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  • Used to treat severe depression, mania, and schizophrenia
  • Therapeutic effects thought to result from release of neurotransmitters or reestablishment of neurotransmitter levels
  • Typically given three times a week for 2 to 4 weeks acutely, then as needed
  • Typically started as inpatient, then possibly administered as outpatient if needed
  • General anesthesia is preferred for ECT treatments

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  • Standard ASA NPO guidelines apply
  • Have patient void before the procedure
  • Contraindications:
    • MI within past 3 months, severe angina
    • CHF, aneurysm of any major vessel
    • Pheochromocytoma
    • Cerebral tumor, elevation of ICP
    • Cerebral aneurysm
    • Recent CVA
    • Respiratory failure
  • Precautions:
    • Pregnancy
    • Thyrotoxicosis
    • Cardiac dysrhythmias
    • Glaucoma and retinal detachment
    • Pacemaker, ICD (to be deactivated before the procedure)
  • Medications:
    • Tricyclic antidepressants can increase the risk of HTN, rhythm and conduction problems, and confusion
    • SSRIs and reversible MAOIs can increase the risk of prolonged seizure
    • Lithium increases the risk of confusion, and can prolong the action of succinylcholine: maintain lithium level around 0.6 mEq/L
    • Carbamazepine can prolong the action of succinylcholine
    • Chronic benzodiazepine treatment can make it more difficult to induce seizures. Flumazenil 0.2–0.3 mg at induction is usually effective without causing withdrawal or prolonged seizures

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Medications needed are an induction agent and a muscle relaxant

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  • Bite block placed to prevent injury to teeth and tongue during seizure (see Figure 82-1)
  • Sequence of events: IV placement, pre-oxygenate, induction agent, muscle relaxant, place bite block, ECT, assist with ventilation if necessary; provide oxygen by mask or nasal cannula throughout
  • ECT results in a generalized tonic-clonic seizure and brief parasympathetic discharge (PSD) followed by sympathetic discharge (SD). There is a brief cerebral vasoconstriction followed by vasodilatation, with increase in CBF, ICP, and oxygen consumption
  • PSD results in bradycardia, possible asystole (rare), increased secretions, increased gastric and intraocular pressures
  • SD results in tachycardia, hypertension, increased myocardial oxygen demand, and possible dysrhythmias
  • Therefore, the following medications should be available immediately:
    • Labetalol, esmolol, nicardipine, verapamil, atropine
  • If the seizure is too short (<20 seconds):
    • Decrease hypnotic dose or use different medication, hyperventilate before shock
  • If the seizure is too long (>90 seconds):
    • Administer more hypnotic (propofol), or midazolam
  • Possible complications (besides those listed above):
    • Laryngospasm, apnea
    • Aspiration
    • Tongue biting, mandible dislocation, long bone fracture, myalgias

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Commonly Used Induction Medications for ECT
MedicationDoseNotes
Etomidate0.15–0.3 mg/kgIncreased risk of PONV
Ketamine0.5–2 mg/kgIncreased sympathetic discharge
Methohexital0.75–1 mg/kgAvoid in patients with porphyria
Propofol0.75–1.0 mg/kgDose can be titrated up or down to achieve maximal seizure
Rocuronium0.45–0.6 mg/kgUse if succinylcholine is contraindicated
Succinylcholine0.2–0.5 mg/kgAvoid in bradyarrhythmias, watch for hyperkalemia
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Figure 82-1. Oral Protector to Prevent Tongue Biting or Tooth Fracture during Seizure.
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  • Surveillance in PACU. Same discharge criteria as surgical patients
  • Side effects include:
    • Amnesia
    • Agitation
    • Confusion
    • Headache
    • Nausea and vomiting
  • Rare complications include:
    • Myocardial ...

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