Neurostimulation: ECT Flashcards
what is the response rate to ECT for mood disorders
75-85% for mood disorders
what is the response rate to ECT for those with mood disorders who have been medication resistant
60-70%
what population has an even higher response rate to ECT
the elderly over age 65
does efficacy of ECT drop off early or late in lifespan?
no
is ECT as good as, worse, or better than sham or standard AD?
PROVEN SUPERIORITY
superior to sham and superior to standard AD therapy (in medication RESISTANT patients)
what are some of the benefits to ECT treatment for patients and hospital systems
ECT can reduce length of stay + hospitalization cost
is both effective and rapid
does the benefit of ECT last after treatment stopped?
may have HIGH RELAPSE rates without maintenance ECT or antidepressant therapy
what 3 disorders have primary indications for ECT
MDD
Mania
Schizophrenia
list primary indications for ECT in someone presenting with MDD
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
list primary indications for ECT in those presenting with Mania
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
list primary indications for ECT in those presenting with schizophrenia
positive symptoms with ABRUPT or RECENT onset
CATATONIA
history of good response to ECT
do those with schizophreniform disorder respond to ECT
yes
in patients presenting with psychosis, which patients are likely to have significant benefit from ECT
is psychosis + significant affective sx
what should the approach to treatment be for someone presenting with psychotic symptoms who is felt to be a good candidate for ECT
ECT + antipsychotics
list disorders for which there is a secondary indication for ECT
catatonia (not due to MDE, mania, schizophrenia)
Parkinsons disease
NMS
delirium
intractable seizure disorder
mood disorder due to another medical condition
what benefit might someone with parkinsons disease see from ECT
may improve MOTOR symptoms (esp. “on/off”)
may need maintenance ECT to sustain remission
what should you do with someones medications if they have parksinsons disease and are receiving ECT
consider adjusting meds during ECT course due to risk of tx emergent dyskinesia or psychosis
how should you approach someone with NMS if you are considering ECT for this patient
DISCONTINUE ANTIPSYCHOTICS first
achieve autonomic stability first
should you do ECT for delirium
it is a secondary indication but should only be RARELY considered
correct reversible physical factors first
can you use ECT in patients with mood sx + dementia
YES
ECT is beneficial for mood symptoms in ALL STAGES of dementia
what benefits might there be from ECT in dementia
may be helpful for AGITATION/SCREAMING even without depression in patients with dementia
–> but NOT RECOMMENDED–> consider nonpharm/pharm approaches first
what are the risks of ECT in patients who are elderly with dementia
increased risk of POST ECT DELIRIUM and COGNITIVE side effects
–> consider changing frequency or technique, and tracking cognitive status
is older age a specific risk for ECT
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
can you do ECT in adolescents
yes–> can be effective for PRIMARY INDICATIONS and CATATONIA
can you do ECT in children
yes but used very rarely
limited data
consider IF…
–> symptoms are severe, persistent, significantly disabling, life threatening
–> medication resistant/intolerant
–> get a second opinion
how does a childs seizure threshold compare to an adults
children have LOWER seizure threshold
can you do ECT in a pregnant person
YES
ECT is SAFE and EFFECTIVE in ALL stages of pregnancy
–> consults anesthesia and OB
–> ensure available resources for neonatal/obstetrical emergency
can you do ECT in post partum women
YES
is SAFE and EFFECTIVE in the post partum period
–> limited risk of anesthetic agents to the nursing infant
can you do ECT in those with congenital and acquired brain injury or mental retardation
yes–> there is case evidence for ECT in primary conditions and catatonia
are there particular risks of ECT in those with congenital and acquired brain injury or mental retardation
may be higher risk of post ECT delirium–> may need to adjust frequency, technique
what is the evidence for doing ECT in those with personality disorder AND mood disorder
there is BENEFIT but there is REDUCED response rate overall and higher RELAPSE rates in this population
list conditions in which there is INSUFFICIENT data to recommend ECT
primary anxiety disorders
PTSD
primary delusional disorder
chronic pain with affective symptoms (though may have some relief)
what are the ABSOLUTE contraindications to ECT
there are NONE
there are NO ABSOLUTE CONTRAINDICATIONS TO ECT
list 6 relative contraindications to ECT
- unstable/severe cardiovascular conditions–> recent MI, unstable angina, poorly-compensated HF, severe valvular cardiac disease, critical aortic stenosis
–> also CAUTION with CARDIAC DEVICES - aneurysm or vascular malformations (risk of rupture with high BP)
- increased ICP–> i.e brain tumors, space occupying lesions
- recent stroke
- pulmonary conditions–> severe COPD, asthma, pneumonia
- ASA level 4/5
list 3 conditions which place patients at higher risk for adverse events with ECT
pheochromocytoma
retinal detachment
acute narrow angle glaucoma
can you do ECT in someone with a cardiac pacemaker
CAUTIOUSLY
ECT is UNLIKELY to disrupt functioning
ensure monitoring leads are WELL GROUNDED
preferable not to have someone holding patient grounded to the floor
can you do ECT in someone with an implantable automatic defibrillator
yes–> but they are more susceptible during ECT stimulation
consult cardiology and anesthesiology ahead of time
which cardiac conditions would be considered relative contraindications to ECT
unstable/severe
recent MI
unstable angina
poorly compensated HF
severe valvular cardiac disease
critical aortic stenosis
why is an aneurysm or vascular malformation a relative contraindication to ECT
risk of rupture with high BP
what pulmonary conditions may be relative contraindications to ECT
severe COPD
asthma
pneumonia
what ASA level is a relative contraindication to ECT
level 4/5
in whcih patients should an ECG be part of pre ECT workup
if older than 45 or if have cardiac disease
are routine labs mandatory for pre-ECT workup
NO not mandatory but consider if clinically indicated
i.e CBC, lytes, renal function
what features are part of the pre ETC workup
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
who should get a CXR before ECT
if florid/unstable cardiopulmonary condition
who should get a cervical spine XR before ECT
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
who should get an anesthesia consult before ECT
if older than age 60
if significant CV or neuro conditions
if pregnant
if unstable C spine
what other speciality consults may be considered before ECT
i.e obstetrics in pregnancy
what needs to be documented prior to performing ECT
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
what are critieria for valid consent
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
what are requirements for capacity for healthcare decisions
patient understands the info given and is able to apply it to their own health
–> ask patient to repeat in own words
what is a typical index course of ECT
6-12 sessions
patients generally respond in 6-12 sessions
what do you do if there is no response to ECT after 15 sessions
get second opinion about continuing treatment
does a patient need to be NPO for ECT
yes should be
how do you manage existing medications for medical illness for patients undergoing a course of ECT
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
which patients should be given priority on the ECT slate
diabetic patients–> insulin + hypoglycemics usually given after treatment
how do you manage existing medications for psychiatric illness for patients undergoing a course of ECT
it is favorable to STOP as many psychotropic drugs as possible
DECREASES risk of DELIRIUM and minimizes cognitive sx
ESP. ANTICHOLINERGIC MEDS
how do you manage existing medications for bipolar disorder for patients undergoing a course of ECT
mood stabilizers likely need to be continued–> risk of iatrogenic switch to mania
is there any evidence yet for combining ECT and meds
no not yet
how do you manage existing SSRIs for patients undergoing a course of ECT
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)
how do you manage existing MAOIs for patients undergoing a course of ECT
likely SAFE to continue but theres little data
if hypotension during ECT–> avoid direct vasopressors–> should use neosynephrine instead (consult anesthesia)
how do you manage existing TCAs for patients undergoing a course of ECT
likely SAFE to continue
STOP if stronger anticholinergic side effects due to risk of post ECT delirium
–> amitriptyline, imipramine, clomipramine, trimipramine
what antidepressant should you stop in ECT and why
stop buproprion
reports of spontaneous seizures, lowers threshold
list medications that can be problematic in ECT
(SSRIs may increase risk for post-ECT delirium)
*buproprion–> lowers seizure threshold
*lithium
*anticonvulsants
FGAs
benzos
what are the risks of continuing lithium during ECT
increased risk of:
DELIRIUM
PROLONGED SEIZURES
decreased seizure THRESHOLD
when might you consider continuing lithium during course of ECT and how should you manage this
may need to continue if refractory mood disorders
HOLD night and morning before ECT–> give post ECT
measure lithium levels BEFORE ECT course
what are the concerns with using anticonvulsants during a course of ECT
DECREASED SEIZURE time
HIGHER seizure threshold
may decrease ECT efficacy
if you need to continue an anticonvulsant due to need for mood stabilization, how should you manage it during ECT
hold night and morning before and give post ECT
what impact do FGAs have on ECT
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
what FGA should you AVOID during a course of ECT and why
reserpine
cases of death with ECT
what is the impact of benzos during a course of ECT
increase seizure threshold
may lessen ECT efficacy for mood sx
if someone needs benzos, and also needs ECT, how do you manage the benzos
use MEDIUM half life benzos
hold morning of ECT and give after
what can be used in the ECT treatment room if benzos are affecting ECT
IV flumazenil
then give midaz in recovery to prevent benzo withdrawal
what type of stimulus do modern ECT machines give
brief pulse
what is the benefit of brief pulse ECT vs older sine wave pulse
equally efficient but less cognitive SEs
what equipment do you need for ECT
what is the conductor in ECT
blood–> brain vasculature carries the current
why do you need careful skin site prep for ECT
skin resist the ECT current–> id inadequate prep, can have inadequate/aborted seizures or skin burns
for unilateral electrode placement in ECT, is it on the dominant or non dominant side
NON dominant hemispheric ECT (which is usually RIGHT hemisphere)
what positioning is recommended for RUL ECT
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
why might you pick unilateral vs bilateral electrode placement or vice versa in ECT
bilateral–> more effective, but more cognitive sx
RUL–> less effective, but less cognitive sx
which is more effective, bitemporal or bifrontal ECT
bitemporal
what is an ECT electrode placement other than RUL, bitemporal and bifrontal
left anterior, right frontal placement
near medial region of frontal lobes
avoids skull sutures
fewer cognitive SEs
why do we pick the dose intensities we do for ECT
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
how do you determine how much stimulus to give for ECT
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
what is the formula method for determining where to initiate stimulus for ECT
initiate at half of patients age–> % of max output of machine
i.e if age 60, start at 30% of output
what stimulus pulse morphology seems to have increased efficacy
SHORTENED pulse width + LONGER pulse trains
RUL ECT is given at what dose
5-6x above seizure threshold
bitemporal or bifrontal ECT is given at what dose
1.5-2.5x seizure threshold
what is considered “effective ECT”
confirmed seizure
generalized seizure to BOTH hemispheres
seizure of adequate INTENSITY for sx recovery
avoids unnecessary cognitive sx
which is more important to ECT efficacy–> seizure time or seizure intensity
seizure intensity is more important than length of seizure
what features on EEG indicate a seizure with good intensity
higher AMPLITUDE spike + wave activity
SHARP post-ictal SUPPRESSION
what is the CV response to ECT
initial parasympathetic response then sympathetic outpouring from seizure itself–> may have sig changes in BP, HR
what is considered an aborted seizure in ECT
less than 15 sec long
*unlikely to benefit from short seizure
list possible causes of a missed or aborted seizure during ECT
- excessive impedance (poor skin contact)
- hypercarbia (inadequate ventilation)
- hypoxia
- dehydration
- medications (benzos, anticonvulsants)
- insufficient stimulus
what do you do if there is an inadequate/missed/aborted seizure during ECT
- review “dynamic impedance” reading from ECT device
- Correct hydration, electrolyte imbalance
- oxygenate adequately, ventilate vigorously before next stimulation
- reduce/stop interfering medication
- can use flumazenil if pt. on high dose benzos then give IV midaz after
- can consider CAFFEINE SODIUM BENZOATE 500-2000mg IV before ECT to lengthen seizure time
what do you do if there is an inadequate/missed/aborted seizure during ECT and the dynamic impedance was found to be too high
correct skin prep, gel and electrode position
what do you do if there is an inadequate/missed/aborted seizure during ECT and dynamic impedance was not found to be too high
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
what medication can lengthen seizure time
caffeine sodium benzoate
what is considered a “prolonged” seizure
in USA, above 180 sec
in UK, above 120 sec
what do you do if someone has a prolonged seizure in ECT
can ABORT with IV benzo like midaz
can ABORT with IV anticonvulsant anesthetic like thiopental
can intubate if necessary
how long should you wait aftet ECT to do a cognitive assessment
more than 24 hours
what factors guide the total number and frequency of ECT treatments
degree/rate of clinical improvement
development/severity of cognitive symptoms
how often do you usually do ECT
usually 2-3 per week on nonconsecutive days
(daily only if rapid response ++ important)
what is the usual course for MDD for ECT
6-12 sessions
taper courses as soon as max response obtained
what do you do if someone has confusion or marked decline in cognition associated with ECT
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
what do you do if someone has slow or minimal improvement after 6-10 sessions of ECT
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
what should you consider if repeated courses of ECT are needed and why
consider the cognitive effects as there can be a cumulative effect
are there any clear strategies in ECT non responder
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”)
state 3 factors that increase risk of post ictal delirium
bilateral placement
high intensity stimulation
pre-existing cerebral impairment
how does post ictal delirium present
marked agitation
disorientation
poor response to commands
–> there is risk of injury, sympathetic response
how long does post ictal delirium take to recover
5-45 min
patients are often amnestic for the episode
how do you manage post ictal delirium
supportive, reassurance
may need IM/IV benzos or IV haldol
if recurrent, can use these prophylactically after patient resumes spontaneous respiration
how often should you assess cognitive during course of ECT
before treatment and then weekly during course
in those receiving ECT for depression, what % switch into hypomania
12%
in those receiving ECT for psychotic depression, what % switch into hypomania
10%
in those receiving ECT for psychotic BIPOLAR depression, what % switch into hypomania
30%
who is more likely to switch into mania due to ECT
if have bipolar or fam hx bipolar
what do you do in cases of switch to mania/hypomania during ECT
no current tx guidelines but there are strategies
- can stop ECT + treat manic sx with meds
- can suspend further tx + observe pt
- can continue ECT to treat manic sx + depressive sx
how might someone present if they have treatment emergent delirium with euphoria (“Organic euphoria”) due to ECT
confusion, disorientation, cognitive impairment
silly, inappropriate quality to mood
is transient–> few hours to days
what are some strategies to facilitate recovery from organic euphoria/delirium with euphoria
increase time between treatments
decrease stimulus intensity
change from bilateral to unilateral
is there an indication for ECT for dementia, in absence of mood sx
no
what is the overall mortality rate of ECT
extremely low
2-10 per 100 000 (0.0001%)
most mortality due to CV event
what are the most common complaints post ECT
dental, tongue injuries
headache
nausea
other somatic complaints
what are the risks for ECT if someone is not NPO before
risk of aspiration/aspiration pneumonia
what is an MSK risk for ECT
fractures–> esp. if have osteoporosis (esp vertebral compression #s)
how quickly does acute confusion typically resolve after ECT
10-30 min
what types of amnesia can be associated with ECT
anterograde
retrograde
how soon does anterograde amnesia typically resolve after a course of ECT
usually within 2 weeks after completing course
what memories after typically affected if retrograde amnesia occurs after completing course of ECT
impersonal memory weeks to few months prior usually
what % of those who receive ECT have some sort of persistent ot permanent memory loss
ranges from 29-55%
list 6 ways to minimize cognitive SEs from ECT
brief pulse (better than sine wave)
lowest stimulus intensity
RUL over bilateral
increased space between sessions, fewer sessions
lowest possible anesthetic dose
avoid lithium
what are the overall response rates to ECT in MDD/MDE
very high!! 75-85% overall
what are the response rates in the elderly with MDD/MDE receiving ECT
80-90%–> even higher than overall rates
what are the response rates to ECT in those with MDD/MDE that were med resistant
60-70%
what physiological changes are seen during ECT
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
describe the progression of physiological effects of ECT (4 stages)
- just after stimulus–> parasympathetic due to direct stimulation of brainstem–> risk of arrhythmias, asystole, AV blocks
- immediately followed by sympathetic discharge–> causes tachycardia and HTN with transient increase in ejection fraction
- end of clonic phase–> parasympathetic is reaactived
- upon awakening there is a second sympathetic burst
what meds should you consider stopping or holding in ECT
benzos/anticonvulsants
lithium
TCAs
MAOIs
list anesthetic agents used in ECT
ketamine, methohexital, propofol
why might you want to have a short acting beta blocker in the ECT room
to manage HTN
what muscle relaxant is used in ECT
succinylcholine
which gender has higher vs lower seizure thresholds
lower–> female
higher–> male
how does caffeine affect seizure threshold
lowers it
how does sleep affect seizure threshold
sleep deprivation lowers it
how does hydration affect seizure threshold
good hydration lowers it
dehydration raises it
how does oxygenation/ventilation affect seizure threshold
hyperventilation lowers it
how does seizure threshold change with age
goes up as someone gets older
how does seizure threshold change during course of ECT
goes up during course
list medications that raise the seizure threshold
anticonvulsants
benzos
hypnotics
antiarrhythmics
list medications that lower seizure threshold
antidepressants
antipsychotics
lithium
theophylline
name two anesthetic induction agents that make the seizure threshold HIGHER
propofol
barbiturates
name three anesthetic induction agents that either do no affect the seizure threshold or LOWER it
methohexital
etomidate
ketamine
what machine characteristics are best FOR ECT
brief pulse
constant current
square wave output
how do you titrate ECT (kaplan table)
what does a good seizure look like on EEG
good amplitude, coherence and symmetry
poly spike, polymorphic, slow waveforms
sharp suppression
duration between 25-120 sec
why might you consider maintenance ECT
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
list 4 criteria for continuation/maintenance ECT
