Shocking facts! Anaesthesia for ECT

airway anaesthesia endoscopy safety Nov 18, 2024

Electroconvulsive therapy (ECT), used in the treatment of severe and/or medication resistant depression, presents an array of unique challenges and considerations for a complex cohort of patients. Facilitating anaesthesia is a balance between ensuring patients are deep enough, whilst minimising adverse effects and ensuring efficacy of treatment.

So what exactly happens within the body when seizure activity is induced?

Cardiovascular effects: 

💓 The cardiovascular response is due to the activation of the autonomic nervous system
⏱️ Initial parasympathetic response (approx 10-15 secs) - results in bradycardia, hypotension, can go as far as a period of asystole
💥 Followed by sympathetic response (peaking at 3-5 mins) - tachycardia, hypertension, potential for arrhythmias, increased oxygen consumption
❤️‍🩹 Can be decreased left ventricular systolic and diastolic function for up to 6 hours post treatment (even in normal, healthy hearts)
👵 In elderly or heavily co-morbid patients, there is an increased risk of myocardial ischemia and infarction

Cerebral effects:
🧠 Increased cerebral blood flow, oxygen consumption and intracranial pressure
🔑 Increased blood-brain barrier permeability
🤯 Cognitive adverse effects including disorientation, impaired attention, memory problems including short-term memory loss lasting several weeks
🔙 Potential for permanent memory loss, retrograde or anterograde amnesia
⚠️ Risk of transient ischaemic deficits, intracranial haemorrhage and cortical blindness

With this in mind, here are some considerations for anaesthesia choices:

Anaesthetic agent choices:
💉 Many anaesthetic agents have anticonvulsive properties which can hinder ECT treatment
🔬 Propofol - reduced seizure duration, but has improved CVS stability when compared with other agents, reduces PONV, and sees quicker emergence
💊 Thiopental - reduced seizure duration (not as much as propofol), but increased risk of dysrhythmias
🔥 Sevoflurane - seizure activity comparable to thiopental, useful with difficult IV access, but more time consuming
💪 Muscle relaxant to reduce muscular convulsion and decrease the risk of serious injury to the patient - Suxamethonium is most commonly used due to rapid onset and short duration

Airway management:
💨 Pre-oxygenation is vital!
🔒 Intubation is not commonly performed unless specific risk factors are identified, LMAs may also be used occasionally
😤 Hyperventilation lowers seizure threshold and can prolong seizure activity
🦷 Bite blocks should always be used to protect the teeth and mouth
🌬️ After the electrical stimulus, gentle bag-mask ventilation can occur until the patient starts breathing again

ECT may seem like a “quick”, minimalist procedure, however there are a great deal of risks associated in a cohort of patients who are particularly complex and vulnerable. Vigilance and close, careful observation are crucial to ensure patient safety.

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References:

Kulkarni, A., Manji, M., Rayner, I. (2014). Anaesthesia for Electro-Convulsive Therapy. WFSA. https://resources.wfsahq.org/atotw/anaesthesia-for-electro-convulsive-therapy-anaesthesia-tutorial-of-the-week-306/

Uppal, V., Dourish, J., Macfarlane, A. (2010). Anaesthesia for electroconvulsive therapy. Continuing education in Anaesthesia Critical Care and Pain. V10(6) pp 192-196 https://doi.org/10.1093/bjaceaccp/mkq039



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