anaesthesia for ect n.
Download
Skip this Video
Download Presentation
Anaesthesia for ECT

Loading in 2 Seconds...

play fullscreen
1 / 16

Anaesthesia for ECT - PowerPoint PPT Presentation


  • 112 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Anaesthesia for ECT' - jermaine-douglas


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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
  • Brietal ideal but ?
  • Hypnomidate
    • Weinig epilepsie onderdrukking
    • Geen sympatische sedatie rydene nodig
  • Propofol meest 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