Electroconvulsive Therapy (ECT)

 

 

Considerations 

 

  • Unprotected airway & remote location 

  • Significant physiological changes: 

    • CNS: ↑ cerebral blood flow & O2 consumption, ↑ICP

    • Cardiovascular: 

      • Initial phase (parasympathetic): bradycardia, hypotension

      • Later phase (sympathetic): tachycardia, dysrhythmia, HTN, ↑ systemic & myocardial O2 consumption

    • ↑ IOP, ↑ intragastric pressure

    • Transient apnea/hypoventilation

  • Contraindications: 

    • Absolute: Pheochromocytoma, MI <3 months, Recent CVA <1 month

    • Relative:  ↑ICP,  Severe cardiac disease (conduction defects, poorly controlled CHF/IHD), Aortic & cerebral aneurysms, High-risk pregnancy

  • Co-morbid disease in patients with mental illness; often elderly

  • Use of concurrent medications (TCAs, MAOIs, etc)

  • Need for brief motor relaxation to prevent physical harm to patient 

 

 

Goals

 

  • Amnesia

  • Prevention of physical injury

  • Control of hemodynamic changes

  • Rapid recovery

  • Minimal interference with seizure activity: 

    • ​If available, methohexital superior to propofol

    • If propofol interfering with seizure activity: consider reducing dose, adding remifentanil or etomidate 

 

 

Conflicts

 

  • “Full stomach”: use NDMR to intubate & reverse

  • Hx pseudocholinesterase deficiency/MH: use NDMR & reverse

 

 

Pregnancy Considerations 

 

  • NOT contraindicated 

  • Obtain obstetrical consultation & plan for fetal monitoring 

  • Aspiration prophylaxis & consider intubation if >20 weeks GA 

  • Resources readily accessible in event of neonatal or obstetrical emergency