Download ECT Guidelines Indications and Overview Preparation

 ECT Guidelines Rev: 9/11/2014 Author: Dr. Sheryl Marks MD Reviewers: Dr. Ken Mellman MD, Dr. David Avery MD Indications and Overview Primary Diagnostic Indications: Major Depressive Disorder, Bipolar Disorder, Schizophrenia Other: psych conditions including schizoaffective disorder and psychotic disorders NOS Secondary Diagnostic Indications: Medical conditions with psych syndromes and often associated with symptoms of suicidal ideation, severe weight loss, catatonia Parkinson’s Disease, Intractable Seizure Disorder, Chronic Pain, Neuroleptic Malignant Syndrome Efficacy in treatment­resistant depression: After 3 failed medication trials, remission with additional meds is approx 15% After 3 failed medication trials remission with ECT is approx 60% Duration: 10­15 min Expected Stay: often done as outpatient procedure, PACU stay is generally 45 min Preparation and Anesthetic Pre­op Evaluation: Currently EKG, CBC, BMP yearly Patients with CKD should have Cr and K repeated q 6 months at a minimum, more frequently if indicated. Pre­op and set­up considerations: Set up should facilitate rapid turnover of cases. The RN will generally turn over the circuit between cases. Prior to patient entering room: IV placed by preop RN Anesthesiologist to discuss whether any additional devices, studies or labs needed with psychiatrist (Cr, K last 6 months in CKD patients? Magnet for PM patients?) Confirm administration of any preop meds (Ofirmev, Maxalt, Imitrex, Naprosyn, Scopolamine) Patient enters the room: Focused H&P with anesthesiologist, safety pause Monitors placed while patient speaks with psychiatrist Pre­O2 and IV induction (please use IV lidocaine if inducing with Etomidate) Benzo reversal after induction Right foot circulation is isolated by a BP cuff prior to paralytic administration to observe seizure activity Paralytic administration Anticholinergic administration if patient is prone to bradycardia Patient is HYPERVENTILATED­this lowers seizure threshold and may prolong seizure time. The psychiatrists have requested that hyperventilation routinely be performed for all patients. Bite block placed prior to stimulation Induction: A GA with IV methohexital induction and mask ventilation is the most common (>99%) type of anesthetic for these patients (endotracheal intubation or LMA may be required if clinically indicated) Rarely an inhaled induction may be indicated for severe needle phobia or difficult IV access, the safety of which will be evaluated on a case­by­case nature. Rarely, a PICC line may be indicated in patients with difficult PIV access requiring frequent treatments. Standard dosing of induction agents are chosen: methohexital 1mg/kg. Methohexital will ultimately be titrated down if prolonged sedation occurs or up for long onset time or awareness. See list of induction agents below. Paralysis: Succinylcholine is generally used however rocuronium may be substituted if clinically indicated. Sux will be titrated down for prolonged apnea or up for inadequate paralysis Paralytic necessary to decrease the risk of seizure related injuries such as compression fractures. (SUX ­the myalgia side effect decreases over time, usual contraindications to sux—hyperK, MH— should be considered) Post Procedure Air Hunger: Patients may experience prolonged sux paralysis (often with initial treatment prior to titrating sux dose). Pre­emptive treatment with propofol may be indicated with the first treatments to decrease the risk of air hunger. Emergence Delirium: Routinely treated with propofol Benzos may be added if propofol ineffective Haldol may be used in the case of severe agitation and aggression Dispo: PACU then to home or in­patient psych Communication with Proceduralist Many patients require a change in medication for: improving seizures, treating hemodynamic instability minimizing the risk of emergence awareness related to mismatched duration of induction agent and paralytic treating emergence delirium nausea, HA or myalgia pain post procedure. Please discuss whether any changes are indicated for treatment. Major Considerations Use of pro­convulsant drugs and maneuvers (HYPERVENTILATION) to increase the efficacy of the stimulus with the goal of optimizing seizure. The duration of seizure may be related to therapeutic effect. Potential for hemodynamic instability (arrhythmias) post­stimulus. Cardiac Effects of ECT: Sinus pause after ECT stimulus is VERY common due to parasympathetic outflow and may last up to 8 seconds (patients receiving non­convulsive stimuli are at highest risk of prolonged pause or arrest because the intense parasympathetic outflow from the stimulus is not counteracted by the sympathetic outflow of the seizure) At the onset of seizure, sympathetic outflow from the diencephalon through the spine sympathetic tract to the heart occurs and persists for duration of seizure. Rise in catecholamines peaks 3 minutes after the seizure onset resulting in HTN, tachycardia, and occasionally persistent arrhythmias (patient with h/o persistent severe arrhythmias may benefit from short acting beta blocker pretreatment) Following resolution of the seizure, parasympathetic tone remains high often causing a transient bradycardia with a return to baseline in 5­10 minutes. (some patients may require pre­treatment w/ anticholinergics) Neurologic Effects of ECT: Cerebral oxygen consumption doubles and cerebral blood flow increases significantly. ICP increases. Maintenance and Meds Induction Agents: Methohexital is the standard induction agent: (+)No change in seizure threshold (­)May cause hypotension (­)Intermittently unavailable Propofol: (+)May be used if methohexital is unavailable (+)May be used if patient has severe emergence delirium with other agents. (­)Increases seizure threshold (anticonvulsant) and thus requires increased electrical stimulus. (­)Decreases seizure length. (­)Patients often require more frequent treatments. (­)May cause hypotension Etomidate: (+)Decreases seizure threshold (proconvulsant) (+)Prolongs seizures (+)May be used when patients are having inadequate seizures/poor response to ECT (+)HD stable (­)More severe post procedural n/v (­)More painful on injection (pre­treat with lidocaine) (­)Adrenal suppression Ketamine: (+)Decreases seizure threshold (proconvulsant) (+)Prolongs seizures (+)Decreased memory disturbances (+)HD stable (­)Longer acting and thus more post procedural somnolence (­)Dysphoria with induction doses, may benefit from post procedure BZ Pro­Convulsants (lowers seizure threshold): Hyperventilation Caffeine Benzo reversal (patient’s taking benzo’s will generally require FLUMAZENIL post induction and pre stimulation) Etomidate Ketamine Remifentanil Procedural Approach and Mechanism of Effect Patient's first treatment: After standard dosing for induction and paralysis, a low level electrical stimulus will be applied in increasing doses. Generally 1­4 stimuli are administered in increasing doses until a seizure is elicited. The seizure threshold is thus determined when the patient seizes. Subsequently, therapeutic seizure stimulus dose is then usually administered at 1.5­2x the pre­determined seizure threshold for bilateral ECT and 6x the seizure threshold for right unilateral ECT. Procedural Approach: Unilateral temporal (usually right sided) stimulus is almost always first applied. Bi­temporal stimulation used in the case of: severe initial clinical presentation, if patient fails to respond to therapy, or if seizure threshold is high and seizure is difficult to achieve with unilateral stimulation. Bi­temporal stimulation is associated with higher risk of post procedural cognitive deficits and memory loss. Mechanism of therapeutic effect: Unknown but theories include seizure mediated alterations in neurotransmitters, alterations in the HPA axis via regulation of stress hormones in the brain, mobilization of endogenous anticonvulsant which have anti­depressant effects and a neurotrophic theory suggesting neuronal and synaptic genesis. Adjuncts Adj Analgesia for Headaches: Routinely treated with IV Ofirmev Routinely treated with preop triptans (po Maxalt, SQ sumitriptan) Toradol may be added in patients without contraindications PONV: Routinely treated with ondansetron and dexamethasone Propofol may be added Scopolamine patch pre procedure may be added Droperidol (requires 2 hours of tele monitoring), IM Phenergan, Reglan, and Compazine may be added in discussion with the psychiatrist Co­morbidities and Contraindications Patient Co­morbidites: No absolute contraindications for ECT Potential Relative Contraindications requiring thorough work up and management: CHF—patients with compensated CHF generally tolerate ECT well though transient brief pulmonary edema may occur immediately post ECT (neurogenic stimulus to lung parenchyma vs. transient decrease in CO) and generally resolves spontaneously. CAD—CAD should be medically or surgically optimized prior to ECT Valvular disease—critical AS should be surgically corrected prior to ECT Arrhythmia Pacemakers/AICD—proper CIED function should be confirmed pre treatment and AICDs should be converted from a demand to a fixed mode with magnet Intracranial Aneurysm—should be secured prior to ECT Pregnancy—fetal monitoring may be indicated when the fetus is viable (the fetus may be spared the neuro and cardiac physiologic stress of ECT due to lack of direct neuronal connection to the mother), may require GETA if patient is considered full stomach by gestational week Recent CVA—case reports indicate that complication rate with ECT is low and ECT may be first choice for post CVA depression Intracranial lesions—ECT may be safely performed in patients with intracranial space occupying lesions, vascular malformations and neurologic diseases after appropriate subspecialty work up. Medications—Anti­depressants are often continued during ECT treatment, and MAOI’s may also be continued though administration of sympathomimetic drugs should be avoided.