1 / 21

Electroconvulsive Therapy

Electroconvulsive Therapy. Presented by 許仲寬 91-0 9-17. Current condition in 西址 OR. Monitor setup, EEG Preoxygenation, bite protection Rapifen 1ml, Pentothal 150mg~250mg One lower leg isolated with tourniquet Succinylcholine 60~80mg ECT discharge

laith-carpenter
Download Presentation

Electroconvulsive Therapy

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. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Electroconvulsive Therapy Presented by 許仲寬 91-09-17

  2. Current condition in 西址 OR • Monitor setup, EEG • Preoxygenation, bite protection • Rapifen 1ml, Pentothal 150mg~250mg • One lower leg isolated with tourniquet • Succinylcholine 60~80mg • ECT discharge • Recovering (Trandate if necessary) • Recheck v/s, pupil reflex

  3. ECT • Programmed electrical stimulation of the CNS to initiate seizure activity. The precise mechanism remains unknown. • The electrical stimulus results in generalized tonic activity for approximately 10 seconds, followed by generalized clonic activity for a variable period ranging from a few seconds to more than 1 minute.

  4. Overall seizure duration is a primary determinant of treatment efficacy • 25~50s optimal, <15s, >120s ineffective • Duration depends on age, energy of stimulus delivered, electrode placement, seizure threshold, and medications administered, including anesthetics. • Electrodes may be placed bilaterally or unilaterally. Bilateral is more effective, but results in greater cognitive side effects

  5. Indication of ECT • severe and medication-resistant depression and mania • schizophrenic patients with affective disorders, suicidal drive, delusional symptoms, vegetative dysregulation, inanition, and catatonic symptoms • 75~85% favorable response

  6. Mortality: 1 per 10,000 (1997, APAC) • Cause – cardiovascular decompensation, prolonged apnea, status epilepticus, cerebral herniation • Morbidity: cardiovascular complication, bone fractures, musculoskeletal injuries, oral injuries • Side effect: headache, muscle pain, nausea • Cognitive dysfunction: amnesia, Postictal Delirium

  7. Physiology • Initial parasympathetic discharge,10~15s, manifested by bradycardia, occasional asystole, and/or premature atrial and ventricular contractions. Hypotension and salivation may be noted. • Followed by sympathetic discharge, associated with tachycardia, hypertension, premature ventricular contractions, and rarely ventricular tachycardia. The tachycardia peaks at 2 minutes after stimulus and is normally self-limited. • ECG changes including ST-segment depression and T-wave inversion may also be seen, without myocardial enzyme changes consistent with myocardial infarction.

  8. SBP is transiently increased by 30%–40%, and HR is increased by 20% or more, resulting in a two- to fourfold increase in the rate-pressure product (RPP), an index of myocardial oxygen consumption • Increases in cerebrovascular resistance followed immediately by increased cerebral blood flow and cerebral metabolic rate • Hyperventilation-induced hypocapnia appears to augment the HR and RPP responses compared with normocapnic conditions

  9. DRUGS

  10. Methohexital: gold standard 0.75-1 mg/kg • Thiopental 1.5-2.5mg/kg: shorten duration, increase bradycardia & PVC, higher MCA flow velocity than propofol • Etomidate 0.15-0.3 mg/kg: longer duration, accentuate hemodynamic response • Propofol 0.75 mg/kg: potent anticonvulsant, cardiovascular depressant, in larger dose 1.5mg/kg, duration shortened but improvement not affected

  11. Ketamine: intrinsic sympathomimetic activity, shortened duration • Benzodiazepine: avoided, anticonvulsant • Sevoflurane: 1.7% Sev + 50% nitrous oxide, or 3.4% Sev alone, similar to thiopental, for late stages of pregnancy to reduce uterine contraction

  12. Succinylcholine: 0.5, 0.75-1.5 mg/kg, avoided in malignant hyperthermia, neuroleptic malignant syndrome • Mivacurium 0.2mg/kg: most often alternative • Atracurium 0.5mg/kg: onset 6 min, recovery 16min • Rocuronium: no clinical reports

  13. Glycopyrrolate: drug of choice, reduce oral secretion and bradycardia • Esmolol 1-1.3 mg/kg • Labetalol 0.1-0.2 mg/kg • Sublingual nifedipine 10mg, 20 min before • NTG 3ug/kg 2 min before • Nitroprusside + b-blocker: for intracranial aneurysm, dissecting aortic aneurysm, aortic stenosis • Opioid: Alfentanil 10ug/kg prolong • Fentamyl 1.5ug/kg shorten

  14. Suggested Technique • NPO overnight, clear fluid allowed 1 h before • To prevent myalgias, aspirin, acetaminophen, ketorolac given as premedication • Oral airway required for both ventilation and protection • EEG, EMG, tourniquet technique to isolate an extremity for seizure activity quantification

  15. Special condition • Cerebral aneurysm - propofol, atenolol 50mg, nitroprusside 30ug • Subdural hemorrhage, intracranial mass - unilateral electrode away from the lesion - pretreat with steroid, diuretic, hyperventilation • Cardiovascular disease • B-blocker for CAD • Anticoagulation for AF • Atropine & avoid large dose SCC for bradycardia • Pheochromocytoma should be excluded

  16. NMS - Avoid succinylcholine & sevoflurane • Pregnancy - tocolytic, sevoflurane, rapid sequence induction • Inadequate seizure activity - etomidate, reduced methohexital in combination with alfentanil / remifentanil, aminophylline, caffeine

  17. References • Anesthesia for electroconvulsive therapy (Anesth Analg 2002;94:1351-64) • Treatment of Psychiatric Disorders (Glen O. Gabbard, p1267-1293) • Anesthesia (Miller, Ch.70 p2269-2273) • Clinical Anesthesiology (Morgan, Ch 27, p594-596) • Clinical Anesthesia Procedures of MGH (Hurford, Ch 31, p558-561)

More Related