ECT - Exam 6 Flashcards
ECT
-PNS response
-bradycardia
-HoTN
-bradydysrhythmias
ECT
-SNS responses
-tachycardia
-HTN
-tachydysrhythmias
ECT
-cerebral responses
-misc responses
-increased cerebral blood flow
-increased ICP
-increased IOP
-increased intragastric pressure
-hypoventilation
Acute ETC pts receive _ treatments per week
3
-can need several treatments until reaching maintenance phase
T/F Clinical improvement is usually seen with ECT within first few treatments
true
ECT
-indications
-mania
-MDD resistant to other treatments
-catatonia
-vegetative dysregulation
-inanition
-suicidal drive
-schizophrenia with affective disorders
-some Parkinson’s disease conditions
3 positions of electrodes in which ECT is performed
-right unilateral
-bitemporal (bilateral)
-bifrontal
Which kind of current is sent through the electrodes during ECT?
alternating current (AC)
-not DC lol
Theories for MOA of ETC involve enhancements of _, _, and _ neurotransmission as well as release of _ and _ hormones, causing antidepressant and _ effects.
-dopaminergic, serotonergic, adrenergic
-hypothalamus and pituitary
-anticonvulsive
T/F ECT produces anticonvulsive effects
TRUE
-raises seizure threshold
-decreases seizure durations
ABSOLUTE CI for ECT
-pheochromocytoma
-recent MI (<4-6wk)
-recent CVA (3 months or less)
-recent intracranial surgery (3 months or less)
-intracranial mass lesion
-unstable C spine
Relative CI for ECT
-angina
-CHF
-cardiac rhythm management device (PPM, AICD)
-severe pulm disease
-major bone fracture
-glaucoma
-retinal detachment
-thrombophlebitis
-pregnant
Meds used for ECT
-Anticholinergics
-Atropine
0.4-1mg IV or IM
-Glycopyrrolate
0.0005mg/kg IV or IM
Meds used for ECT
-Anesthetics
-Etomidate
0.15-0.3mg/kg IV
-Ketamine
0.5-1mg/kg
-Methohexital
0.5-1mg/kg
-Propofol
0.75-1.5mg/kg IV
Meds used for ECT
-DMR
-Sux
0.5-1mg/kg IV
Meds for ECT
-NDMR
-Cisatracurium
0.15-0.25mg/kg IV (onset 1-2min)
-Rocuronium
0.3-0.9mg/kg IV (onset 1-2min)
T/F Hypercarbia and hypoxia lengthen seizure duration
false
-shorten
Monitoring devices necessary for ECT:
-EKG leads
-NIBP
-Pulse ox
-temp
-peripheral nerve monitoring
-highly suggested : EtCO2
Goals of giving anticholinergics for ECT
-antisialagogue
-prevention of asystole
How should you assess patients first time for ECT? (thorough, focused)
Thorough preop assessment
-Airway
-Neurologic
-Cardiac disease
-Retinal disease
-Renal disease
-Recent long bone fractures
-GERD/HH
If a patient has cardiac disease, what must they have before ECT?
Clearance from internist or cardiologist
12 lead pre-procedure
Heart sounds
Hx: CHF, valvular heart disease, recent MI (<6 months), thoracic/aortic aneurysm, pacemaker/AICD, require monitoring
When should you intubate an ECT patient?
HH/GERD
Full beard
Obesity
Difficult mask fit
Pregnant
Typical airway mangement for ECT?
Mask
Bite block
Ventilation device (Jackson reese or bag valve mask)
Should you switch up induction agents between the same patient’s cases?
no, stay consistent
What drug blunts baroreceptor reflex?
propofol
Why is ketamine problematic for induction for ECT?
-enhanced hemodynamic response
-increased ICP
How often do you take the blood pressure in ECT?
Q 1 min
Procedure for ECT
induce
tourniquet
paralyze
ventilate
stop for seizure
resume ventilation
await spontaneous respirations
Side effects of ECT
Muscle aches
-NSAIDs
Confusion and short-term memory loss
Nausea
Headache
Post-procedure myalgia
-Toradol young
-Tylenol old
Profound myalgia prevention?
higher dose of sux for next treatment
Pt with Afib must be on a/an _ for ECT
anticoagulant`
Number 1 Cause of problems from ECT
laryngospasm (pulmonary)
What should you do with AICDs for ECT?
turn them off
Typical MR of choice for ECT?
sux
ECT seizure lasts _ - _ sec
30-90
T/F For ECT, you can tell how long a seizure lasts by watching the motor seizure a pt experiences
false,
motor seizure is a shorter duration than what is seen on the EEG
What will the patient typically start doing at the end of the ECT seizure?
breathing spontaneously
T/F Hyperventilation increases duration of seizure
true!!
-high CO2 and hypoxia SHORTEN seizure duration
Adult fasting guidelines for ECT:
6+ hrs for solids
2 hr liquids
RSI for ECT for _ and _ _ pts
GERD
Hiatal hernia
Meds that PROLONG ECT seizure duration
-Alfentanil with Prop
-Aminophylline
-Caffeine
-Clozapine
-Etomidate
-Ketamine (proconvulsant)
Conditions that PROLONG ECT seizure duration
hyperventilation / hypocapnia
Meds that SHORTEN ECT seizure duration
-Diltiazem (Cardizem)
-Diazepam
-Fentanyl
-Lidocaine
-Lorazepam
-Midazolam
-Propofol
-Sevo
Meds that are safe for seizure for ECT (doesn’t affect)
-clonidine
-precedex
-esmolol
-labetalol
-nicardipine (cardene)
-NTG
-nitroprusside (nipride)
1st type of cognitive/memory impairment seen after ECT:
postictal confusion
-transient restlessness, confusion, agitated
-lasts ~30 mins after ECT
3 types of cognitive/ memory impairment seen after ECT:
-postictal confusion
-anterograde memory dysfunction
-retrograde memory dysfunction
Anterograde memory loss occurs with forgetting _ information
new
-for ECT, may forget information for a few days after
Retrograde memory loss occurs with forgetting _ information
old
-for ECT, could forget information from weeks/months prior
T/F IV benzo or propofol and/or restraints are appropriate management techniques for postictal agitation
true
Factors influencing cognitive/memories changes seen after ECT:
-frequency of ECT
-number of ECT treatments
-quantity of energy used
-placement of electrodes
-type of anesthetics used
Cardiovascular stimulation from ECT may result in:
increased CRMO2
arrhythmias
transient ischemic changes
Transient cardiac changes BEFORE ECT should be managed by:
-anticholinergics
-IV LA (Lidocaine)
-IV narcotics (Remifentanil)
Transient cardiac changes AFTER ECT can be managed with:
-beta blockers
-CCB
-other antihypertensives
HA/ muscle aches from ECT can be treated with:
-acetaminophen
-NSAIDs
-ASA
Nausea from ECT can be treated with:
-ondansetron
-dolasetron
-granisetron
-metoclopramide
What electrode placement is associated with fewer cognitive side effects of ECT?
R UL
How strong and long is the current of electricity used for ECT?
70-130 volts for 0.1-0.5seconds
What are the two phases of the ECT treatment and how long does each phase last? How does each phase correlate with autonomic nervous system function
Tonic Phase: 10-15 seconds, PNS
Clonic Phase: 30-60 seconds, SNS -longer is better!
What kind of patients should have additional monitoring during ECT?
CHF, Valve disease, MI<6 months, Aneurism, AICD
Goal ETCO2 for ECT
30
Seizure lasts _______, cumulative treatment time lasts______.
What is the normal treatment period?
Seizure: 30-90seconds
Treatment: 200-1000 seconds
3 times a week for 2 months
Which is longer, the motor seizure or the seizure seen on EEG?
EEG
How do tricyclic antidepressants work and what are some anesthetic considerations for ECT?
Block re-uptake of catcholamines
Sympathomimetic drugs may have an exaggerated effect
How do MAO-I antidepressants work and what are some anesthetic considerations for ECT?
Inhibit the breakdown of catecholamines causing accumulation of them in the nerve terminal
Indirect sympathomimetics (ephedrine) can have an exaggerated effect!
PICK NEO
How does lithium work and what are some anesthetic considerations for ECT?
Inhibits Na-K-ATPase pump
May cause nephrogenic DI
Prolongs recovery from GA and NMBDs
Can cause EKG changes
How do SSRI antidepressants work and what are some anesthetic considerations for ECT?
Inhibit the reuptake of serotonin only, causing accumulation in the nerve terminal
Can cause SIADH with anesthetics
What is a possible treatment for headaches pre-ECT?
Caffeine (prolongs seizure)
5-hydroxytyramine-1 agonist (Sumatriptan)
What are some things that can cause nausea from ECT?
stress and anxiety
Anesthetic agent/ seizure itself
Air in stomach
What is the preferred induction agent and why? What is the dose?
Methohexital because it potentiates the seizure and has a lower incidence of dysrhythmias
0.5-1mg/kg
What is the second choice induction agent and what is the dose? Possible side effects?
Propofol, 0.75-1.5mg/kg
May cause bradycardia and asystole!
What is the dose of penothal?
1.5-3mg/kg
What is the ECT dose of etomidate? What are some positive and negative side effects of it?
0.15-0.3mg/kg
Positive: longer seizure, cardiac stable
Negative: increased PONV
What NMBD is used if succ is contraindicated and what is the dose?
Mivacurium 0.08mg/kg
What is the ECT does of precedex and what would it be used for?
1mcg/kg over 10 minutes to help control BP without changing seizure duration
Postictal confusion may be caused by increased plasma levels of what? What should be changed to avoid this for the next treatment?
Lactate
Increase paralytic dose
What happens to vital signs AFTER ECT?
Decrease for 10-15 seconds first (brady and asystole possible)
Then 1 to 5-7 minutes after they increase
After ECT, how much does BP increase? When does heart rate and myocardial oxygen consumption peak? At what point could you see LV dysfunction?
SBP: 30-40%
HR/ O2: peaks 3-5 mins
LV: 6 hours after
ECT patients should be monitored in PACU for how long?
30 min
When patients die after ECT, what are the common causes? CV and Respiratory
CV: Arrhythmia, MI
Resp: aspiration and laryngospasm
Major depressive disorder may be associated with dysfunction in what part of the brain? How does ECT work in this area?
Dorsolateral prefrontal cortices
It doesnt! Neither do meds
What is rTMS? How does it compare to ECT?
repetitive transcranial magnetic stimulation
Delivers rapid magnetic pulses to specific areas of the brain
Vs. ECT: scalp and skull are transparent, fewer cognitive side effects, faster recovery
What is MST? How does is compared to rTMS and ECT?
Higher intensity, frequency, and duration magnetic pulses than rTMS. It can stimulate a seizure in more localized regions.
Does NOT produce jaw contractions, DOES produce vital sign changes
Faster recovery
Increases auditory threshold (earplugs)
What is vagus nerve stimulation
Surgical implant of stimulator into chest - for MDD patients who have failed 4 meds
What is the most common adverse event associated with ECT?
Memory impairment
How does Theophylline impact the seizure threshold?
It lowers it
Why are muscle relaxants used in ECT?
To protect patients from musculoskeletal injury
Which beta blocker is preferred after ECT and what is a possible side effect?
Esmolol
Dose dependent bradycardia
If a patient repeatedly has headaches and severe muscle aches, what change may be necessary?
Increased dose of paralytic
Which induction agent is preferred if there is inadequate seizure activity with maximal current?
Etomidate
Which type of muscle relaxants do not offer benefit for ECT?
Non-steroidal muscle relaxants
(-onium)
If clonidine is used for BP control with ECT, what is the dose and timing?
0.3-0.5mg 60-90 minutes before
For ECT patients with cerebral anuerysm, which meds should be considered and why?
Nitroprusside (decreases CBF)
Atenolol
For patients with SDH or intracranial mass, where should electrodes be placed and what should they be treated with?
Unilateral away from lesion
Steroids and diuretics
What is recommended for patients with CAD receiving ECT?
Pre-treatment with beta blockers
What should be done for patients with an AICD prior to ECT?
Temporary fixed rate pacing
Deactivate AICD
How does aminophylline affect seizure activity?
Increases duration
What should be considered for pregnant women before ECT?
B2 agonist (tocolytic)
Sevo instead of brevitol
