Anaesthesia for ECT

JPMulier VVP 29 09 2009JPMulier VVP 29 09 2009 11

Anaesthesia for ECT Anaesthesia for ECT

Jan P Mulier, MD PhDJan P Mulier, MD PhDChairman anaesthesiologie Chairman anaesthesiologie sint Jan brugge-oostendesint Jan brugge-oostende

www.publicationslist.org/jan.mulierwww.publicationslist.org/jan.mulier

1150 1850 1947 1977 2010


IntroductionIntroduction

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

ECT indication is growingGeriatric ECTAmbulant repetition at low frequencyHigh repetition frequency

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


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.


Anaesthetic Problems with ECT2

Dental dammage due to biting during ECTDental dammage due to biting during ECT Use patient adapted bite blocksUse patient adapted bite blocks

Poor venous accessPoor venous access Small canule 22 G Small canule 22 G

Lowest dose possible of anestheticsLowest dose possible of anesthetics To minimize suppression of epileptic insultTo minimize suppression of epileptic insult Awareness preventionAwareness prevention

Sympathetic storm after short suppressionSympathetic storm after short suppression Sufficient Hypnotic with cardiovascular stabilizationSufficient Hypnotic with cardiovascular stabilization

Deep muscle relaxation not neededDeep muscle relaxation not needed Just enough to prevent mechanical damageJust enough to prevent mechanical damage


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.


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.


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.


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.


Induction agents

Brietal ideal but ?Hypnomidate

Weinig epilepsie onderdrukkingGeen sympatische sedatie rydene nodig

Propofol meest gebruikteBeperkte epileptische onderdrukkingGeen sympatische storm


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.


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


Practische procedure tweede ECT

Daaropvolgende ECT telkens één stroomstoot op zelfde ampere, dosis afh van gewicht, sedatiegraad door antidepressiva, dosis gebruikt bij vorige ECT sessies0,5 mg/kg myoplegine – 1 mg/kg propofolKnelband opspannen tot ver boven art

bloeddruk voor inspuiten van myoplegineBijtblok tussen tanden


Dilemma’s

Dosis: Brietal – Propofol – UltivaDosis: Brietal – Propofol – UltivaAnti Epilepsie vs awareness / sympatic toneAnti Epilepsie vs awareness / sympatic tone

Dosis: Myoplegine – esmeronDosis: Myoplegine – esmeronVisualisatie effect/ restcurarisatie vs protectieVisualisatie effect/ restcurarisatie vs protectie

Bijtblok:Bijtblok:Lip, tong letsels vs tandletselsLip, tong letsels vs tandletsels

Masker ventilatie: hyperventilatie Masker ventilatie: hyperventilatie Aspiratie vs intubatieAspiratie vs intubatie


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


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.


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.

Anaesthesia for ECT

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