1. Anaesthesia for ECT
Dr Hannah Rose
April 2006

2. Overview Introduction to ECT Anaesthesia for ECT History Indications
Practicalities
Side Effects
Anaesthesia for ECT
Patient factors – Hx / Exam / Ix
Venue / Equipment
Conduct
Induction / Muscle relaxation
Recovery

3. 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 : )

4. Indications Life threatening illness Treatment resistance
Attempted suicide / strong ideation
Catatonia
Refusal of food / fluids
Depressive delusions / hallucinations
Prolonged / severe manic episode
Treatment resistance
Depression
Mania
Schizophrenia (4th line treatment)
Patient choice
Maintenance therapy

5. 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
ECT machine – measured dose of electirical charge. Constant current stimulus by a Train if brief pulses 1 ms in length. Electrical dose range measured in Coulombs mC.
Electrode placement – bitemporal or unilateral --- lower incidence of memory and cognition loss and reduced time for reorientation

6. 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
Prolonged seizures more likely on 1st treatment and without eeg monitoring
Worsens cognitive impairment and disorientation.

7. 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
Theophylline, TCA’s. SSRI’s, Lithium, neuroleptics lower seizure threshold
Anticonvulsants, hypnotics, membrane stabilisers, MAOI’s raise the seizure threshold

8. Examination and Investigations
Behaviour
Airway (incl wobbly teeth)
Vitals
Routine Examination
Ix only as needed

9. 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,

10. 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

11. Conduct IV access Monitoring Pre O2 IV induction Muscle relaxant
Mouth block
Seizure induction
Recovery

12. Seizure Induction Hyperventilation Minor tonic, then clonic activity
Seizure pattern on EEG
Missed seizures
Prolonged / Tardive seizures
Haemodynamic responses
MISSED insufficient stimulus, too much impedance, hypercarbia, dehydration, drugs. Wait 20s and try again. Try reducing iv anaestheitci dose/change agent/BZD reversal
PROLONGED / TARDIVE late return of seizure activity ----o2 and BZD/Anaesthetic agent to stop it.

13. 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

14. Muscle Relaxation Suxamethonium Dose (0.5-1mg/kg)
Uses (Reduce muscle activity and injury)
Stimulus post-fasciulations
Non-depolarising if C / I

15. RECOVERY Adequate no. of trained personel Fully equipped
O2 until awake and maintaining Sats
Familiar escort
Written instructions

16. Questions ?