Anaesthesia for ect
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Anaesthesia for ECT. 1150 1850 1947 1977 2010. Jan P Mulier, MD PhD Chairman anaesthesiologie sint Jan brugge-oostende www.publicationslist.org/jan.mulier. Introduction.

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Anaesthesia for ECT

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Anaesthesia for ect

Anaesthesia for ECT

1150 1850 1947 1977 2010

Jan P Mulier, MD PhD

Chairman anaesthesiologie

sint Jan brugge-oostende

www.publicationslist.org/jan.mulier

JPMulier VVP 29 09 2009


Introduction

Introduction

  • Electro convulsive therapy (ECT) is the electrical induction of a grandmal seizure.

  • ECT indication is growing

    • Geriatric ECT

    • Ambulant repetition at low frequency

    • High repetition frequency

  • A short general anaesthetic and muscle relaxant is usually given for the procedure.

JPMulier VVP 29 09 2009


Anaesthetic problems with ect1

Anaesthetic Problems with ECT1

  • Patient Population.

    • Patients are often elderly with associated comorbidity

  • Drug Interactions.

    • frequently taking psychotrophic drugs.

  • Repeat General Anaesthetics.

    • ECT is usually given 2x, 3x a week over several weeks.

  • Location.

    • administered at isolated sites away from operating theatres. Help to deal with unexpected problems can be delayed or unavailable.

  • Like Any Anaesthetic.

    • Nausea. Myalgia.

JPMulier VVP 29 09 2009


Anaesthetic problems with ect2

Anaesthetic Problems with ECT2

  • Dental dammage due to biting during ECT

    • Use patient adapted bite blocks

  • Poor venous access

    • Small canule 22 G

  • Lowest dose possible of anesthetics

    • To minimize suppression of epileptic insult

    • Awareness prevention

  • Sympathetic storm after short suppression

    • Sufficient Hypnotic with cardiovascular stabilization

  • Deep muscle relaxation not needed

    • Just enough to prevent mechanical damage

JPMulier VVP 29 09 2009


Effects of ect

Effects of ECT

  • Central Nervous System:

    • increase in cerebral blood flow, oxygen consumption, intracranial and intraocular pressure.

    • confusion, agitation or amnesia.

    • headache after the procedure.

  • Musculoskeletal:

    • musculoskeletal injury.

    • The current directly stimulates the jaw muscles and causes the teeth to clench which lead to dental or oral injury.

    • oxygen extraction is increased with desaturation

  • Cardiovascular System:

    • parasympathetic stimulation with risk of bradycardia and hypotension

    • sympathetic stimulation with tachycardia, hypertension and dysrhythmias.

  • Gastrointestinal System:

    • intra gastric pressure rises

    • increased salivation, nausea and vomiting.

JPMulier VVP 29 09 2009


Anaesthetic management

Anaesthetic Management

  • Aims

    • Safety. Pleasant and stress free environment

    • Rapid loss of consciousness and attenuation of the hyperdynamic response.

    • Reduction of seizure movements to avoid injury but allowing a visual assessment.

    • Minimal interference with seizure activity.

    • Prompt recovery of spontaneous ventilation and consciousness

  • Preoperatively

    • history, physical examination, and investigations as appropriate.

    • Identify and optimise co-existing disease

    • informed consent. However the underlying condition may lead to patients refusing

    • Ensure that the patient is fasted.

JPMulier VVP 29 09 2009


Anaesthetic management1

Anaesthetic Management

  • Monitoring

    • Pulse oximeter to monitor cardiac rate and any desaturation that may occur during the fit.

    • ECG and non invasive blood pressure.

    • The psychiatric team monitors the electroencephalogram.

  • Induction

    • Preoxygenate the patient.

    • Use a sleep dose of one of the following intravenous induction agents: methohexitone, propofol, thiopentone, or etomidate.

    • Maintain the airway with an anaesthetic facemask, hand ventilating with 100% oxygen.

JPMulier VVP 29 09 2009


Commonly used induction agents

Commonly used induction agents

  • 1. Methohexital

    • rapid action, short duration (Mokriski et al, 1992), minimal anticonvulsant effects (dose-related), The APA Task Force on ECT recommends its use as an induction agent of choice (APA, 1990). dose is 0.5-1 mg/kg.

  • 2. Thiopental

    • greater anticonvulsant effects and longer duration of action

  • 3. Ketamine

    • slower onset, delayed recovery, nausea, hypersalivation, ‘bad trips’, and ataxia during recovery (McInnes & James, 1972). increased seizure threshold, dose is 0.5-2 mg/kg (APA, 1990, 2001).

  • 4. Propofol

    • rapid onset, short duration, pain on injection. It has potent anticonvulsant properties (APA, 1990), as evidenced by a number of studies. Propofol (dose 0.75-1.5 mg/kg) resulted in: 1) markedly decreased the intensity and the duration of seizure (Avramov et al, 1995; Boy & Lai, 1990; Chanpattana, 2000; Kirkby et al, 1995; Rampton et al, 1989; Rouse, 1988),

  • Nevertheless, randomized trials between propofol and either methohexital or thiopental do not demonstrate a difference in the therapeutic outcome or the speed of postictal recovery (Martensson et al, 1994; Matters et al, 1995).

  • 5. Etomidate

    • pain on injection, myoclonic activity during induction. low cardiac output state increased seizure threshold (APA, 1990). dose is 0.15-0.3 mg/kg.

JPMulier VVP 29 09 2009


Induction agents

Induction agents

  • Brietalideal but ?

  • Hypnomidate

    • Weinig epilepsie onderdrukking

    • Geen sympatische sedatierydene nodig

  • Propofolmeest gebruikte

    • Beperkte epileptische onderdrukking

    • Geen sympatische storm

JPMulier VVP 29 09 2009


Muscle relaxation

Muscle Relaxation

  • incomplete muscular paralysis. 20-50mg. Maintain the airway and ventilate with 100% oxygen Insert an oropharyngeal airway or bite block before allowing the psychiatrist to administer the stimulus when suxamethonium fasciculations has finished.

  • Appropriate: slight twitching of face and limbs

  • Dose too high: no movements

  • The adequacy of ECT is judged by duration of seizure.

  • A prolonged seizure of 120seconds should be terminated with drugs.

JPMulier VVP 29 09 2009


Practische procedure eerste ect

Practische procedure eerste ECT

  • Eerste sessie: repetitieve stijgende stroomdosis tot voldoende lange epilepsie aanval gemeten met EEG of fysiche: 1 tot 4 stroomstoten met 2 minuten interval

    • Linker arm: Infuus, pulse oximeter, bloeddrukmeter

    • Rechter arm: bloeddrukmanchette of knelband om circulatie arm af te sluiten voor inspuiten van myoplegine

    • Electrocardiogram

  • Dubbele dosis propofol en myoplegine: 1 mg/kg myoplegine – 2 mg/kg propofol

  • 1 en 2 stroomstoot

  • Bijkomende normale dosis propofol en myoplegine: 0,5 mg/kg myoplegine – 1 mg/kg propofol

  • 3 stroomstoot

  • Afhankelijk van spierreactie en tijdsverschil ( > 2 minuten) nog een halve dosis bijgeven

    • : 0,25 mg/kg myoplegine – 0,5 mg/kg propofol

JPMulier VVP 29 09 2009


Practische procedure tweede ect

Practische procedure tweede ECT

  • Daaropvolgende ECT telkens één stroomstoot op zelfde ampere, dosis afh van gewicht, sedatiegraad door antidepressiva, dosis gebruikt bij vorige ECT sessies

    • 0,5 mg/kg myoplegine – 1 mg/kg propofol

    • Knelband opspannen tot ver boven art bloeddruk voor inspuiten van myoplegine

    • Bijtblok tussen tanden

JPMulier VVP 29 09 2009


Dilemma s

Dilemma’s

  • Dosis: Brietal – Propofol – Ultiva

    • Anti Epilepsie vs awareness / sympatic tone

  • Dosis: Myoplegine – esmeron

    • Visualisatie effect/ restcurarisatie vs protectie

  • Bijtblok:

    • Lip, tong letsels vs tandletsels

  • Masker ventilatie: hyperventilatie

    • Aspiratie vs intubatie

JPMulier VVP 29 09 2009


Bijtblokken

Bijtblokken:

  • Geen tanden -> geen bijtblok

  • Normale stevige tanden -> bijtblok rechts + links: dikke rubber blok.

  • Peridontitis, loszittende tanden, caries -> tandverzorging eerst en op maat gemaakte tandprotector boven en onder kaak: beste protectie doch duur

  • Ontbrekende tanden, caries en geen tandprotector op maat gemaakt: alleen rechts of links rubber bijtblok of helemaal geen bijtblok

JPMulier VVP 29 09 2009


Post ect care

Post ECT Care

  • Treat headache with simple analgesics or intra nasal sumatriptan.

  • Monitor the patient in recovery area until the patient is fully alert and able to ambulate.

  • Post ECT agitation, confusion and aggressive behaviour can be attenuated by excessive stimulation during the recovery period. A small dose of benzodiazepine (eg midazolam) or haloperidol may be given.

JPMulier VVP 29 09 2009


Side effects of ect

Side effects of ECT

  • from the anesthesia, the ECT or both.

  • Common side effects

    • temporary short-term memory loss,

    • nausea,

    • muscle aches and headache.

  • Less frequent:

    • longer-lasting memory problems.

    • Sustained hypertension or dysrhythm.

JPMulier VVP 29 09 2009


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