1. Introduction to the practice of Electroconvulsive Therapy (ECT)
Oliver M. Glass, MD Cornel N. Stanciu, MD
East Carolina University

2. Goals / Objectives
To give background to what ECT is and why it is used
To understand how ECT works
To explain what is needed before performing ECT
To understand how to perform ECT at Vidant Medical Center

3. History of ECT
Observational reports noted symptoms of dementia praecox (schizophrenia) were diminished when pts developed epilepsy such as after head traumas or neurological illnesses and that pts with epilepsy had a low incidence of psychosis
In 1934, Joseph von Meduna, a Hungarian neuropsychiatrist, used low doses of the stimulant Camphor to induce seizures (later switched to Metrazol (faster))
Observations: a= schizophrenic symptoms decrease after a seizure; b= it was incorrectly believed that schizophrenia and epilepsy cannot coexist in the same patient – hence inducing seizures would rid pts of schizophrenia.

4. History of ECT
- Metrazol induced seizures were used for 4 years until the introduction of electrically induced seizures (without the side effects of Metrazol) by Bini
First ECT treatment in Rome= by Meduna, Cerletti and Bini in 1938
Due to motor activity many experienced bone fractures
In 1950s Bennett developed curare (and ether)
Since 1950s, with the introduction of antidepressants and antipsychotics, use declined

5. Electrophysiological Principles
Ohm’s Law: I=E/R (I=current, E=voltage, and R=resistance)
Dose of electricity in ECT= milliCoulombs
Brain has low impedance (resistance), skull has very high impedance. Only 20% of applied charge actually enters the brain.
Seizure involves propagation of action potentials in a large percentage of neurons.

6. Mechanism of action
Neurotransmitter levels all increase in CSF following seizures resulting in down-regulation of post-synaptic B-adrenergic receptors (same change observed with all antidepressant treatments)
During a seizure, PET studies show an increase in BBB permeability and in cerebral blood flow, and metabolism
After seizure, blood flow and metabolism is decreased especially in the frontal lobes. Research shows this correlated w/ response.

7. Mechanism of Action
ECT itself acts as an anticonvulsant because its administration is associated with an increase in the seizure threshold as treatment progresses.
 When EEG is done 1-2 months following a session of ECT, records show large increase in slow wave activity located over the prefrontal cortex in pts who responded well to the ECT. Even though this wave pattern disappeared later, the clinical benefit persisted

8. Indications for ECT Major Depressive Episode / Disorder
Initial treatment when there is urgency (attempted suicide / strong ideas or plans; life threatening illness b/c of pts’ refusal of food / fluids) or when depressive illness associated with stupor, marked psychomotor agitation or depressive psychosis (delusions or hallucinations)
Pregnancy also a consideration
Treatment resistant depression that has failed 2+ antidepressants and/or augmentive strategies, especially in elderly
70% response rate
*Presence of melancholic feature increases likelihood of response.
*Elderly typically respond more slowly than younger individuals.

9. Indications for ECT (cont.)
Acute Schizophrenia
Usually reserved for those whom Clozapine has proven ineffective or intolerable
Pregnancy also a consideration
More effective for patients with catatonia, affective symptoms or who have marked positive symptoms

10. Indications for ECT (cont.)
Mania (Bipolar I disorder)
Usually reserved for severe mania associated with life threatening physical exhaustion or treatment resistance (mania unresponsive to mood stabilizer + antipsychotic)
Pregnancy also a consideration
Effectiveness at least equal to Lithium
  *ECT should be carefully used in patients who are on lithium, as lithium may increase possibility of delirium and increases the effect of succinylcholine
In all, patient choice and a previous experience of ineffective or intolerable medical treatment, or previous recovery with ECT, are relevant

11. Indications for ECT (cont.)
Catatonia
Reserved for those nonresponsive to benzodiazepines
Delirium
NMS
Hypopituitarism
Intractable seizure disorders
Parkinson’s disease (both motor and affective symptoms in those with disability despite medical treatment) and other movement disorders (ie. Huntington’s disease)
Others (ie. OCD, chronic pain syndromes, etc)

12. ECT less beneficial in:
Somatization disorder
Personality disorders
Anxiety disorders

13. Adverse Effects
Memory loss – greatest concern; most pts back to baseline within 6 months.
Back/muscle pain- NSAIDs
HA- pretreat with toradol or acetaminophen; also used after the procedure is ultram/Darvon;
ECT may induce migraine HA
Confusion and delirium –delirium may after ECT and may be hypoactive
N/V/dizziness ; N/V= pretreat with zofran (ondansetron), prochlorperazine
GERD= pretreat with shohl’s (sodium citrate)

14. Pre-treatment evaluation
Full H&P; with list of medications they have been tried on (and adequate trials of them); always ask about h/o head trauma, seizures, brain lesions, cardio vascular disease, any other medical conditions.
Ask about previous ECT treatment history- how long ago, how many, unilateral/bilateral/LART/medications used/any adverse events from the procedure
Ask about previous experience with anesthesia, and any adverse events with anesthesia, ask about sleep apnea,
Do a MOCA and a QIDS – for baseline
Have the patient, guardian, family watch the ECT video

15. Informed consent Consent form needs to be signed
A new consent form needs to be signed when transitioned to outpatient
Explain beneficial and adverse effects and alternative treatment approaches. Explain the disorder, its natural course and the option of receiving no treatment.

16. Pre-Medical Workup Standard physical and neurological examinations
-  Complete medical history
-  Labs- CBC, BMP, chest x-ray, EKG, if there is suspicion of loose teeth, then need to examine
(dental consult possibly) and have them removed ; spine x-ray if there is other evidence of spinal disorder, CT/MRI brain if suspicion of seizure disorder/lesions, or had head trauma (although a lesion is not an absolute contraindication)
Do not let patient’s drive for 24 hours after ECT- have to inform the patient of that

18. Medications: cautions
Benzos are usually tapered off, but flumazenil can be given right before ECT if needed.
Lithium may increase post-ECT confusion, but does not necessarily need to be discontinued
Avoid lidocaine (xylocaine) as it markedly increases seizure threshold; theophylline is contraindicated because it increases the duration of seizures;
Reserpine is contraindicated as its associated with further compromise of the respiratory and cardiovascular systems during ECT

20. Premedications/anesthesics/muscle relaxants:
NPO after midnight (may take only necessary medication such as synthroid with a few sips of water) generally 6 hours NPO prior to procedure
Depending on pt, analgesia (Ibuprophen/Ketorolac/Acetaminophen), antinausea (Phenergan/Compazine/Zofran), antiGERD (schols) may be given
Bite block placed in the mouth right before the treatment to protect teeth and tongue during the seizure – consider a dental consult if there are missing teeth or poor oral health (risk of excessive occlusal force to the opposing side)

21. Premedications/anesthesics/muscle relaxants (cont.)
100% oxygen administered (except for a brief period during the stimulation)- hyperventilation is required to lower seizure threshold- you will see anesthesiologist hyperventilate pts during re-treatment
To minimize oral and respiratory secretions, prevent asystole/bradycardia- muscarinic anticholinergic medications can be used before ECT, such as atropine. Another option is robinul (glycopyrrolate) as it is less likely to cross the blood brain barrier and less likely to cause cognitive dysfunction and nausea (but less cardio protective activity than atropine). We rarely use these medications here.

22. Anaesthetics
Brevital (methohexital) to 1.0 mg/kg—most commonly used-- short duration of action and lower association with postictal arrhythmias
Etomidate (does not increase the seizure threshold, hence can be used in the elderly)
Ketamine (6-10 mg/kg IM- does not increase seizure threshold, and has an antidepressant quality- may be used when patients are not getting adequate seizures with 100% current)
Propofol ( mg/kg IV- has anticonvulsant properties)

23. Muscle Relaxants
Given after the onset of anesthetic effect, usually within a minute.
Succinylcholine (depolarizing) quick action- ( mg/kg)- but 1 mg/kg mostly used. Will notice fasciculations which will indicate its onset of action- the disappearance of fasciculations especially in the feet (L foot especially is where you will most likely observe) indicates maximal muscle relaxation. ;
If pt has a h/o pseudocholinesterase deficiency, severe neuromuscular disease or burns, use nondepolarizing agents (curare/atracurium/rocuronium) instead. These will require reversal with physostigmine/neostigmine

24. Electrode Placement
Unilateral = less marked cognitive adverse effects at least in the first week or weeks after the treatment= electrode mostly in the right hemisphere - need to close the circuit by grounding the patient.
Bilateral= more rapid therapeutic response = introduced first- electrodes bifrontotemporally associated with a higher chance of cognitive effects
Modified bilateral= LART- was developed here and hence is widely used here. You get the best of both- quicker response similar to bilateral and less marked cognitive adverse effects. Other institutions have also been using this placement mode; but there is not much literature on it forthcoming study underway in our institution

25. Electrode Placement (cont.)
Starting with unilateral is the most common approach- due to favorable adverse effect profile; after 4-6 treatments if no improvements- move on to bilateral. Since the discovery of LART, you will see a lot of patients who don’t have cognitive issues being directly placed on LART treatments
But starting with bilateral treatments may be indicated for someone with severe depressive symptoms, marked agitation, immediate suicide risk, manic symptoms, catatonic stupor, and treatment- resistant schizophrenia
Ultra brief (pulse width <0.5ms) unilateral is becoming a popular method of treatment, however not practiced here yet

27. Electrical Stimulus
Modern ECT machines use a brief pulse waveform that administers the stimulus in 1-2 ms at a rate of pulses a second. Some machines use an ultrabrief pulse of 0.5 ms are thought to be not as effective. We use thymatron
Start with a current of 5 % in females and 10% in males – also it differs if its bilateral vs. unilateral for start current.
Establish seizure threshold- which may increase % during the treatment; threshold is higher in men than in women and higher in older than in younger adults.

28. Electrical Stimulus (cont.)
Common technique- start with an electrical stimulus that is thought to be below the seizure threshold for a patient and then increase this intensity slowly if no seizure is elicited.
The higher the stimulus the increased risk for cognitive side effects

30. Seizure
 Starts with the tonic phase (plantar extension) and then the clonic phase (muscle contractions are strongest in the face and jaw)
 A seizure should last at least 25 seconds to be effective - EMG should last 20 sec at least, and EEG at least 25 seconds to be effective
If no effective seizure or no seizure at all; may attempt 2 more times; but generally we attempt only one more time (a total of two attempts per ECT treatment). If re-treating may increase the stimulus current by % depending on various factors, prior to the second electrical stimulus.

31. Seizure (cont.)
Have to wait for seconds before administering the second stimulus. During the wait time, hyperventilation is preferred to lower the threshold;
Some may administer caffeine ( mg IV) or remifentanil right before the administration of anesthesia to lower the threshold

35. Treatments
Here the course of treatments are given 3 times a week (M/W/F) on average for MDD.
The average ECT treatments are 6-12 but can be more

36. Maintenance Treatments
Need to relapse 3 index courses of ECT treatments to qualify for maintenance treatments.
 Weekly, bi-weekly or monthly
 Technically maintenance treatment is pharmacological (hence think about the medications you want the patient to be on after ECT); but if a pt relapses, then maintenance ECT is effective in relapse prevention.
Literature states that the indications for maintenance ECT is rapid relapse after initial ECT,
Severe symptoms, psychotic symptoms, and the inability to tolerate medications.

37. Contraindications for ECT
No absolute contraindications
In pregnancy; fetal monitoring is generally unnecessary unless pregnancy is high risk
Pts with space- occupying CNS lesions are at increased risk of edema and brain herniation after ECT;
If lesion is small pre-treatment with dexamethasone is considered.
Electrode placements may also differ in these pts.

38. Contraindications for ECT (cont.)
Pts with increased intracerebral pressure or at risk for cerebral bleeding (aneurysms); are at risk during ECT as cerebral blood flow increases during the seizure. Controlling BP during treatment can lessen the risk.
Pts with recent MI are a high risk group- although risk is greatly decreased 2 weeks following MI; if someone has a pacemaker/cardiac conditions get cardiology consult for clearance of ECT.

39. Contraindications for ECT (cont.)
Pts with HTN, stabilize on oral antihypertensive before ECT is started. But can be controlled during the procedure – here with labetalol/hydralazine IV; can also use propranolol .

40. ECT Rotation
3 times a week – M/W/F; M and F = start time is 7 am; get there by 6:30 ; W= start time is 8 am; get there by 7:30 at least
Have ECT orders signed and released prior to pt going into PACU (generally 45 minutes prior to start time)
ECT order sets- inpatient and outpatient
ECT notes: 2 notes for inpatient ECT and 4 notes for outpatient ECT – to be completed before the patient leaves the PACU – (dot phrases)

41. ECT Rotation
Update the ECT treatment flow sheet with recent ECT treatment Procedure itself
Talk to patients on how they are doing prior to the procedure for the subjective part of your notes and to monitor their progress

42. ECT Procedure
Megan and PACU nurse will assist with placing electrodes and EKG leads on the patients. Helpful to assist Megan with electrode placement, so that to know where each lead goes.
You have to place the electrodes on the right foot- gives the EMG reading- one right below the medial malleolus and the second on the dorsum of the foot.
You have to tie the BP cuff on the right foot (for simplicity we use right foot all the time)- do not inflate the cuff yet
Have a stop watch with you. Reflex hammer and other instruments will be already available.

43. ECT Procedure (cont.)
Have to do time out (either attending or you). Confirm the current stimulus, medications and dosages being used (the anesthetic and the muscle relaxant; any pre-treatment medications, any additional medications)
Anesthesia will give the anesthetic. Once you feel patient is going under, inflate the BP cuff and clamp it to avoid deflation. This will block blood flow (and any subsequently administered muscle relaxant) to that foot. You will monitor the contractions in the foot during the seizure. Let anesthesia know you are ready for succinylcholine.

44. ECT Procedure (cont.)
Then succinylcholine will be given; after which you will start the time. Anywhere from seconds, the patient should be relaxed to give you a general idea. Test relaxation by either doing a Babinski on the left foot and noticing fasciculations or checking for their tone and fasciculations.
Once relaxed let the attending know that the patient is ready for stimulus administration. Stop the time. Anesthesia will place the bi-block. Stimulus will be given. Once given and the patient starts to seize, you start the timer, to record the time – look mostly at the right foot where you have blocked succ to flow, also look elsewhere where there may still be some seizure like activity going on.

45. ECT Procedure (cont.)
Thymatron machine will print out the EEG strip that will show the EEG/EMG readings- compare your clinical EMG reading with that of the machine. Sometimes machine will not pick up the muscle activity, so you have to time the clinical seizure activity.

46. ECT Procedure (cont)
The end part of the EEG/EMG strip will give you all the parameters that were involved in this procedure- static impedance, pulse stimulus, frequency, etc; so make sure you have that to record it in the healthspan.
Coordinate with the inpatient psych team, with pt’s family to monitor the patient’s progress (most of the time the patient will be the last one to notice a change)

47. Key Points
ECT has good efficacy when used for (treatment resistant) psychiatric conditions
Although there are no absolute contraindications, a thorough pre-procedural screen of candidates in important in risk stratification
There is lots of variability when it comes to practices (ie. lead placement, machine type, anesthetic choice, seizure duration, etc) and treatment should be individualized