Ect
Content
ELECTROCONVULSIVE
THERAPY
Mental Health Care Pre-1930’s
What is…
• Electroconvulsive therapy (ECT) is a
treatment for certain mental illnesses.
During this therapy a precise, timed
electrical current is passed through a
patient’s brain in order to induce a seizure.
The procedure is most often used to treat
patients who do not respond to medication
or talk therapy.
History of ECT
• Von Meduna (1934)- Autopsies of patients
w/ Seizure disorders and of patients w/
Schizophrenia.
Chemically induced seizures(camphor, pentylenetetrazol)
Insulin Shock Therapy
• In the 1930’s , Dr Sakel developed Insulin
Shock Therapy
Cerletti and Bini (1934):
Electricity
Initially done without
muscle blocker or
anesthetic
Early ECT
•
•
•
•
Assylums
Few effective medications
Many often severe side effects
1950’s- ether, and curare extract developed
(Abram Bennett- a psychiatrist helped develop a
method for extracting curare).
• In 1950’s antidepressant and antipsychotic meds
introduced- significantly decreased utilization of
ECT
Types of ECT
• There are two major types of ECT—unilateral and
bilateral.
• In bilateral ECT, electrodes are placed on either side of
the head. The treatment affects the entire brain.
• In unilateral ECT, one electrode is placed on the top of
the head. The other is placed on the right temple. This
treatment affects only the right side of the brain.
• Some hospitals employ “ultra-brief” pulses during ECT.
These last less than half a millisecond, compared to the
standard one millisecond pulse. The shorter pulses are
believed to help prevent memory loss.
Electrophysiological Principles
• Ohm’s Law: I=E/R (I=current, E=voltage, and
R=resistance)
• Dose of electricity in ECT= 100-500
milliCoulombs
• Brain has low impedance (resistance), skull has
very high impedance. Only 20% of applied
charge actually enters the brain.
• Seizure involves propagation of action potentials
in a large percentage of neurons.
Mechanism of Action
• Neurotransmitter levels all increased in CSF after
seizure. Results in down regulation of Beta
adrenergic receptors.
• During seizure- PET studies show an increase in
BBB permeability and in cerebral blood flow and
metabolism.
• After seizure, blood flow and metabolism is
decreased especially in the frontal lobes. Research
shows this correlated w/ response.
Indications
• Major Depression w/ or w/o psychotic
features
• Bipolar disorder - manic or depressed phase
• Acute or Catatonic Schizophrenia
• Some studies have shown efficacy in
treating OCD, Delirium, NMS, Chronic
pain syndromes, and intractable seizure
disorders
Major Depression
• Efficacy vs antidepressants
• When is it a first line treatment
consideration?
• Length of Antidepressant effect
• Maintenance ECT
Bipolar Mania
• Efficacy vs Lithium
• Indications for First Line Treatment
•
Pre ECT Workup
•
•
•
•
•
•
Physical Exam
Head CT
CXR
CBC, Basic Chem
EKG
? Spinal Films
Contraindications?
• No Absolute Contraindications
• Relative Contraindications: Recent MI,
Berry Aneurysm, Brain Mass, Increased
Intracranial Pressure
Treatments
• Premedicate w/ Glycopyrrolate, consider
short acting Beta blocker
• Patient not intubated
• Bite block
• Cuff leg to monitor sz
• EEG and EMG
• Length of sz- 20 sec to 1 min.
Number and Spacing of ECT
• 2-3x/wk- efficacy vs less memory
impairment
• 5-12 sessions/ treatment (although up to 20
is possible)
• Point of maximum improvement- no more
improvement after 2 further treatments.
Adverse Effects
• Mortality rate: .002% per treatment
session, .01% per patient.
• Sore Muscles
• Head ache
• Short term confusion/ delirium
• Memory
Consent?
Selection ?
Pre ECT Nursing care
• The patient must be escorted to the ECT clinic waiting area, through
ECT and recovery and back to the ward by a qualified nurse or
equivalent.
• In the case of in-patients, the ideal escort is the patient’s Named
Nurse, while in the case of out-patients, the patient’s community nurse,
key-worker, a member of the ECT team or out-patient department team
should perform a similar function.
• The escort should be known to the patient and be aware of the
patient’s legal and consent status and have an understanding of ECT.
• To further minimise anxiety the escort nurse should consider the use
of anxiety management techniques, ensuring as short a wait as possible
in the treatment waiting room, offering reassurance and support.
•
•
The doctor may prescribe a pre-med as per local protocol.
Special arrangements should be made when patients are given ECT in
a clinic remote from a hospital base, i.e. the patient should have an
individual trained nurse escort, and commuting patients should be
treated at the beginning of the session to allow maximum time for
recovery.
• Regarding anaesthesia outside hospital, the view of the Association of
Anaesthetists is that the standards of monitoring used during general
anaesthesia should be exactly the same in all locations.
During ECT
•
•
•
•
•
•
There will be several people in the treatment room, including psychiatrists, the
treatment nurse and the anaesthesia staff, the patient should be introduced to
each member of the team and given a brief explanation of the member’s role in
the ECT procedure.
The patient should then be assisted on to a trolley and asked to remove his /
her prostheses, dentures, glasses etc. Removing the patients shoes will allow
for the clear observation of the patient’s extremities during the treatment.
One member of the team should provide explanation of the procedure as it
occurs
An initial recording of the patient’s blood pressure, pulse and oxygen
saturation should be made at this stage.
The psychiatrist or nurse cleans areas of the patient’s head with alcohol swabs
and / or gel at the sites of electrode contact as per local protocol.
A disposable or autoclavable bite block is inserted into the patient’s mouth
prior to the delivery of the stimulus to prevent tooth, tongue or gum damage or
joint dislocation.
Post ECT
• The recovery area should be next to the treatment room to allow access
for the anaesthetic staff in the event of an emergency.
• Oxygen should be administered routinely to the patient. The area must
contain, suction, monitoring and emergency equipment as
recommended by Institutional protocols
• The nurse should maintain the patient’s airway and monitor / record
vital signs at regular intervals or more frequently if complications
arise.
• The patient should be observed by a staff member in close proximity
until he or she awakens.
• The nurse should provide frequent reassurance and reorientation until
the patient retains the information
• When the patient is ready he or she should be escorted to a
final stage area for refreshments and rest until the recovery
staff deem him or her fit to return to the ward.
• A longer time for rest and reorientation may be required.
• Closer observation may be required.
• The patient should be assessed on return to the ward
regarding level of observation required and degree of
orientation
• The ECT nurse should ensure that the ECT
machine functioning and maintenance is
checked and recorded at least every year or
according to machine guidance.
• A record of ECT administration should be
maintained for quality assurance
CNE
• Is it needed?
• For what?
THERAPY
Mental Health Care Pre-1930’s
What is…
• Electroconvulsive therapy (ECT) is a
treatment for certain mental illnesses.
During this therapy a precise, timed
electrical current is passed through a
patient’s brain in order to induce a seizure.
The procedure is most often used to treat
patients who do not respond to medication
or talk therapy.
History of ECT
• Von Meduna (1934)- Autopsies of patients
w/ Seizure disorders and of patients w/
Schizophrenia.
Chemically induced seizures(camphor, pentylenetetrazol)
Insulin Shock Therapy
• In the 1930’s , Dr Sakel developed Insulin
Shock Therapy
Cerletti and Bini (1934):
Electricity
Initially done without
muscle blocker or
anesthetic
Early ECT
•
•
•
•
Assylums
Few effective medications
Many often severe side effects
1950’s- ether, and curare extract developed
(Abram Bennett- a psychiatrist helped develop a
method for extracting curare).
• In 1950’s antidepressant and antipsychotic meds
introduced- significantly decreased utilization of
ECT
Types of ECT
• There are two major types of ECT—unilateral and
bilateral.
• In bilateral ECT, electrodes are placed on either side of
the head. The treatment affects the entire brain.
• In unilateral ECT, one electrode is placed on the top of
the head. The other is placed on the right temple. This
treatment affects only the right side of the brain.
• Some hospitals employ “ultra-brief” pulses during ECT.
These last less than half a millisecond, compared to the
standard one millisecond pulse. The shorter pulses are
believed to help prevent memory loss.
Electrophysiological Principles
• Ohm’s Law: I=E/R (I=current, E=voltage, and
R=resistance)
• Dose of electricity in ECT= 100-500
milliCoulombs
• Brain has low impedance (resistance), skull has
very high impedance. Only 20% of applied
charge actually enters the brain.
• Seizure involves propagation of action potentials
in a large percentage of neurons.
Mechanism of Action
• Neurotransmitter levels all increased in CSF after
seizure. Results in down regulation of Beta
adrenergic receptors.
• During seizure- PET studies show an increase in
BBB permeability and in cerebral blood flow and
metabolism.
• After seizure, blood flow and metabolism is
decreased especially in the frontal lobes. Research
shows this correlated w/ response.
Indications
• Major Depression w/ or w/o psychotic
features
• Bipolar disorder - manic or depressed phase
• Acute or Catatonic Schizophrenia
• Some studies have shown efficacy in
treating OCD, Delirium, NMS, Chronic
pain syndromes, and intractable seizure
disorders
Major Depression
• Efficacy vs antidepressants
• When is it a first line treatment
consideration?
• Length of Antidepressant effect
• Maintenance ECT
Bipolar Mania
• Efficacy vs Lithium
• Indications for First Line Treatment
•
Pre ECT Workup
•
•
•
•
•
•
Physical Exam
Head CT
CXR
CBC, Basic Chem
EKG
? Spinal Films
Contraindications?
• No Absolute Contraindications
• Relative Contraindications: Recent MI,
Berry Aneurysm, Brain Mass, Increased
Intracranial Pressure
Treatments
• Premedicate w/ Glycopyrrolate, consider
short acting Beta blocker
• Patient not intubated
• Bite block
• Cuff leg to monitor sz
• EEG and EMG
• Length of sz- 20 sec to 1 min.
Number and Spacing of ECT
• 2-3x/wk- efficacy vs less memory
impairment
• 5-12 sessions/ treatment (although up to 20
is possible)
• Point of maximum improvement- no more
improvement after 2 further treatments.
Adverse Effects
• Mortality rate: .002% per treatment
session, .01% per patient.
• Sore Muscles
• Head ache
• Short term confusion/ delirium
• Memory
Consent?
Selection ?
Pre ECT Nursing care
• The patient must be escorted to the ECT clinic waiting area, through
ECT and recovery and back to the ward by a qualified nurse or
equivalent.
• In the case of in-patients, the ideal escort is the patient’s Named
Nurse, while in the case of out-patients, the patient’s community nurse,
key-worker, a member of the ECT team or out-patient department team
should perform a similar function.
• The escort should be known to the patient and be aware of the
patient’s legal and consent status and have an understanding of ECT.
• To further minimise anxiety the escort nurse should consider the use
of anxiety management techniques, ensuring as short a wait as possible
in the treatment waiting room, offering reassurance and support.
•
•
The doctor may prescribe a pre-med as per local protocol.
Special arrangements should be made when patients are given ECT in
a clinic remote from a hospital base, i.e. the patient should have an
individual trained nurse escort, and commuting patients should be
treated at the beginning of the session to allow maximum time for
recovery.
• Regarding anaesthesia outside hospital, the view of the Association of
Anaesthetists is that the standards of monitoring used during general
anaesthesia should be exactly the same in all locations.
During ECT
•
•
•
•
•
•
There will be several people in the treatment room, including psychiatrists, the
treatment nurse and the anaesthesia staff, the patient should be introduced to
each member of the team and given a brief explanation of the member’s role in
the ECT procedure.
The patient should then be assisted on to a trolley and asked to remove his /
her prostheses, dentures, glasses etc. Removing the patients shoes will allow
for the clear observation of the patient’s extremities during the treatment.
One member of the team should provide explanation of the procedure as it
occurs
An initial recording of the patient’s blood pressure, pulse and oxygen
saturation should be made at this stage.
The psychiatrist or nurse cleans areas of the patient’s head with alcohol swabs
and / or gel at the sites of electrode contact as per local protocol.
A disposable or autoclavable bite block is inserted into the patient’s mouth
prior to the delivery of the stimulus to prevent tooth, tongue or gum damage or
joint dislocation.
Post ECT
• The recovery area should be next to the treatment room to allow access
for the anaesthetic staff in the event of an emergency.
• Oxygen should be administered routinely to the patient. The area must
contain, suction, monitoring and emergency equipment as
recommended by Institutional protocols
• The nurse should maintain the patient’s airway and monitor / record
vital signs at regular intervals or more frequently if complications
arise.
• The patient should be observed by a staff member in close proximity
until he or she awakens.
• The nurse should provide frequent reassurance and reorientation until
the patient retains the information
• When the patient is ready he or she should be escorted to a
final stage area for refreshments and rest until the recovery
staff deem him or her fit to return to the ward.
• A longer time for rest and reorientation may be required.
• Closer observation may be required.
• The patient should be assessed on return to the ward
regarding level of observation required and degree of
orientation
• The ECT nurse should ensure that the ECT
machine functioning and maintenance is
checked and recorded at least every year or
according to machine guidance.
• A record of ECT administration should be
maintained for quality assurance
CNE
• Is it needed?
• For what?
