix 1- Equality Impact Assessment Tool
To be completed and attached to any policy document when submitted to the Executive Management Team for
consideration and approval.
Yes/No
1.
Comments
Does the policy/guidance affect one group less or
more favourably than another on the basis of:
 Race
 Ethnic origins
travellers)
NO
(including
gypsies
and
NO
 Nationality
NO
 Gender
NO
 Culture
NO
 Religion or belief
NO
 Sexual orientation including lesbian, gay
and bisexual people
NO
 Age
NO
 Disability - learning disabilities, physical
disability, sensory impairment and mental
health problems
NO
2.
Is there any evidence that some groups are
affected differently?
YES
3.
If you have identified potential discrimination,
are any exceptions valid, legal and/or justifiable?
NO
4.
Is the impact of the policy/guidance likely to be
negative?
NO
5.
If so can the impact be avoided?
N/A
6.
What alternatives are there to achieving the
policy/guidance without the impact?
N/A
7.
Can we reduce the impact by taking different
N/A
action?
If you have identified a potential discriminatory impact of this policy, please refer it to the Director of Corporate
Development or Head of Involvement and Inclusion together with any suggestions as to the action required to
avoid/reduce this impact.
For advice in respect of answering the above questions, please contact the Director of Corporate Development
or Head of Involvement and Inclusion.
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Appendix 2 - Checklist for the Review and Approval of Procedural Document
To be completed and attached to any policy document when submitted to EMT for consideration and approval.
Title of document being reviewed:
1.
2.
4.
5.
6.
Comments
ECT policy and protocols
Title
Is the title clear and unambiguous?
YES
Is it clear whether the document is a guideline,
policy, protocol or standard?
YES
A set of protocols
Rationale
Are reasons for development of the document
stated?
3.
Yes/No/
Unsure
YES
Development Process
Is the method described in brief?
YES
Are people involved in the development identified?
YES
Do you feel a reasonable attempt has been made to
ensure relevant expertise has been used?
YES
Is there evidence of consultation with stakeholders
and users?
?
Content
Is the objective of the document clear?
YES
Is the target population clear and unambiguous?
YES
Are the intended outcomes described?
YES
Are the statements clear and unambiguous?
YES
Evidence Base
Is the type of evidence to support the document
identified explicitly?
YES
Are key references cited?
YES
Are the references cited in full?
YES
Are supporting documents referenced?
YES
Approval
Does the document identify which committee/group
will approve it?
D&TTAG
If appropriate have the joint Human Resources/staff
side committee (or equivalent) approved the
document?
7.
Dissemination and Implementation
Is there an outline/plan to identify how this will be
done?
Does the plan include the necessary training/support
to ensure compliance?
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Unsure
YES
51
Title of document being reviewed:
8.
Yes/No/
Unsure
Document Control
Does the document identify where it will be held?
YES
Have archiving arrangements for superseded
documents been addressed?
9.
10.
Comments
On intranet
To do
Process to Monitor Compliance and
Effectiveness
Are there measurable standards or KPIs to support
the monitoring of compliance with and
effectiveness of the document?
YES
Is there a plan to review or audit compliance with
the document?
YES
Review Date
Is the review date identified?
YES
April 2011
Is the frequency of review identified? If so is it
acceptable?
11.
Overall Responsibility for the Document
Is it clear who will be responsible implementation
and review of the document?
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Appendix 3 - Version Control Sheet
This sheet should provide a history of previous versions of the policy and changes made
Version
Date
Author
Status
Comment / changes
1
January
2007
Clive Cruikshank
2
April 2009
Clive Cruikshank
3
December
2011
Clive Cruikshank
Approved
by D&T
Updated in line with new guidance
Approved
by D&T
1. Capacity assessments on
incapacitous patients receiving ECT
should be undertaken in the 24 hours
prior to treatment (the Treatment
Record has been amended to make this
clear).
Driving and ECT is quite complex, but
generally speaking patients should be
advised that they should not drive
during a course of ECT (particularly
relevant for patients on leave or
receiving ECT as a day case), and for a
period of time following the completion
of the ECT course (see protocols and
DVLA guidance). This is more to do
with the severity of the depression
rather than the ECT.
4
May 2015
Clive Cruickshank
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