TOPIC 4: ECT

• an italian psychiatrist and neuropsychiatrist, together research and discover the method of electro-magnetic shock treatment or ECT


  Lucio Bini and Ugo Cerletti
• Still stigmatized – he has suggested the use of the term electrocortical therapy

  Paul Greengard
• • Major depression, especially if suicidal or refusing to eat
  • Severe Mania and Catatonic subtype

  Electroconvulsive Therapy indications
• • MI in the past 6 months
  • Pregnancy is not a contraindication!
  • Increased intracranial pressure
  • Recent cerebral infarction
  • Aneurysm


  Contraindications: NO ABSOLUTE CONTRAINDICATIONS
• • ECT affects the cellular mechanisms of memory and mood regulation
  • All neurotransmitters systems are affected by ECT
  • Clue to mechanism (neurochemical): Focus on changes in neurotransmitter receptors and second-messenger systems

  Mechanism of Action
• • Best effect: from high-intensity, bilateral stimulation
  • Weakest effect: from low-intensity, unilateral stimulation


  Effectiveness
• Pretreatment evaluation:

  • Standard physical, neurological, and pre-anesthesia examinations, with complete medical history
  • Lab evaluations: blood and urine chemistries, a chest x-ray, and ECG.
  • Dental exam for elderly patients, and patients with inadequate dental care.
  • X-ray of spine if with evidence of spinal disorder.
  • CT/MRI if seizure disorder or space-occupying lesion is suspected (not an absolute contraindication anymore but ECT must be done by expert)
• Theophylline is CONTRAINDICATED – increases duration of seizures.
• Clinical Guidelines - Premedications

  • NPO 6 hours prior to treatment
  • Check for dentures
  • Insert IV line Use a bite block
  • 100% O2 is administered at 5lpm during procedure until spontaneous respiration returns
  • Ready with emergency airway
• Muscarinic Anticholinergic Drugs:

  • Usually atropine: 0.3 – 0.6 mg per IM or SC 30-60 minutes prior to anesthetic OR 0.4 to 1.0mg IV 2-3 minutes prior to anesthetic.
• Anesthesia:

  • GA and oxygenation required.
  • Should be as light as possible to minimize adverse effects and avoid elevating seizure threshold.
• • Methohexital (0.75-1.0mg/kg IV bolus)
  • Etomidate (0.15-0.3mg/kg IV)
  • Thiopental (2-3mg/kg IV)


  Anesthesia
• Clinical Guidelines – Monitoring Seizures:

  • A good seizure lasts at least 25 seconds.
• Failure to induce seizures:

  • Up to 4 attempts at seizure induction
  • May be delayed by 20-30 seconds
  • Check skin placement
  • Change anesthetic agent
  • Hyperventilation or administration of caffeine sodium benzoate 5-10 minutes before the stimulus can lower the seizure threshold.
• Physical Symptoms

  • Vomiting
  • Memory loss
  • Jaw pain
  • Muscle Ache
  • Headache
  • Nausea