ECT - BB Flashcards
ECT general process
- Bilateral or unilateral electrode placement (if memory problems, on R hemisphere, one on FT region and one on top of head) - frontotemporal region
- Twice weekly
- Mouth guard used to bite down on to prevent damage to teeth/mouth
- Causes tonic clonic movements - muscle relaxant and GA used so minimal
- Lasts 30-60s
- If lasts more than 2 minutes - abort
- Course up to 12 treatmens (usually need 8-10)
- Stopped as soon as patient has max benefit
- Inpatient or outpatient
Common drugs used for ECT
- Etomidate/propofol
- Suxamethonium for muscle relaxant
- SO should fast for 6 hrs prior to ECT
What happens during ECT?
- Electrical current passed through brain
- Induce therapeutic seizures
Why is ECT controversial?
- Seen as barbaric by some people
- Can cause memory problems
- Patient often lack capacity to consent
Development of ECT
- Now modified - includes brief pulse stimulation, GA and muscle relaxant
- Brief pulse stimulation = sharp pulse, less memory problems (not sine wave)
- ECT machine - EEG used, and brain stimulated
- General anaesthetic used and muscle relaxant
- Strictly regulated to avoid misuse - ECT accreditation services, visit once every 3 years to check standards
ECT vs other interventions
- ECT superior to simulated ECT - no difference in discontinuation, better memory, no difference 6 months later
- ECT superior to medications - lower discontinuation rate, memory affected in one trial, response rate >70% (often given with meds in UK though)
Patient satisfaction after ECT
- Discrepency between service user studies and clinicians
Indications for ECT
- Severe depressive illness
- Catatonia
- A prolonged or severe manic episode
Used for Schizphrenia too - but not NICE guided
Contraindications/cautions for ECT
- Raised ICP - only absolute contraindication
Relative:
* Neuro - cerebral aneurysm, recent cerebrovascular event
* Cardio - MI within 3 months, unstable angina, DVT, K+ imbalance, uncontrolled HR/BP
* Resp - acute respiratory infection, other conditions
* General - recent food, fluid, gum, cigarettes, sweets
* Cochlear implants
* Phaechromocytoma
* Unstable fracture
* Bariatric patients
Cautions for ECT - not necessarily contraindicated
- Pregnancy
- Controlled epilepsy
- Pacemakers
Side effects of ECT
- Risk of anaesthetic - MI, arrhythmia, aspiration pneumonia, nausea, malignant hyperthermia, muscle aches, death
- ECT - confusion, headache, status epilepticus, stroke, arrhythmias, bleeding from ulcers, PE, subconjunctival haemorrhages, raised intraocular pressure, broken teeth
- Memory loss - depends on total energy and site
Types of memory loss associated with ECT
- Retrograde + anterograde
- Episodic
- Semantic
- Geographical orientation
- Procedural memory
Physiological changes during ECT
- EEG changes
- CVS - PS followed by sympathetic stimulation = bradycardia then tachycardia, BP falls then rises
- Cerebral blood flow increases
- Blood brain barrier may be breached
- Hormone changes - TSH, ACTH, GH, prolactin, endoprhins, brain derived naturetic peptides etc
How does ECT work?
- Neurotransmitter hypothesis - increases serotonin and NA at synapses
- Neurophysiological
- Neuroanatomical - increasing at synapses
- Endocrine - hormones released
- Neurogenesis and synaptic plasticity (BDNF)
Neuroconnectivity hypothesis
- Hypoactivity of brain in depression
- Reversal of this after ECT
- = normal brain acitivity after with improvement in depression scores
Consenting for ECT
- Has capacity –> consent them, if detained under MHA need to complete T4
- If have capacity and do not consent - can’t give ECT
- If lack capacity - SOAD and complete T6, if emergency complete T6 (section 62), once patient regains capacity, obtain consent
Monitoring during ECT - ECTAs standards
- Pre ECT physical health check
- Consent
- Medication not affect treatment
- Monitor for side effects - memory and seizure effects
- Hamilton depression rating scale - baseline and after every other treatment, one week and 1-2 months after ECT
- Montreal cognitive assessment - baseline, post 2, 6, one week and 1-2 months after ECT
- ESCORT nurse - when brought from ward, nurse knows about patient and gives handover
What is ECT app?
- Patients, carers and professionals
- Available on app store
- Allows demystification of ECT
- Talks about patient experience
- Allows you to see what it looks like
Why has patients who have ECT reduced in numbers?
- More regulated
- Few centres that offer
- Strict guidelines who can have
- More medications available
Newer neurology techniques
- Vagus nerve stimulation - left side chest implanted, wire sits on vagus nerve, stimulates
- Transcranial magnetic stimulation therapy - no anaesthetic needed, 40 mins, patient alert, can drive after. Can get headache. Need daily for 5 days a week for 5-7 weeks.
What is psychotic depression treated with initially?
- antidepressant eg sertaline
- Antipsychotic eg Olanzapine
Indications for ECT
- Moderate to severe depression that has not responded to other treatments
- Catatonia
- Prolonged/severe mania
- Severe life treatening depression - not taking care of self, eating drinking etc
What occurs after T6 form filled out for emergency ECT treatment?
- SOAD ASAP - authorise that they don’t have capacity, that this treatment is best for them, authorise full course
Which drugs are used in Leicester for ECT and why?
- Etomidate - more cardiovascularly stable
- Suxamethonium - relaxes muscles, does not need reversing
How is ECT treatment monitored throughout?
- Monitor patient - signs of motor seizure, tonic clonic movements of hands and feet usually
- EEG - seizure activity usually lasts longer on here than is visible motor wise, polyphasic waves
- If lasts longer than 100s - terminate with Midazolam
4 parts to seizure
- Baseline
- Seizure
- Post-ictal supression
- Back to baseline
What happens to patient when they arrive at ECT and after?
- Asked 5 orientation questions - eg name, DOB, where we are, what they are here for today, remember previous treatment etc
- This is repeated after treatment and time to become re-orientated is recorded
Who is available to discuss with patients re ECT treatment if they are worried?
- Patient advocate
- In Leicester, they have had ECT treatment before - can talk patient through process etc
- Also takes feedback from treatment - non-bias
How long do they give electrical stimulation for?
- About 10s
- Seizure is then over usually within 60s
What happens before patient can start ECT?
- First prescription for treatment - includes whether or not they have capacity, why treating them, give confirmation to begin treatment
- Full anaesthetic review
- Hamilton depression rating scale - 17 = severe depression
- Montreal cognitive assessment - should be at least 26
If under MHA, can you consent to ECT?
- May have capacity to make that decision even when detained under MHA
- Need to assess capacity independent of this
