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ECT Workshop - 1st day

ECT Workshop - 1st day
Dr Amr Kamal - Dr Shimaa Wagih
17-3-2012

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    Ect   part 3 Ect part 3 Presentation Transcript

    • Under supervision Of DR: AMR KAMAL
    • The purpose of the electrical stimulus in ECT is to induce a generalized grand mal type of seizure.The seizure produced is not an all- or-nothing phenomenon.
    • seizures can be monitored both by observingthe ictal motor response (convulsion)monitoring ictal EEG activity (the electrophysiological activity of the brain occurring during theSeizure) , ( use muscle relaxant)EEG seizure activity is typically 10–20 seconds longer.
    • The intensity of convulsive motor activity is influenced by two factors: the dose of muscle relaxant (generally succinylcholine) intensity of the electrical stimulusMost physicians use a practiceknown as the cuff technique to allow the motor convulsion to be monitored after giving muscle relaxant
    • the cuff technique to allow the motor convulsion to be monitored.Just before the muscle relaxant is administered, a blood pressure cuff is placed on a distal extremity(wrist or ankle) and inflated well above the systolic pressure (about 200 mm Hg).This activity procedure prevents the flow of muscle relaxant distal to the cuff and enables unblocked muscles to manifest convulsive
    • .The ECT stimulus and the inducedseizure both exert cardiovascular,effectsprimarily through the direct neuronal transmission fromthe hypothalamus to the heartvia parasympathetic tracts (the vagus nerve)and sympathetictracts (primarily in the spinal cord).The activation of the parasympathetic system causes adecrease in bloodpressure and heart rate. t
    • The cardiovascular response pattern can best be describedas a four-stage process,involving shifts from parasympathetic to sympathetic to parasympathetic to sympathetic phases The activation of the sympathetic system produces opposite effects: blood pressure, venous pressure, and heart rate increase, resulting in an overall acceleration of cardiac output
    • MISSED SEIZUREINADEQUATE SEIZUREPROLONGED SEIZURE
    • Missed Seizureswhen no motor and ictal evidence of seizure activity is seen following the electrical stimulus,
    • Causes Insufficientstimulus intensity Premature termination of stimulus Poor electrode contact with the skin Patient’s high intrinsic seizure threshold Hypercarbia due to hypoventilationNB the patient should be restimulated within 20–30 seconds, using a 25%–125% increase in stimulus intensity
    • Seizures of “inadequate” duration Restimulation (should be delayed for 30–60 sec)
    •  Evidence suggests that missed or inadequate seizures occurring at maximum stimulus intensity decrease the likelihood that the patient will respond to treatment. When these phenomena occur, efforts should be directed at:  Decreasing the seizure threshold  Increasing the seizure duration  or both (Krystal et al. 2000).
    • Presently, four methods of seizure enhancement are commonly used: Decreasing the anesthetic dosage (if possible and if the agent used has anticonvulsant properties) Hyperventilation (inducing hypocarbia) Caffeine (and other adenosine receptor antagonists) Ketamin anesthesia (Weiner et al. 1991).
    • Seizure activity lasting longer than 3 minutes (American Psychiatric Association 2001).
    • 1) At the first treatment2) During benzodiazepine withdrawal3) In patients in whom proconvulsant medications (e.g., caffeine, theophylline) and lithium4) In patients who have epilepsy or preexisting paroxysmal EEG activity
    •  Inaddition to making the decisions of ECT, the practitioner must also make a determination of:  How frequently the seizures should be induced (i.e., the interval between treatments)  How many treatments should be administered in the treatment course.
    •  Most ECT treatments are given three times a week whereas in other countries they may be administered twice weekly. Increased frequency is associated with a more rapid response, it may also be associated with increased cognitive side effects A three-times-weekly schedule appears to be an acceptable
    • A total number of treatments averaging between six and twelve but no exact number The number of treatments will vary according to the individual and severity of medical condition.
    • After the conclusion of a course of ECT, three options are available for continued treatment:r Administration of applicable psychotropic medications (e.g., antidepressant, antimanic, and/or antipsychotic agent)r Administration of continuation ECTf Psychotherapy combined with either medication or continuation ECT.
    • A fourth option, involving the use of both continuation medication and ECT, may be necessary for patients with a history of failure of prophylaxis with either treatment alone.
    • Multiple psychiatric disorders respond to maintenance ECT including: major depressive disorder psychotic depression bipolar disorder and schizoaffective disorder (Birkenhager et al. 2005).
    •  Use of maintenance ECT in the geriatric population is also well documented (Thienhaus et al. 1990).
    •  Particular forms of schizophrenia (catatonia, refractory positive symptoms) may also be responsive to the combination of ECT and antipsychotic medication (Shimizu et al. 2007; Suzuki et al. 2006)
    • A typical arrangement would involve weekly ECT for 4 weeks, then incremental increases in the interval between ECT treatments to once a month over the next few months (Clarke et al. 1989).
    • ‫‪ ‬مــادة )03( :‬ ‫ل يجوز إجراء العلج الكهربائى اللزم لحالة المريض‬‫النفسى إل تحت تأثير مخدر عام وباسط للعضلت ،‬ ‫ويتعين الحصول على موافقته على ذلك كتابة بناء‬ ‫على إرادة حره مستنيره وبعد إحاطته علما بطبيعة‬ ‫هذا العلج والغرض منه ،والثار الجانبيه التى قد‬ ‫تنجم عنه، والبدائل العلجيه له، فإذا رفض المريض‬‫الخاضع لجراءات الدخول والعلج اللزامى هذا النوع‬ ‫من العلج وكان لزما لحالته فرض عليه بعد إجراء‬ ‫تقييم طبى مستقل.‬
    • Presented byShaiamaa wageih