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LECTURE NO. 11 Electroconvulsive Therapy Learning Objectives Define ECT Describe the possible mechanisms of action of ECT State the indications, contraindications and adverse effects of ECT Apply the steps of nursing care to clients receiving ECT Definition Electroconvulsive therapy (ECT) is a procedure in which generalized seizures are induced by passing electrical current through the brain with the help of electrodes applied across the scalp. Historical Background Von Meduna (1934) observed that there was relief in the symptoms of schizophrenia after a client had generalized seizure. Ugo Cerletti and Lucio Bini introduced ECT in 1938. ECT was modified in 1951 with the advent of succinylcholine, a muscle relaxant. Historical Background (cont.) There have been numerous modifications in the electrical waveforms and electrode placements, making the procedure all the more safe and comfortable for the client. Mechanism of Action The mechanism of action remains uncertain. It is speculated that generalized seizure cause biochemical changes in the areas that control emotions, sleep and appetite. The neurotransmitter theory ECT corrects the levels of various neurotransmitters responsible for various psychiatric symptoms. Mechanism of Action (cont.) The neuroendocrine hypothesis ECT stimulates the hypothalamus and pituitary, causing release of various hormones which in turn control mood, appetite and sleep. Another hypothesis ECT alters the way chemical messages are passed in the brain by modifying various messenger systems involved in neurotransmission. Indications of ECT Clinical Indications: Life-threatening situations Suicidal Violence towards self or others Catatonia—refusal of food/water Poor response to drug treatment Intolerance to drug treatment, e.g. marked side effects Indications of ECT (cont.) Diagnostic Indications: Major depressive disorder especially with psychotic symptoms Acute schizophrenia Mania with over excitement Catatonia Others: NMS, Parkinson’s disease Contraindications There are no absolute contraindications to ECT although any condition that causes increased intracranial pressure calls for extra care and caution. Relative contraindications: – Recent myocardial infarction – Recent cerebrovascular accident – Intracranial mass – Retinal detachment Contraindications (cont.) – – – – Acute narrow angle glaucoma Congestive heart failure Uncontrolled hypertension Conditions associated with increased anaesthetic risk such as bronchial asthma and severe chronic obstructive pulmonary disease Pregnancy is not a contraindication. Pre-treatment Evaluation Detailed general physical examination Routine laboratory tests including complete blood count, complete urine examination and serum electrolytes Fundus examination Electrocardiogram Pre-treatment Evaluation (cont.) Assessment of dentition especially in the elderly Pre-anaesthetic consultation (PAC) Informed consent for both the ECT and the anaesthesia Pre-treatment Nursing Care Provide information and emotional support to the client and the family Complete pre-ECT protocols/documents Ensure a process of ongoing assessment of the efficacy of the ECT Prepare the patient the night before and on the morning of the ECT Nursing Care during ECT Escort the client to ECT room Introduce the client to the staff in ECT room Secure various monitoring leads as well as ECT electrodes in place Explain the procedure to the client as it takes place Monitor the vitals Post-treatment Nursing Care Monitor the vital signs Ensure the safety of the client especially if he is confused Give reorientation reminders to the client Frequently reassure the client to lessen the anxiety Post-treatment Nursing Care (cont.) Shift the client to the ward Communicate with the other nurses regarding the client’s condition, medications given, recovery pattern and any untoward incidence during ECT Assessment and Evaluation Review the progress of ECT. – improvement as well as side effects Document any changes prescribed for the next treatment. Communicate these with the family and the other members of the treating team. Adverse Effects of ECT Prolonged apnoea Cardiac arrhythmia Headache Confusion Amnesia Agitation Fractures and vertebral compression— rare