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ELECTROCONVULSIVE THERAPY. ECT. INDICATIONS: - common -depression, schizophrenia with catatonia, schizophreniform and schizoaffective disorders - uncommon -mania, bipolar disorder, suicidal tendency, patient preference. ECT. PSYCHOPHARMACOTHERAPY:

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Presentation Transcript
slide3
ECT
  • INDICATIONS:
  • -common-depression, schizophrenia with catatonia, schizophreniform and schizoaffective disorders
  • -uncommon-mania, bipolar disorder, suicidal tendency, patient preference
slide4
ECT
  • PSYCHOPHARMACOTHERAPY:
  • -TCA’s-amitryptyline, imipramine, nortriptyline, etc
  • -MAOI’s-deprenyl, phenelzine, isocarboxazid, etc
  • -SSRI’s-fluoxetine, etc
  • -Li+
slide5
ECT
  • TCA’s:
  • -block reuptake of catecholamines at the presynaptic-nerve terminal and result in inc circulatory catecholamines
  • -inc in resting adrenergic tone
  • -sympathomimetic drugs (ephedrine) may result in exaggerated pressor response
slide6
ECT
  • MAOI’s:
  • -block monoamine oxidase (enzyme selectively deaminates amine neuro-transmitters)
  • -results in accumulation in nerve terminals
  • -indirect sympathomimetics can precipitate HTNsive crises and direct sympatho-mimetics (neo) can have exaggerated responses
  • -potentiate effects of barbs (STP)
slide7
ECT
  • LITHIUM:
  • -interrupts Na-K cell membrane pump and interferes with production of cAMP
  • -ECG changes may result
  • -inc Li+ levels may prolong awakening
  • -NMB action is prolonged
slide9
ECT
  • MECHANISM OF ACTION:
  • -electrically induced grand mal sz
  • -stimulus is a short square wave pulse
  • -cellular mechanism?
  • -duration must be >30 sec
  • -CV, CNS, other physiologic effects
slide10
ECT
  • -CVS: initial-brady, hypotension; later-tachy, dysrhythmias, ischemic changes, HTN, inc myocardial O2 consumption
  • -CNS: inc CBF, inc ICP, inc O2 consumption
  • -Other: inc IOP, inc IGP
slide11
ECT
  • RELATIVE CONTRAINDICATIONS:
  • -intracranial mass lesions
  • -recent CVA (3 months)
  • -retinal detachment
  • -pregnancy
  • -long bone Fx’s
  • -thrombophlebitis
  • -acute a/o severe pulmonary disease
slide13
ECT
  • ANESTHETIC REQUIREMENTS:
  • -amnesia
  • -airway management
  • -prevention of bodily harm from sz
  • -control of hemodynamics (B-blockers, short-acting vasodilators)
  • -smooth, rapid emergence
slide14
ECT
  • -preoxygenate/airway control
  • -barbs, etomidate, propofol
  • -sux, short-acting nondep
  • -consider ETT if severe GERD
  • -additional bp cuff to isolate an arm to visually assess length of sz (>30 sec)
venous air embolism

VENOUS AIR EMBOLISM

IAN LIPSKI, CA3

SUPERVISOR: DR. PIVALIZZA

UTHSC AT HOUSTON: DEPT OF ANESTHESIOLOGY

slide16
VAE
  • -may occur whenever the operative field is elevated >=5cm above the RA
  • -crainiotomy and spine cases
  • -sitting position
  • -also lateral, supine, prone
slide17
VAE
  • PATHOPHYSIOLOGY:
  • -intense vasoconstriction of pulmonary circ which results in V/Q mismatch, interstitial pulmonary edema, inc PVR and dec CO and eventual cardiopulmonary collapse and failure
  • -paradoxical emboli to CNS/coronaries with PFO (20-30% pop) and RAP>LAP
slide18
VAE
  • -MONITORING:
  • -TEE (most sensitive)
  • -precordial doppler- air as small as 0.25cc detected, R parasternal border btw 3rd and 6th intercostal spaces, high-pitched noise
  • -PAC- inc in PA pressures, change correlates with volume of air
  • -EtCO2- decreased sec to V/Q mismatching
  • -EtN2 (least sensitive)-increased sec to air that crosses cap-alv membrane and is exhaled
slide22
VAE
  • -MONITORS(CONT’D):
  • -CVP catheter at 3 cm above jxn of SVC and RA-position confirmed by CXR or by following P wave configuration
  • -multi-orifice catheter better than single orifice
  • -entrained air can be aspirated from RA
slide23
VAE
  • -early diagnosis of air embolism is essential for successful treatment
slide24
VAE
  • -TREATMENT:
  • -flood surgical field with saline, packing and wax bone edges
  • -D/C N2O is utilized, 100% O2
  • -lower surgical field to below heart i.e. Trendelenburg
  • -aspirate air from CV catheter
  • -compress neck veins
  • -supportive care: hydrate, volume expansion, pressors, etc
  • -PEEP/valsalva???