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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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    1. 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

    2. 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

    3. 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

    4. 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

    5. 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

    6. 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

    7. 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

    8. 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

    9. 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

    10. 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

    11. 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

    12. 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

    13. 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

    14. 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

    15. 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

    16. 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