Download Anaesthesia for ECT

Anaesthesia for ECT
Dr Hannah Rose
April 2006
Overview
Introduction to ECT
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History
Indications
Practicalities
Side Effects
Anaesthesia for ECT
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Patient factors – Hx / Exam / Ix
Venue / Equipment
Conduct
Induction / Muscle relaxation
Recovery
History
1934 Von Meduna – Insulin
induced seizures for
schizophrenia
1938 Ugo Cerletti – Electric
shock induced seizures
Found to be more effective for
mood disorders. Popular in
1940’s and 50’s
1962 ‘One flew over the
Cuckoo’s Nest’
Waning popularity 60’s and 70’s
Safer (Mortality 2-5 : 100 000)
Indications
Life threatening illness
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Attempted suicide / strong ideation
Catatonia
Refusal of food / fluids
Depressive delusions / hallucinations
Prolonged / severe manic episode
Treatment resistance
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Depression
Mania
Schizophrenia (4th line treatment)
Patient choice
Practical Aspects
In- or out-patients
First / repeat visit
Consent
ECT suite
Anaesthetic Equipment
ECT machine
EEG monitor
Electrode placement
Dosing / duration
Anaesthetic
‘Shared’ Airway
Recovery / Home
SIDE EFFECTS
Safe low-risk procedure
Risks associated with anaesthesia
Cognitive dysfunction
Prolonged seizures (>3mins)
Injuries
Cardiac risks
Other – disorientation, h/a, PONV, weakness,
anorexia, muscle aches, confusion
Anaesthetic Considerations
HISTORY
Routine Hx
Previous Anaes Hx
IHD / MI / HT / Valvular
pathology /
Dysrhythmias
CVA / Raised ICP
HH / GORD / NBM
Diabetes
Medications
Drugs / Alcohol
Reliability
Consent
Examination and
Investigations
Behaviour
Airway (incl wobbly
teeth)
Vitals
Routine
Examination
Ix only as needed
Contraindications
Uncontrolled CCF
DVT (untreated)
Acute respiratory tract infection
Recent MI / CVA
Unstable major fracture
Untreated phaeochromocytoma
Raised ICP / untreated cerebral aneurysm
“A balance must be struck between risks of anaesthesia vs untreated depression. ECT
may be life-saving, under which circumstances there may be no absolute
contraindications”
Kelly and Zisselman (2000) Update on ECT in Older Adults. Journalof the American
Geriatrics Society , 48, 560-566.
Venue and Equipment
ECT Suite – Remote site !
Resuscitation equipment
Experienced Anaesthetist and
ODP
Minimum mandatory monitoring
+/- PNS
Tilting trolley / padded cot sides
Flow controlled oxygen supply +
suction
Anaesthetic / Emergency drugs
Airway / Circuits / Disposables
Clock
Mouth guards
EEG machine / ECT machine
Staffed recovery area
Written records
Conduct
IV access
Monitoring
Pre O2
IV induction
Muscle relaxant
Mouth block
Seizure induction
Recovery
Seizure Induction
Hyperventilation
Minor tonic, then clonic activity
Seizure pattern on EEG
Missed seizures
Prolonged / Tardive seizures
Haemodynamic responses
Induction agent
Methohexitone
 Barbiturate
 No longer available
 Lowered seizure threshold
Propofol
Phenol
 Widely used
 Increases seizure
threshold, reduces duration
 Better cardiovascular
stability
Etomidate
 Imidazole
 Greater haemodynamic
responses
 Longer seizures
 Useful in resistant cases or
abortive seizures
 PONV / HP axis
suppression
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Muscle Relaxation
Suxamethonium
Dose (0.5-1mg/kg)
Uses (Reduce muscle activity and injury)
Stimulus post-fasciulations
Non-depolarising if C / I
RECOVERY
Adequate no. of trained personel
Fully equipped
O2 until awake and maintaining Sats
Familiar escort
Written instructions
Questions ?