Podcast
Questions and Answers
What is the primary reason general anesthesia is required during electroconvulsive therapy (ECT)?
What is the primary reason general anesthesia is required during electroconvulsive therapy (ECT)?
- To ensure patient compliance and cooperation during the treatment session.
- To provide unconsciousness and muscle relaxation, preventing physical injury. (correct)
- To minimize the psychological trauma associated with the procedure.
- To potentiate the therapeutic effects of the electrical stimulation on brain chemistry.
A patient with a history of which condition would be considered a contraindication for electroconvulsive therapy (ECT)?
A patient with a history of which condition would be considered a contraindication for electroconvulsive therapy (ECT)?
- Well-managed type II diabetes mellitus.
- Stable chronic obstructive pulmonary disease (COPD).
- Controlled hypertension managed with medication.
- Recent myocardial infarction (MI). (correct)
Why are selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) typically preferred over tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) as first-line treatments for depression?
Why are selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) typically preferred over tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) as first-line treatments for depression?
- SSRIs and SNRIs have fewer side effects and a lower risk of toxicity compared to TCAs and MAOIs. (correct)
- SSRIs and SNRIs are more effective at treating atypical depression than TCAs and MAOIs.
- SSRIs and SNRIs have a faster onset of therapeutic effect compared to TCAs and MAOIs.
- SSRIs and SNRIs do not require the same dietary restrictions as MAOIs.
A patient undergoing electroconvulsive therapy (ECT) is at the highest risk for which of the following complications?
A patient undergoing electroconvulsive therapy (ECT) is at the highest risk for which of the following complications?
A patient with bipolar disorder is prescribed lithium for mood stabilization. What is a critical consideration for the safe and effective use of lithium?
A patient with bipolar disorder is prescribed lithium for mood stabilization. What is a critical consideration for the safe and effective use of lithium?
Why was there a renewed interest in electroconvulsive therapy (ECT) in the 1980s?
Why was there a renewed interest in electroconvulsive therapy (ECT) in the 1980s?
Which patient population is MOST likely to benefit from electroconvulsive therapy (ECT) for mental illness?
Which patient population is MOST likely to benefit from electroconvulsive therapy (ECT) for mental illness?
What is the typical duration of the tonic phase during a grand mal seizure induced by electroconvulsive therapy (ECT)?
What is the typical duration of the tonic phase during a grand mal seizure induced by electroconvulsive therapy (ECT)?
Why is a tourniquet sometimes applied during electroconvulsive therapy (ECT) before administering succinylcholine?
Why is a tourniquet sometimes applied during electroconvulsive therapy (ECT) before administering succinylcholine?
What is the primary difference between bilateral ECT and right unilateral ECT (RUL-ECT) concerning stimulus strength?
What is the primary difference between bilateral ECT and right unilateral ECT (RUL-ECT) concerning stimulus strength?
A patient undergoing electroconvulsive therapy (ECT) exhibits electrocardiographic changes, including atrioventricular dissociation. What is the typical course of the hyperdynamic response to the electrical stimulus?
A patient undergoing electroconvulsive therapy (ECT) exhibits electrocardiographic changes, including atrioventricular dissociation. What is the typical course of the hyperdynamic response to the electrical stimulus?
Electroconvulsive therapy (ECT) increases intracranial pressure (ICP). Increased ICP is due to what?
Electroconvulsive therapy (ECT) increases intracranial pressure (ICP). Increased ICP is due to what?
How does the ultra-brief pulse width affect the cognitive side effects of right unilateral electroconvulsive therapy (RUL-ECT)?
How does the ultra-brief pulse width affect the cognitive side effects of right unilateral electroconvulsive therapy (RUL-ECT)?
Which waveform used in electroconvulsive therapy (ECT) is associated with greater memory loss and is rarely used in the United States?
Which waveform used in electroconvulsive therapy (ECT) is associated with greater memory loss and is rarely used in the United States?
What is the significance of achieving a minimum seizure duration of 25 seconds during electroconvulsive therapy (ECT)?
What is the significance of achieving a minimum seizure duration of 25 seconds during electroconvulsive therapy (ECT)?
Given its mechanism of action, for which condition would ECT NOT be an effective treatment modality?
Given its mechanism of action, for which condition would ECT NOT be an effective treatment modality?
What is the rationale for using general anesthesia and muscle relaxation during electroconvulsive therapy (ECT)?
What is the rationale for using general anesthesia and muscle relaxation during electroconvulsive therapy (ECT)?
A patient undergoing electroconvulsive therapy (ECT) asks about the placement of electrodes during the procedure. Where are the electrodes placed during bilateral ECT?
A patient undergoing electroconvulsive therapy (ECT) asks about the placement of electrodes during the procedure. Where are the electrodes placed during bilateral ECT?
Which neuroendocrine response is associated with electroconvulsive therapy (ECT)?
Which neuroendocrine response is associated with electroconvulsive therapy (ECT)?
Considering the delivery method of electroconvulsive therapy (ECT), what is associated with a rapid initial response and a longer remission of symptoms?
Considering the delivery method of electroconvulsive therapy (ECT), what is associated with a rapid initial response and a longer remission of symptoms?
How is seizure duration monitored during electroconvulsive therapy (ECT)?
How is seizure duration monitored during electroconvulsive therapy (ECT)?
How many seizure seconds are needed before there is a therapeutic effect?
How many seizure seconds are needed before there is a therapeutic effect?
After a series of electroconvulsive therapy (ECT) treatments, what is recommended for patients with a high rate of recurring depression?
After a series of electroconvulsive therapy (ECT) treatments, what is recommended for patients with a high rate of recurring depression?
What is the typical electrical energy delivered during ECT to produce a grand mal seizure?
What is the typical electrical energy delivered during ECT to produce a grand mal seizure?
What is the standard frequency of electroconvulsive therapy (ECT) treatments in a typical series?
What is the standard frequency of electroconvulsive therapy (ECT) treatments in a typical series?
Why should lithium carbonate ideally be discontinued before initiating electroconvulsive therapy (ECT)?
Why should lithium carbonate ideally be discontinued before initiating electroconvulsive therapy (ECT)?
A patient with a history of salt restriction or taking thiazide diuretics should be closely monitored when undergoing electroconvulsive therapy (ECT) due to their impact on which medication?
A patient with a history of salt restriction or taking thiazide diuretics should be closely monitored when undergoing electroconvulsive therapy (ECT) due to their impact on which medication?
Which of the following conditions is considered a MAJOR contraindication to electroconvulsive therapy (ECT)?
Which of the following conditions is considered a MAJOR contraindication to electroconvulsive therapy (ECT)?
Why is electroconvulsive therapy (ECT) typically postponed for at least 6 to 8 weeks following an acute myocardial infarction (MI) or cerebrovascular accident (CVA)?
Why is electroconvulsive therapy (ECT) typically postponed for at least 6 to 8 weeks following an acute myocardial infarction (MI) or cerebrovascular accident (CVA)?
What is the typical frequency of electroconvulsive therapy (ECT) administration in a standard treatment plan?
What is the typical frequency of electroconvulsive therapy (ECT) administration in a standard treatment plan?
What is the primary action of tricyclic antidepressants (TCAs) on neurotransmitters in the brain?
What is the primary action of tricyclic antidepressants (TCAs) on neurotransmitters in the brain?
Which of the following best describes the mechanism of action of monoamine oxidase inhibitors (MAOIs)?
Which of the following best describes the mechanism of action of monoamine oxidase inhibitors (MAOIs)?
What is the primary mechanism by which selective serotonin reuptake inhibitors (SSRIs) exert their antidepressant effect?
What is the primary mechanism by which selective serotonin reuptake inhibitors (SSRIs) exert their antidepressant effect?
What is the combined effect of salt restriction and thiazide diuretics on lithium levels in patients undergoing electroconvulsive therapy (ECT)?
What is the combined effect of salt restriction and thiazide diuretics on lithium levels in patients undergoing electroconvulsive therapy (ECT)?
Which of the following is NOT considered a relative contraindication for electroconvulsive therapy (ECT)?
Which of the following is NOT considered a relative contraindication for electroconvulsive therapy (ECT)?
When should a stress test or cardiac catheterization be considered as part of the preoperative testing for a patient undergoing electroconvulsive therapy (ECT)?
When should a stress test or cardiac catheterization be considered as part of the preoperative testing for a patient undergoing electroconvulsive therapy (ECT)?
During electroconvulsive therapy (ECT), what effect does lithium have on muscle relaxants?
During electroconvulsive therapy (ECT), what effect does lithium have on muscle relaxants?
Ideally, what is the recommendation regarding antidepressant use during electroconvulsive therapy (ECT) treatments?
Ideally, what is the recommendation regarding antidepressant use during electroconvulsive therapy (ECT) treatments?
What differentiates serotonin-norepinephrine reuptake inhibitors (SNRIs) from selective serotonin reuptake inhibitors (SSRIs)?
What differentiates serotonin-norepinephrine reuptake inhibitors (SNRIs) from selective serotonin reuptake inhibitors (SSRIs)?
How long may maintenance electroconvulsive therapy (ECT) sessions be continued after the initial series of treatments?
How long may maintenance electroconvulsive therapy (ECT) sessions be continued after the initial series of treatments?
Why is a baseline ECG indicated for patients undergoing electroconvulsive therapy (ECT)?
Why is a baseline ECG indicated for patients undergoing electroconvulsive therapy (ECT)?
A patient presenting for electroconvulsive therapy (ECT) is currently taking multiple antidepressant medications, including a selective serotonin reuptake inhibitor (SSRI), a serotonin-norepinephrine reuptake inhibitor (SNRI), and lithium. According to the information provided, which of these medications should be of HIGHEST concern to the anesthesiologist and ideally be discontinued prior to ECT?
A patient presenting for electroconvulsive therapy (ECT) is currently taking multiple antidepressant medications, including a selective serotonin reuptake inhibitor (SSRI), a serotonin-norepinephrine reuptake inhibitor (SNRI), and lithium. According to the information provided, which of these medications should be of HIGHEST concern to the anesthesiologist and ideally be discontinued prior to ECT?
A patient with a history of which condition would warrant extra caution and possibly require further cardiac evaluation before undergoing electroconvulsive therapy (ECT)?
A patient with a history of which condition would warrant extra caution and possibly require further cardiac evaluation before undergoing electroconvulsive therapy (ECT)?
Which of the following conditions presents a relative contraindication for electroconvulsive therapy (ECT) due to the risk of exacerbation or complications?
Which of the following conditions presents a relative contraindication for electroconvulsive therapy (ECT) due to the risk of exacerbation or complications?
What is the PRIMARY reason for discontinuing antidepressants, particularly lithium, during a series of electroconvulsive therapy (ECT) treatments?
What is the PRIMARY reason for discontinuing antidepressants, particularly lithium, during a series of electroconvulsive therapy (ECT) treatments?
Why is it important to discontinue drugs that increase the seizure threshold before electroconvulsive therapy (ECT)?
Why is it important to discontinue drugs that increase the seizure threshold before electroconvulsive therapy (ECT)?
What is the primary reason for administering general anesthesia during electroconvulsive therapy (ECT)?
What is the primary reason for administering general anesthesia during electroconvulsive therapy (ECT)?
Which intravenous (IV) anesthetic agent is known to prolong seizure duration during electroconvulsive therapy (ECT), potentially benefiting patients with short seizure durations?
Which intravenous (IV) anesthetic agent is known to prolong seizure duration during electroconvulsive therapy (ECT), potentially benefiting patients with short seizure durations?
How does remifentanil affect seizure parameters and hemodynamic response when used with lower doses of methohexital or propofol during electroconvulsive therapy (ECT)?
How does remifentanil affect seizure parameters and hemodynamic response when used with lower doses of methohexital or propofol during electroconvulsive therapy (ECT)?
Why should Benzodiazepines be avoided before and during electroconvulsive therapy (ECT)?
Why should Benzodiazepines be avoided before and during electroconvulsive therapy (ECT)?
Why might sevoflurane be considered useful for women requiring electroconvulsive therapy (ECT) in the late stages of pregnancy?
Why might sevoflurane be considered useful for women requiring electroconvulsive therapy (ECT) in the late stages of pregnancy?
What NMDA receptor antagonist may offer protection against neuronal damage associated with electroconvulsive therapy (ECT)?
What NMDA receptor antagonist may offer protection against neuronal damage associated with electroconvulsive therapy (ECT)?
What is the primary purpose of using muscle relaxants during electroconvulsive therapy (ECT)?
What is the primary purpose of using muscle relaxants during electroconvulsive therapy (ECT)?
What is the initial autonomic response observed immediately following the electrical stimulus during electroconvulsive therapy (ECT)?
What is the initial autonomic response observed immediately following the electrical stimulus during electroconvulsive therapy (ECT)?
Why is glycopyrrolate administered prior to electroconvulsive therapy (ECT)?
Why is glycopyrrolate administered prior to electroconvulsive therapy (ECT)?
Why might lidocaine or esmolol be administered before electroconvulsive therapy (ECT)?
Why might lidocaine or esmolol be administered before electroconvulsive therapy (ECT)?
Which parameter of the electrical stimulus used in electroconvulsive therapy (ECT) is MOST directly associated with cognitive side effects?
Which parameter of the electrical stimulus used in electroconvulsive therapy (ECT) is MOST directly associated with cognitive side effects?
In contrast to succinylcholine, why are nondepolarizing muscle relaxants (NDMRs) NOT as commonly used during electroconvulsive therapy (ECT)?
In contrast to succinylcholine, why are nondepolarizing muscle relaxants (NDMRs) NOT as commonly used during electroconvulsive therapy (ECT)?
How does the frequency of electroconvulsive therapy (ECT) treatments per week impact cognitive side effects?
How does the frequency of electroconvulsive therapy (ECT) treatments per week impact cognitive side effects?
Which of the following best balances the need for adequate anesthesia without compromising the therapeutic effect of electroconvulsive therapy (ECT)?
Which of the following best balances the need for adequate anesthesia without compromising the therapeutic effect of electroconvulsive therapy (ECT)?
Why is hyperventilation typically avoided during mask ventilation in electroconvulsive therapy (ECT)?
Why is hyperventilation typically avoided during mask ventilation in electroconvulsive therapy (ECT)?
What is the typical protocol for post-electroconvulsive therapy (ECT) monitoring and management in the postanesthesia care unit (PACU)?
What is the typical protocol for post-electroconvulsive therapy (ECT) monitoring and management in the postanesthesia care unit (PACU)?
How does ketamine potentially counteract a side effect associated with repeated electrocortical stimulation?
How does ketamine potentially counteract a side effect associated with repeated electrocortical stimulation?
Why should theophylline be discontinued before electroconvulsive therapy (ECT)?
Why should theophylline be discontinued before electroconvulsive therapy (ECT)?
How does pretreatment with glycopyrrolate assist in managing the parasympathetic response during electroconvulsive therapy (ECT)?
How does pretreatment with glycopyrrolate assist in managing the parasympathetic response during electroconvulsive therapy (ECT)?
What is a key difference between atropine and glycopyrrolate when pretreating patients for electroconvulsive therapy (ECT)?
What is a key difference between atropine and glycopyrrolate when pretreating patients for electroconvulsive therapy (ECT)?
Why is it important to titrate the stimulus strength to the individual patient during electroconvulsive therapy (ECT)?
Why is it important to titrate the stimulus strength to the individual patient during electroconvulsive therapy (ECT)?
What is the rationale for administering oral nonsteroidal anti-inflammatory drugs (NSAIDs) before electroconvulsive therapy (ECT)?
What is the rationale for administering oral nonsteroidal anti-inflammatory drugs (NSAIDs) before electroconvulsive therapy (ECT)?
How does nifedipine assist in managing the hemodynamic response during electroconvulsive therapy (ECT), particularly in hypertensive patients?
How does nifedipine assist in managing the hemodynamic response during electroconvulsive therapy (ECT), particularly in hypertensive patients?
Which volatile anesthetic agent has been found useful for women requiring electroconvulsive therapy (ECT) in late pregnancy?
Which volatile anesthetic agent has been found useful for women requiring electroconvulsive therapy (ECT) in late pregnancy?
Why is it crucial to ensure the patient is unconscious before administering succinylcholine and the electrical stimulus during electroconvulsive therapy (ECT)?
Why is it crucial to ensure the patient is unconscious before administering succinylcholine and the electrical stimulus during electroconvulsive therapy (ECT)?
A patient undergoing electroconvulsive therapy (ECT) reports persistent memory deficits several months after completing the treatment series. Which of the following factors is MOST likely to contribute to this outcome?
A patient undergoing electroconvulsive therapy (ECT) reports persistent memory deficits several months after completing the treatment series. Which of the following factors is MOST likely to contribute to this outcome?
A patient with a complex psychiatric history is scheduled for electroconvulsive therapy (ECT). What strategy would MOST effectively balance the need for adequate anesthesia while minimizing potential complications and cognitive side effects?
A patient with a complex psychiatric history is scheduled for electroconvulsive therapy (ECT). What strategy would MOST effectively balance the need for adequate anesthesia while minimizing potential complications and cognitive side effects?
After completing a standard series of electroconvulsive therapy (ECT) treatments, a patient experiences a significant improvement in their depressive symptoms. What is the MOST appropriate next step in their treatment plan?
After completing a standard series of electroconvulsive therapy (ECT) treatments, a patient experiences a significant improvement in their depressive symptoms. What is the MOST appropriate next step in their treatment plan?
Which of the following scenarios presents the GREATEST risk for underreporting awareness and recall during electroconvulsive therapy (ECT)?
Which of the following scenarios presents the GREATEST risk for underreporting awareness and recall during electroconvulsive therapy (ECT)?
During the preoxygenation phase of anesthesia for electroconvulsive therapy (ECT), hyperventilation is performed. What is the PRIMARY reason for this intervention?
During the preoxygenation phase of anesthesia for electroconvulsive therapy (ECT), hyperventilation is performed. What is the PRIMARY reason for this intervention?
A patient undergoing electroconvulsive therapy (ECT) exhibits an excessive sympathetic response intraoperatively. Which of the following medications would be MOST appropriate to manage this response?
A patient undergoing electroconvulsive therapy (ECT) exhibits an excessive sympathetic response intraoperatively. Which of the following medications would be MOST appropriate to manage this response?
Which combination of medications is typically administered during electroconvulsive therapy (ECT) to induce anesthesia and muscle relaxation?
Which combination of medications is typically administered during electroconvulsive therapy (ECT) to induce anesthesia and muscle relaxation?
A patient with bipolar disorder is being evaluated for electroconvulsive therapy (ECT). Which of the following signs or symptoms, if present, would MOST strongly suggest the patient is currently experiencing a manic episode?
A patient with bipolar disorder is being evaluated for electroconvulsive therapy (ECT). Which of the following signs or symptoms, if present, would MOST strongly suggest the patient is currently experiencing a manic episode?
A patient undergoing electroconvulsive therapy (ECT) is at risk for post-treatment headache and myalgia. Which of the following medications is MOST appropriate for prophylactic administration BEFORE the procedure?
A patient undergoing electroconvulsive therapy (ECT) is at risk for post-treatment headache and myalgia. Which of the following medications is MOST appropriate for prophylactic administration BEFORE the procedure?
Flashcards
Electroconvulsive Therapy (ECT)
Electroconvulsive Therapy (ECT)
A treatment for severe depression and other psychiatric disorders that involves inducing a brief seizure under anesthesia.
Bipolar disorder
Bipolar disorder
Severe depression and abnormally elevated mood (mania) or hypomania (less severe).
Selective Serotonin Reuptake Inhibitors (SSRIs)
Selective Serotonin Reuptake Inhibitors (SSRIs)
Medications like fluoxetine, citalopram, and sertraline that primarily affect serotonin levels in the brain to alleviate depression.
Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)
Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)
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Mood Stabilizers
Mood Stabilizers
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Electroconvulsive Therapy
Electroconvulsive Therapy
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Bilateral ECT
Bilateral ECT
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Right Unilateral (RUL) ECT
Right Unilateral (RUL) ECT
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ECT Electrical Stimulus
ECT Electrical Stimulus
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Seizure Threshold
Seizure Threshold
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Tourniquet Use in ECT
Tourniquet Use in ECT
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Seizure Duration
Seizure Duration
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EEG in ECT
EEG in ECT
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Hyperdynamic Response to ECT
Hyperdynamic Response to ECT
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TCAs Mechanism of Action
TCAs Mechanism of Action
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MAOIs Mechanism of Action
MAOIs Mechanism of Action
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SSRIs Mechanism of Action
SSRIs Mechanism of Action
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SNRIs Mechanism of Action
SNRIs Mechanism of Action
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Absolute ECT Contraindications
Absolute ECT Contraindications
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Relative ECT Contraindications
Relative ECT Contraindications
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Pre-ECT Testing
Pre-ECT Testing
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Typical ECT Schedule
Typical ECT Schedule
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Lithium and ECT
Lithium and ECT
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Lithium Concerns with ECT
Lithium Concerns with ECT
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Anesthesia Goals for ECT
Anesthesia Goals for ECT
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ECT: Pre-Op Fasting
ECT: Pre-Op Fasting
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ECT: Drugs to Avoid
ECT: Drugs to Avoid
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Theophylline and ECT
Theophylline and ECT
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NSAIDs Role in ECT
NSAIDs Role in ECT
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Glycopyrrolate Before ECT
Glycopyrrolate Before ECT
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Post-ECT Ventilation
Post-ECT Ventilation
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Anesthetic Dosage & ECT
Anesthetic Dosage & ECT
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Methohexital for ECT
Methohexital for ECT
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Etomidate in ECT
Etomidate in ECT
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Remifentanil Use in ECT
Remifentanil Use in ECT
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Benzodiazepines and ECT
Benzodiazepines and ECT
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Sevoflurane in Pregnancy
Sevoflurane in Pregnancy
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Succinylcholine in ECT
Succinylcholine in ECT
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ECT: Initial Autonomic Response
ECT: Initial Autonomic Response
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ECT: Secondary Autonomic Response
ECT: Secondary Autonomic Response
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ECT: Limit Parasympathetic
ECT: Limit Parasympathetic
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Lidocaine/Esmolol Uses
Lidocaine/Esmolol Uses
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ECT: Pulse Width Benefit
ECT: Pulse Width Benefit
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Postictal Confusion
Postictal Confusion
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Retrograde Amnesia (ECT)
Retrograde Amnesia (ECT)
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Antegrade Amnesia (ECT)
Antegrade Amnesia (ECT)
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Recall During ECT
Recall During ECT
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Long-Term ECT Outcome
Long-Term ECT Outcome
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Glycopyrrolate
Glycopyrrolate
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Hyperventilation in ECT
Hyperventilation in ECT
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Mania Symptoms
Mania Symptoms
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Depression Diagnosis
Depression Diagnosis
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Propofol or Etomidate
Propofol or Etomidate
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Study Notes
- General anesthesia facilitates rapid loss of consciousness, amnesia, and muscle relaxation during ECT.
- Ideal anesthetic agents attenuate the hyperdynamic response to electrical stimulus and allow prompt return of consciousness and spontaneous ventilation.
- Patients should be NPO for 6 to 8 hours before ECT.
- Cardiovascular disease patients should take their cardiovascular medications on the morning of the procedure.
- Discontinue drugs that increase the seizure threshold (anticonvulsants, benzodiazepines, lidocaine) before ECT.
- Theophylline is associated with status epilepticus during ECT and should be discontinued prior.
- Oral NSAIDs can prevent posttreatment myalgia or headache; ketorolac 30 mg IV can be used for patients with a history of severe symptoms.
- Tracheal intubation is unnecessary unless the patient has a full stomach or is in the last trimester of pregnancy.
- ECT is usually administered in the PACU or a psychiatric treatment room.
- Standard monitoring includes ECG, pulse oximetry, and BP measurement.
- Preoxygenate and pretreat with glycopyrrolate 0.2 mg IV before administering induction agent and muscle relaxant.
- Insert a bite block after LOC, ventilate by mask using 100% oxygen, and discontinue ventilation during electrical stimulus.
- Hyperventilation will decrease the seizure threshold but may increase the hemodynamic response to stimulation.
- Monitor the patient for at least 30 minutes after return of consciousness and spontaneous ventilation.
- Midazolam can treat emergence agitation.
- IV anesthetics generally have anticonvulsant properties; dosing is crucial to avoid interfering with treatment efficacy.
- Overdosing IV anesthetics shortens seizure duration, reducing ECT efficacy; inadequate dosing may cause awareness and recall.
- Methohexital (0.5 to 1 mg/kg) is an alternative to thiopental for ECT induction.
- Propofol at lower doses (0.75 mg/kg) has similar seizure duration to barbiturates; higher doses (1 to 1.5 mg/kg) can shorten it, but treatment outcome isn't affected.
- A potential advantage of propofol is an earlier recovery of cognitive function.
- Etomidate (0.15 to 0.3 mg/kg) prolongs seizure duration, which may be beneficial in patients with seizure durations less than 25 seconds.
- Etomidate is associated with greater hemodynamic response and a prolonged recovery period.
- Alfentanil (10 to 25 mcg/kg) and remifentanil (1 mcg/kg) with lower doses of methohexital and propofol prolong seizure duration and attenuate the hyperdynamic cardiovascular response.
- Remifentanil improves seizure response in patients refractory to seizure induction after methohexital.
- Remifentanil is associated with lower seizure threshold, prolonged seizure duration, decreased hemodynamic response, and no increase in recovery time.
- Benzodiazepines significantly shorten seizure duration and should be avoided before and during ECT, due to their anticonvulsant activity.
- Benzodiazepines may be required for termination of a prolonged ECT-induced seizure.
- Sevoflurane (1.7%) has a similar effect on seizure duration and hemodynamic response as thiopental.
- Higher concentrations of sevoflurane are more effective in blunting the hemodynamic response.
- Sevoflurane may reduce ECT-stimulated uterine contractions in women in late stages of pregnancy.
- Concerns about increased ICP, sympathetic activity, and prolonged recovery have limited the use of ketamine for ECT.
- The S isomer of ketamine shows increased potency and decreased psychomimetic effects.
- Excitotoxic neuronal damage, mediated by glutamate via the NMDA receptor, may cause postoperative cognitive dysfunction associated with ECT.
- Ketamine, an NMDA antagonist, may protect against this neuronal damage.
- Ketamine blocks the development of mossy fiber sprouting, which correlates with ECT-induced memory impairment.
- Ketamine is associated with shorter reorientation times despite a longer elimination half-life.
- Muscle relaxants prevent myalgia and musculoskeletal complications associated with ECT, including dislocations and fractures.
- Succinylcholine is the most commonly used muscle relaxant and can produce posttreatment myalgia secondary to muscular fasciculations.
- NDMRs are an alternative to succinylcholine but may not be as effective in preventing muscle contractions during ECT and require a prolonged period of ventilatory support.
- The initial response to the electrical stimulus is a brief period of parasympathetic nervous system predominance, lasting less than 20 seconds.
- Parasympathetic effects include increased salivation, severe bradycardia, hypotension, and the potential for brief episodes of asystole.
- Intense sympathetic stimulation follows parasympathetic response, lasting several minutes, and causes tachycardia (≥20% increase in heart rate), arrhythmias, and hypertension (30% to 40% increase in systolic pressure).
- Pretreatment with glycopyrrolate can limit or prevent the parasympathetic response to ECT.
- Glycopyrrolate is effective as an antisialagogue and is associated with less tachycardia post-ECT than atropine.
- Atropine is used to treat bradycardia that persists during the procedure.
- Sympathetic effects such as tachycardia and hypertension are usually self-limiting.
- Lidocaine or esmolol can be used to reduce the incidence of tachycardia and hypertension before initiating ECT.
- Labetalol blunts the cardiovascular response but is associated with a prolonged period of hypotension immediately after the treatment and in the early recovery period.
- Nifedipine provides better control of the hyperdynamic response, especially in elderly patients.
- Sublingual nifedipine pretreatment may prevent or limit an increase in SVR in response to electrical stimulation in hypertensive patients.
- A brief pulse stimulus (0.5 to 2 msec) has a less negative effect on cognition compared to a sine wave stimulus.
- Ultra-brief pulse waveforms (less than 0.5 msec) may produce even fewer cognitive side effects.
- RUL electrode placement requires a higher dosage but is associated with a lower incidence of cognitive side effects.
- Treatments twice a week are associated with a lower incidence of cognitive side effects compared to three times a week.
- Titrating the stimulus strength to minimally exceed the threshold produces the therapeutic effect and affects cognitive function to a lesser degree
Postoperative Complications
- During a standard course of ECT treatments, the overall mortality is less than 0.5%; the major causes of death are MI, CHF, and cardiac arrest.
- Complications include vertebral fracture, laryngospasm, myalgia, headache, confusion, memory loss, jaw pain, dental damage, and nausea and vomiting.
- Hemorrhagic and embolic stroke, prolonged seizure, postictal delirium, and brain-stem herniation associated with a preexisting intracranial mass may also occur
Cognitive Changes
- All seizures are associated with a period of cognitive impairment.
- Short-term effects include emergence agitation.
- Posttreatment disorientation (postictal confusion) lasting for minutes to hours is not uncommon; however, it occurs more frequently in the elderly population.
- Retrograde amnesia generally affects memories for weeks to months preceding the treatment.
- Memory loss gradually improves over time, usually within 7 months, but some patients complain of persistent or permanent memory loss.
- Antegrade amnesia can also occur immediately after the treatment, but these effects are short-lived and temporary compared with retrograde amnesia.
- Cognitive side effects appear to be more frequent in patients taking lithium.
- To minimize cognitive dysfunction, ECT should be administered to the nondominant hemisphere.
- The degree of long-term memory loss increases as the number of treatments increases
Risk of Awareness and Recall
- Awareness under anesthesia, recall of paralysis, and seizures can occur as a result of an inadequate dosage of the induction agent and/or premature administration of the muscle relaxant during ECT.
- LOC should be assured before administering succinylcholine and the electrical stimulus.
- Awareness and recall during ECT may be underreported because bilateral ECT tends to obliterate the memory of the ECT procedure.
- RUL-ECT, which is associated with less memory loss, may increase the incidence of recall if an inadequate induction dose is used or succinylcholine is administered before LOC
Long-Term Outcome
- ECT is an effective short-term treatment for depression and other psychiatric disorders.
- Relapse of symptoms is not uncommon
- Patients who respond positively to a course of ECT will need to continue a treatment regimen with antidepressants after the prescribed series of ECT treatments.
- Some patients may require monthly maintenance ECT treatments for an extended period
Anesthesia for ECT:
- Verify signed informed consent.
- Perform a preanesthetic assessment.
- Ensure presence of emergency airway equipment, suction, medications, and cardiac defibrillator.
- Establish IV access.
- Administer ketorolac to patients at risk for posttreatment headache or myalgia.
- Apply monitors: ECG, pulse oximeter, BP.
- Apply tourniquet or second blood pressure cuff for observation of seizure activity.
- Administer glycopyrolate for the antisialagogue effect.
- Preoxygenate patient: Administer induction agent (propofol, 0.75-1.5 mg/kg or etomidate, 0.15-0.3 mg/kg) and a muscle relaxant (succinylcholine 0.5-1 mg/kg).
- Insert bite block after loss of consciousness.
- Hyperventilate to decrease seizure threshold and prolong duration of seizure.
- Monitor duration seizure.
- Treat excessive sympathetic response with esmolol or labetalol.
- Treat emergence agitation with midazolam.
- Monitor recovery for ≥30 minutes.
- For a diagnosis of depression, five of the following symptoms must be present nearly every day for at least 2 weeks:
- Feelings of sadness or emptiness
- Decreased interest or pleasure in activities
- Appetite change with weight loss or weight gain
- Decreased or increased sleeping
- Fatigue or loss of energy
- Feelings of worthlessness or guilt
- Agitation
- Difficulty in thinking or concentrating
- Recurrent thoughts of death or suicide
Symptoms of Mania (or a Manic Episode) in a Patient With Bipolar Disorder
- Increased energy and activity, restlessness
- Euphoric mood
- Extreme irritability
- Fast speech patterns and flight of ideas
- Inability to concentrate
- Little need for sleep
- Unrealistic beliefs in one's abilities and powers
- Poor judgment
- Spending sprees
- A lasting change of behavior that is different from usual
- Increased sexual drive
- Drug abuse, especially cocaine, alcohol, and sedatives
- Provocative and/or aggressive behavior
- Denial
- Symptoms of psychosis, such as hallucinations and delusions, may also be present
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