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1. Child and Adolescent Psychiatry > Neurostimulation: ECT > Flashcards

Neurostimulation: ECT Flashcards

1
Q

what is the response rate to ECT for mood disorders

A

75-85% for mood disorders

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2
Q

what is the response rate to ECT for those with mood disorders who have been medication resistant

A

60-70%

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3
Q

what population has an even higher response rate to ECT

A

the elderly over age 65

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4
Q

does efficacy of ECT drop off early or late in lifespan?

A

no

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5
Q

is ECT as good as, worse, or better than sham or standard AD?

A

PROVEN SUPERIORITY

superior to sham and superior to standard AD therapy (in medication RESISTANT patients)

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6
Q

what are some of the benefits to ECT treatment for patients and hospital systems

A

ECT can reduce length of stay + hospitalization cost

is both effective and rapid

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7
Q

does the benefit of ECT last after treatment stopped?

A

may have HIGH RELAPSE rates without maintenance ECT or antidepressant therapy

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8
Q

what 3 disorders have primary indications for ECT

A

MDD

Mania

Schizophrenia

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9
Q

list primary indications for ECT in someone presenting with MDD

A

ACUTE SUICIDALITY, high risk

PSYCHOTIC features

CATATONIA

rapidly deteriorating PHYSICAL STATUS due to the depression

history of poor response to meds

history of good response to ECT

if the risk of standard AD treatment is higher than ECT in this patient

patient PREFERENCE

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10
Q

list primary indications for ECT in those presenting with Mania

A

ACUTE SUICIDALITY, high risk

PSYCHOTIC features

CATATONIA

rapidly deteriorating PHYSICAL STATUS due to the depression

history of poor response to meds

history of good response to ECT

if the risk of standard AD treatment is higher than ECT in this patient

patient PREFERENCE

specific to mania:
–> extreme and sustained AGITATION
–> manic DELIRIUM

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11
Q

list primary indications for ECT in those presenting with schizophrenia

A

positive symptoms with ABRUPT or RECENT onset

CATATONIA

history of good response to ECT

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12
Q

do those with schizophreniform disorder respond to ECT

A

yes

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13
Q

in patients presenting with psychosis, which patients are likely to have significant benefit from ECT

A

is psychosis + significant affective sx

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14
Q

what should the approach to treatment be for someone presenting with psychotic symptoms who is felt to be a good candidate for ECT

A

ECT + antipsychotics

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15
Q

list disorders for which there is a secondary indication for ECT

A

catatonia (not due to MDE, mania, schizophrenia)

Parkinsons disease

NMS

delirium

intractable seizure disorder

mood disorder due to another medical condition

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16
Q

what benefit might someone with parkinsons disease see from ECT

A

may improve MOTOR symptoms (esp. “on/off”)

may need maintenance ECT to sustain remission

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17
Q

what should you do with someones medications if they have parksinsons disease and are receiving ECT

A

consider adjusting meds during ECT course due to risk of tx emergent dyskinesia or psychosis

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18
Q

how should you approach someone with NMS if you are considering ECT for this patient

A

DISCONTINUE ANTIPSYCHOTICS first

achieve autonomic stability first

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19
Q

should you do ECT for delirium

A

it is a secondary indication but should only be RARELY considered

correct reversible physical factors first

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20
Q

can you use ECT in patients with mood sx + dementia

A

YES

ECT is beneficial for mood symptoms in ALL STAGES of dementia

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21
Q

what benefits might there be from ECT in dementia

A

may be helpful for AGITATION/SCREAMING even without depression in patients with dementia
–> but NOT RECOMMENDED–> consider nonpharm/pharm approaches first

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22
Q

what are the risks of ECT in patients who are elderly with dementia

A

increased risk of POST ECT DELIRIUM and COGNITIVE side effects
–> consider changing frequency or technique, and tracking cognitive status

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23
Q

is older age a specific risk for ECT

A

no–> may actually predict a favorable response

however, dementia and physical illness DO increase the risk of ECT adverse events
–> consider physiological factors during an after anesthesia

**do a preop/anesthesia consult

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24
Q

can you do ECT in adolescents

A

yes–> can be effective for PRIMARY INDICATIONS and CATATONIA

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25
Q

can you do ECT in children

A

yes but used very rarely
limited data

consider IF…
–> symptoms are severe, persistent, significantly disabling, life threatening
–> medication resistant/intolerant
–> get a second opinion

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26
Q

how does a childs seizure threshold compare to an adults

A

children have LOWER seizure threshold

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27
Q

can you do ECT in a pregnant person

A

YES

ECT is SAFE and EFFECTIVE in ALL stages of pregnancy
–> consults anesthesia and OB
–> ensure available resources for neonatal/obstetrical emergency

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28
Q

can you do ECT in post partum women

A

YES

is SAFE and EFFECTIVE in the post partum period
–> limited risk of anesthetic agents to the nursing infant

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29
Q

can you do ECT in those with congenital and acquired brain injury or mental retardation

A

yes–> there is case evidence for ECT in primary conditions and catatonia

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30
Q

are there particular risks of ECT in those with congenital and acquired brain injury or mental retardation

A

may be higher risk of post ECT delirium–> may need to adjust frequency, technique

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31
Q

what is the evidence for doing ECT in those with personality disorder AND mood disorder

A

there is BENEFIT but there is REDUCED response rate overall and higher RELAPSE rates in this population

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32
Q

list conditions in which there is INSUFFICIENT data to recommend ECT

A

primary anxiety disorders

PTSD

primary delusional disorder

chronic pain with affective symptoms (though may have some relief)

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33
Q

what are the ABSOLUTE contraindications to ECT

A

there are NONE

there are NO ABSOLUTE CONTRAINDICATIONS TO ECT

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34
Q

list 6 relative contraindications to ECT

A
  1. unstable/severe cardiovascular conditions–> recent MI, unstable angina, poorly-compensated HF, severe valvular cardiac disease, critical aortic stenosis
    –> also CAUTION with CARDIAC DEVICES
  2. aneurysm or vascular malformations (risk of rupture with high BP)
  3. increased ICP–> i.e brain tumors, space occupying lesions
  4. recent stroke
  5. pulmonary conditions–> severe COPD, asthma, pneumonia
  6. ASA level 4/5
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35
Q

list 3 conditions which place patients at higher risk for adverse events with ECT

A

pheochromocytoma

retinal detachment

acute narrow angle glaucoma

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36
Q

can you do ECT in someone with a cardiac pacemaker

A

CAUTIOUSLY

ECT is UNLIKELY to disrupt functioning

ensure monitoring leads are WELL GROUNDED

preferable not to have someone holding patient grounded to the floor

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37
Q

can you do ECT in someone with an implantable automatic defibrillator

A

yes–> but they are more susceptible during ECT stimulation

consult cardiology and anesthesiology ahead of time

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38
Q

which cardiac conditions would be considered relative contraindications to ECT

A

unstable/severe

recent MI

unstable angina

poorly compensated HF

severe valvular cardiac disease

critical aortic stenosis

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39
Q

why is an aneurysm or vascular malformation a relative contraindication to ECT

A

risk of rupture with high BP

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40
Q

what pulmonary conditions may be relative contraindications to ECT

A

severe COPD

asthma

pneumonia

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41
Q

what ASA level is a relative contraindication to ECT

A

level 4/5

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42
Q

in whcih patients should an ECG be part of pre ECT workup

A

if older than 45 or if have cardiac disease

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43
Q

are routine labs mandatory for pre-ECT workup

A

NO not mandatory but consider if clinically indicated

i.e CBC, lytes, renal function

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44
Q

what features are part of the pre ETC workup

A

physical exam

dentition–> dentures, dental problems may affect bite block; TMJ problems

ECG if indicated

labs only if indicated

imaging (i.e CXR, cervical spine) if indicated

anesthesia consult if indicated

pertinent specialty consultation if indicated

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45
Q

who should get a CXR before ECT

A

if florid/unstable cardiopulmonary condition

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46
Q

who should get a cervical spine XR before ECT

A

if suspected cervical spine instability
–> rheumatoid arthritis
–> severe osteroporosis
–> down syndrome
–> certain collagen vascular diseases

*would warrant full muscle relaxation in ECT–> monitor relaxation time with nerve stimulator

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47
Q

who should get an anesthesia consult before ECT

A

if older than age 60

if significant CV or neuro conditions

if pregnant

if unstable C spine

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48
Q

what other speciality consults may be considered before ECT

A

i.e obstetrics in pregnancy

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49
Q

what needs to be documented prior to performing ECT

A

indication for ECT

comorbid psych dx

concurrent medical conditions esp if increase risk of ECT

current meds–> which to hold, which to give in AM, which to continue post ECT

allergies

describe relevant physical exam including baseline BP, HR, dentition, cardiac pacemaker or defibrillator, baseline cognitive function with MMSE

if consent obtain, who signed it
if sample info given to patient and family
if anesthesia consulted, and if so, what the ASA category was

copies of pertinent consults in workup

prior hx of ECT and outcomes

if preferred technique or frequency

name and signature of attending physician

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50
Q

what are critieria for valid consent

A

consent given for proposed health care

consent given voluntarily

consent not obtained by fraud or misrepresentation

adult is capable

provider gives information a REASONABLE PERSON would require
–> condition for which care is proposed
–> nature of proposed health care
–> risks and benefits
–> any alternative courses, including not receiving care

give opportunity to ask questions and receive answers

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51
Q

what are requirements for capacity for healthcare decisions

A

patient understands the info given and is able to apply it to their own health
–> ask patient to repeat in own words

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52
Q

what is a typical index course of ECT

A

6-12 sessions

patients generally respond in 6-12 sessions

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53
Q

what do you do if there is no response to ECT after 15 sessions

A

get second opinion about continuing treatment

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54
Q

does a patient need to be NPO for ECT

A

yes should be

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55
Q

how do you manage existing medications for medical illness for patients undergoing a course of ECT

A

usually CONTINUED throughout course of ECT

give 1 hour before ECT with sips of water or after tx once awake

*insulin + hypoglycemia agents usually given AFTER tx

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56
Q

which patients should be given priority on the ECT slate

A

diabetic patients–> insulin + hypoglycemics usually given after treatment

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57
Q

how do you manage existing medications for psychiatric illness for patients undergoing a course of ECT

A

it is favorable to STOP as many psychotropic drugs as possible

DECREASES risk of DELIRIUM and minimizes cognitive sx

ESP. ANTICHOLINERGIC MEDS

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58
Q

how do you manage existing medications for bipolar disorder for patients undergoing a course of ECT

A

mood stabilizers likely need to be continued–> risk of iatrogenic switch to mania

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59
Q

is there any evidence yet for combining ECT and meds

A

no not yet

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60
Q

how do you manage existing SSRIs for patients undergoing a course of ECT

A

commonly used during ECT course–> maybe improved results?

may affect SEIZURE LENGTH–> shorten/lengthen

may need to DISCONTINUE before ECT for some patients, esp. those at higher risk for post-ECT delirium (i.e patients wiht polypharmacy, elderly, co-existing dementia)

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61
Q

how do you manage existing MAOIs for patients undergoing a course of ECT

A

likely SAFE to continue but theres little data

if hypotension during ECT–> avoid direct vasopressors–> should use neosynephrine instead (consult anesthesia)

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62
Q

how do you manage existing TCAs for patients undergoing a course of ECT

A

likely SAFE to continue

STOP if stronger anticholinergic side effects due to risk of post ECT delirium
–> amitriptyline, imipramine, clomipramine, trimipramine

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63
Q

what antidepressant should you stop in ECT and why

A

stop buproprion

reports of spontaneous seizures, lowers threshold

64
Q

list medications that can be problematic in ECT

A

(SSRIs may increase risk for post-ECT delirium)

*buproprion–> lowers seizure threshold

*lithium

*anticonvulsants

FGAs

benzos

65
Q

what are the risks of continuing lithium during ECT

A

increased risk of:
DELIRIUM
PROLONGED SEIZURES
decreased seizure THRESHOLD

66
Q

when might you consider continuing lithium during course of ECT and how should you manage this

A

may need to continue if refractory mood disorders

HOLD night and morning before ECT–> give post ECT

measure lithium levels BEFORE ECT course

67
Q

what are the concerns with using anticonvulsants during a course of ECT

A

DECREASED SEIZURE time
HIGHER seizure threshold
may decrease ECT efficacy

68
Q

if you need to continue an anticonvulsant due to need for mood stabilization, how should you manage it during ECT

A

hold night and morning before and give post ECT

69
Q

what impact do FGAs have on ECT

A

they LOWER seizure threshold

risk of post ECT delirium is stronger if there is an anticholinergic profile i.e nozinan, CPZ, fluphenazine

do not use reserpine

70
Q

what FGA should you AVOID during a course of ECT and why

A

reserpine

cases of death with ECT

71
Q

what is the impact of benzos during a course of ECT

A

increase seizure threshold
may lessen ECT efficacy for mood sx

72
Q

if someone needs benzos, and also needs ECT, how do you manage the benzos

A

use MEDIUM half life benzos

hold morning of ECT and give after

73
Q

what can be used in the ECT treatment room if benzos are affecting ECT

A

IV flumazenil

then give midaz in recovery to prevent benzo withdrawal

74
Q

what type of stimulus do modern ECT machines give

A

brief pulse

75
Q

what is the benefit of brief pulse ECT vs older sine wave pulse

A

equally efficient but less cognitive SEs

76
Q

what equipment do you need for ECT

A
77
Q

what is the conductor in ECT

A

blood–> brain vasculature carries the current

78
Q

why do you need careful skin site prep for ECT

A

skin resist the ECT current–> id inadequate prep, can have inadequate/aborted seizures or skin burns

79
Q

for unilateral electrode placement in ECT, is it on the dominant or non dominant side

A

NON dominant hemispheric ECT (which is usually RIGHT hemisphere)

80
Q

what positioning is recommended for RUL ECT

A

d’Elia position

first electrode is midpoint one inch above midpoint of line between external canthus of eye to tragus of ear

second electrode is midpoint one inch to right of intersection of line between 2 tragi of ears and in line between inion and nasion

81
Q

why might you pick unilateral vs bilateral electrode placement or vice versa in ECT

A

bilateral–> more effective, but more cognitive sx

RUL–> less effective, but less cognitive sx

82
Q

which is more effective, bitemporal or bifrontal ECT

A

bitemporal

83
Q

what is an ECT electrode placement other than RUL, bitemporal and bifrontal

A

left anterior, right frontal placement

near medial region of frontal lobes

avoids skull sutures

fewer cognitive SEs

84
Q

why do we pick the dose intensities we do for ECT

A

if just barely above seizure threshold, then you get a grand mal seizure but with little impact on symptoms

if you go to high above threshold, then you improve sx, but get more cognitive SEs

85
Q

how do you determine how much stimulus to give for ECT

A

titrate

initial very low dose, “in search” of threshold

gradual dose increase until get an adequate seizure–> determined by EEG morphology

dose then maintained or gradually increased

seizure threshold varies between patients

86
Q

what is the formula method for determining where to initiate stimulus for ECT

A

initiate at half of patients age–> % of max output of machine

i.e if age 60, start at 30% of output

87
Q

what stimulus pulse morphology seems to have increased efficacy

A

SHORTENED pulse width + LONGER pulse trains

88
Q

RUL ECT is given at what dose

A

5-6x above seizure threshold

89
Q

bitemporal or bifrontal ECT is given at what dose

A

1.5-2.5x seizure threshold

90
Q

what is considered “effective ECT”

A

confirmed seizure

generalized seizure to BOTH hemispheres

seizure of adequate INTENSITY for sx recovery

avoids unnecessary cognitive sx

91
Q

which is more important to ECT efficacy–> seizure time or seizure intensity

A

seizure intensity is more important than length of seizure

92
Q

what features on EEG indicate a seizure with good intensity

A

higher AMPLITUDE spike + wave activity

SHARP post-ictal SUPPRESSION

93
Q

what is the CV response to ECT

A

initial parasympathetic response then sympathetic outpouring from seizure itself–> may have sig changes in BP, HR

94
Q

what is considered an aborted seizure in ECT

A

less than 15 sec long

*unlikely to benefit from short seizure

95
Q

list possible causes of a missed or aborted seizure during ECT

A
  1. excessive impedance (poor skin contact)
  2. hypercarbia (inadequate ventilation)
  3. hypoxia
  4. dehydration
  5. medications (benzos, anticonvulsants)
  6. insufficient stimulus
96
Q

what do you do if there is an inadequate/missed/aborted seizure during ECT

A
  1. review “dynamic impedance” reading from ECT device
  2. Correct hydration, electrolyte imbalance
  3. oxygenate adequately, ventilate vigorously before next stimulation
  4. reduce/stop interfering medication
  5. can use flumazenil if pt. on high dose benzos then give IV midaz after
  6. can consider CAFFEINE SODIUM BENZOATE 500-2000mg IV before ECT to lengthen seizure time
97
Q

what do you do if there is an inadequate/missed/aborted seizure during ECT and the dynamic impedance was found to be too high

A

correct skin prep, gel and electrode position

98
Q

what do you do if there is an inadequate/missed/aborted seizure during ECT and dynamic impedance was not found to be too high

A

can RESTIMULATE at 50-100% ABOVE original dose

if seizure missed–> wait 20 sec before restimulating to ensure no (rare) delayed response

if seizure aborted–> wait 45 sec before restimulating to overcome seizure refractory period

99
Q

what medication can lengthen seizure time

A

caffeine sodium benzoate

100
Q

what is considered a “prolonged” seizure

A

in USA, above 180 sec

in UK, above 120 sec

101
Q

what do you do if someone has a prolonged seizure in ECT

A

can ABORT with IV benzo like midaz

can ABORT with IV anticonvulsant anesthetic like thiopental

can intubate if necessary

102
Q

how long should you wait aftet ECT to do a cognitive assessment

A

more than 24 hours

103
Q

what factors guide the total number and frequency of ECT treatments

A

degree/rate of clinical improvement

development/severity of cognitive symptoms

104
Q

how often do you usually do ECT

A

usually 2-3 per week on nonconsecutive days

(daily only if rapid response ++ important)

105
Q

what is the usual course for MDD for ECT

A

6-12 sessions

taper courses as soon as max response obtained

106
Q

what do you do if someone has confusion or marked decline in cognition associated with ECT

A

review possible medical/medication causes

reduce treatment frequency

reduce treatment intensity/stimulus dose

change electrode placement i.e to RUL

suspend tx until cognitive function improves

107
Q

what do you do if someone has slow or minimal improvement after 6-10 sessions of ECT

A

reassess indication of continued ECT

optimize ECT technique–> increase stimulus intensity, change from unilateral to bilateral, decrease/stop interfering meds (benzos, anticonvulsants, propofol)

formal r/a of ECT after 15 tx including second opinion

108
Q

what should you consider if repeated courses of ECT are needed and why

A

consider the cognitive effects as there can be a cumulative effect

109
Q

are there any clear strategies in ECT non responder

A

no
–> try different meds
–> try combo of ect and meds
–> try different type of ect

(need at least 10x and optimization of technique before can say “non responder”)

110
Q

state 3 factors that increase risk of post ictal delirium

A

bilateral placement

high intensity stimulation

pre-existing cerebral impairment

111
Q

how does post ictal delirium present

A

marked agitation

disorientation

poor response to commands

–> there is risk of injury, sympathetic response

112
Q

how long does post ictal delirium take to recover

A

5-45 min

patients are often amnestic for the episode

113
Q

how do you manage post ictal delirium

A

supportive, reassurance

may need IM/IV benzos or IV haldol

if recurrent, can use these prophylactically after patient resumes spontaneous respiration

114
Q

how often should you assess cognitive during course of ECT

A

before treatment and then weekly during course

115
Q

in those receiving ECT for depression, what % switch into hypomania

A

12%

116
Q

in those receiving ECT for psychotic depression, what % switch into hypomania

A

10%

117
Q

in those receiving ECT for psychotic BIPOLAR depression, what % switch into hypomania

A

30%

118
Q

who is more likely to switch into mania due to ECT

A

if have bipolar or fam hx bipolar

119
Q

what do you do in cases of switch to mania/hypomania during ECT

A

no current tx guidelines but there are strategies

  1. can stop ECT + treat manic sx with meds
  2. can suspend further tx + observe pt
  3. can continue ECT to treat manic sx + depressive sx
120
Q

how might someone present if they have treatment emergent delirium with euphoria (“Organic euphoria”) due to ECT

A

confusion, disorientation, cognitive impairment

silly, inappropriate quality to mood

is transient–> few hours to days

121
Q

what are some strategies to facilitate recovery from organic euphoria/delirium with euphoria

A

increase time between treatments

decrease stimulus intensity

change from bilateral to unilateral

122
Q

is there an indication for ECT for dementia, in absence of mood sx

A

no

123
Q

what is the overall mortality rate of ECT

A

extremely low

2-10 per 100 000 (0.0001%)

most mortality due to CV event

124
Q

what are the most common complaints post ECT

A

dental, tongue injuries

headache

nausea

other somatic complaints

125
Q

what are the risks for ECT if someone is not NPO before

A

risk of aspiration/aspiration pneumonia

126
Q

what is an MSK risk for ECT

A

fractures–> esp. if have osteoporosis (esp vertebral compression #s)

127
Q

how quickly does acute confusion typically resolve after ECT

A

10-30 min

128
Q

what types of amnesia can be associated with ECT

A

anterograde

retrograde

129
Q

how soon does anterograde amnesia typically resolve after a course of ECT

A

usually within 2 weeks after completing course

130
Q

what memories after typically affected if retrograde amnesia occurs after completing course of ECT

A

impersonal memory weeks to few months prior usually

131
Q

what % of those who receive ECT have some sort of persistent ot permanent memory loss

A

ranges from 29-55%

132
Q

list 6 ways to minimize cognitive SEs from ECT

A

brief pulse (better than sine wave)

lowest stimulus intensity

RUL over bilateral

increased space between sessions, fewer sessions

lowest possible anesthetic dose

avoid lithium

133
Q

what are the overall response rates to ECT in MDD/MDE

A

very high!! 75-85% overall

134
Q

what are the response rates in the elderly with MDD/MDE receiving ECT

A

80-90%–> even higher than overall rates

135
Q

what are the response rates to ECT in those with MDD/MDE that were med resistant

A

60-70%

136
Q

what physiological changes are seen during ECT

A

ECT stimulus + seizure–> CV effect via direct neuronal transmission from hypothalamus to heart via parasympathetic and sympathetic tracts

acute increase in cerebral blood flow

raised ICP

137
Q

describe the progression of physiological effects of ECT (4 stages)

A
  1. just after stimulus–> parasympathetic due to direct stimulation of brainstem–> risk of arrhythmias, asystole, AV blocks
  2. immediately followed by sympathetic discharge–> causes tachycardia and HTN with transient increase in ejection fraction
  3. end of clonic phase–> parasympathetic is reaactived
  4. upon awakening there is a second sympathetic burst
138
Q

what meds should you consider stopping or holding in ECT

A

benzos/anticonvulsants

lithium

TCAs

MAOIs

139
Q

list anesthetic agents used in ECT

A

ketamine, methohexital, propofol

140
Q

why might you want to have a short acting beta blocker in the ECT room

A

to manage HTN

141
Q

what muscle relaxant is used in ECT

A

succinylcholine

142
Q

which gender has higher vs lower seizure thresholds

A

lower–> female

higher–> male

143
Q

how does caffeine affect seizure threshold

A

lowers it

144
Q

how does sleep affect seizure threshold

A

sleep deprivation lowers it

145
Q

how does hydration affect seizure threshold

A

good hydration lowers it

dehydration raises it

146
Q

how does oxygenation/ventilation affect seizure threshold

A

hyperventilation lowers it

147
Q

how does seizure threshold change with age

A

goes up as someone gets older

148
Q

how does seizure threshold change during course of ECT

A

goes up during course

149
Q

list medications that raise the seizure threshold

A

anticonvulsants

benzos

hypnotics

antiarrhythmics

150
Q

list medications that lower seizure threshold

A

antidepressants

antipsychotics

lithium

theophylline

151
Q

name two anesthetic induction agents that make the seizure threshold HIGHER

A

propofol

barbiturates

152
Q

name three anesthetic induction agents that either do no affect the seizure threshold or LOWER it

A

methohexital

etomidate

ketamine

153
Q

what machine characteristics are best FOR ECT

A

brief pulse

constant current

square wave output

154
Q

how do you titrate ECT (kaplan table)

A
155
Q

what does a good seizure look like on EEG

A

good amplitude, coherence and symmetry

poly spike, polymorphic, slow waveforms

sharp suppression

duration between 25-120 sec

156
Q

why might you consider maintenance ECT

A

relapse rate is high without maintenance

can add antidepressants (i.e nortriptyline) and/or lithium after ECT to improve relapse rates but relapse rates are still high

157
Q

list 4 criteria for continuation/maintenance ECT

A

1. Child and Adolescent Psychiatry (32 decks)

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