electroconvulsive therapy

2.  Also known as Electroshock
 Is a psychiatric treatment modality in which a
grandmal seizure (tonic phase 10-15sec, clonic
phase:30-60 sec.) is artificially induced through
the application of electrical current(70 to 120
volts for 0.7 to1.5sec) to the brain in an
anesthetized patient.
 stimulus is applied through electrodes which
are placed either bilaterally in the fronto-
temporal region or unilaterally on the non
dominant side

3.  Firstly used by Meduna in 1935 for treating
schizophrenic symptoms
 Seizure was induced with intramuscular
injection of camphor in a patient with
catatonic schizophrenia.
 Cerletti and Bini introduced the use of electric
shock to induce seizures in 1938.Later it
became the standard.

4.  Neuro-transmitter theory
 Neuro-endocrine theory
 Anti-convulsant theory
 Brain damage theory
 Psychological theory

5.  Neurotransmitter theory. ECT works like
anti-depressant medication, changing the way brain
receptors receive important mood-related chemicals.
 Anti-convulsant theory. ECT-induced
seizures teach the brain to resist seizures. This effort
to inhibit seizures dampens abnormally active brain
circuits, estabilishing mood.
 Neuroendocrine theory. The seizure causes
the hypothalamus to release chemicals that cause
changes throughout the body. The seizure may
release a neuropeptide that regulates mood.
 Brain damage theory. Shock damages the
brain, causing memory loss and disorientation that
creates an illusion that problems are gone, and
euphoria, which is a frequently observed result of
brain injury. Both are temporary.
 Psychological theory. Depressed people often
feel guilty, and ECT satisfies their need for
punishment. – the placebo effect

6.  NEUROLOGICAL RESPONSE:- generalized
motor seizure
 CARDIOVASCULAR RESPONSE:- It consists of
generalized autonomic nervous system
stimulation, with an initial parasympathetic-
induced bradycardia lasting 10 to 15 s
followed immediately by a more prominent
sympathetic response that results in transient
tachycardia and hypertension lasting 5 min or
longer
 both results in a marked increase in cerebral
blood flow and intracranial pressure

7. DIRECT ECT
 Anesthetic agents and muscle relaxants are not
used
 generalized convulsions produced can result in
fractures or teeth dislocation
MODIFIED ECT
 Anesthetic agents and muscle relaxants are used
 Risk of fractures gets minimized
 Amnesia of the event

8.  First line of treatment
 acutely suicidal patients
 severe depression
 catatonic schizophrenia
 Can also be used for the treatment of mania
in pharmacologically refractive cases
 Occasionally used in intractable
seizure,neuroleptic malignant syndrome and
delirium

9. No absolute contraindication
Relative contraindications includes:
 Increased ICP
 Cardiovascular (Coronary artery disease, HTN,
aneurysms, arrhythmias)
 Cerebrovascular effects (Recent strokes,
space occupying lesions, aneurysms)
 Severe pulmonary diseases (T.B, Pneumonia,
Asthma)

10.  Impairment of Cognition
 Memory Loss :- retrograde amnesia is more
common
 Delirium
 Headache, nausea and vomiting

11.  As many of the anesthetic drugs used for ECT
have anticonvulsant properties, so they can
decrease the duration of ECT-induced seizure
activity in a dose-dependent manner.
 Use of larger than necessary dosages of
general anesthetics will shorten the duration
of ECT-induced seizure activity and could
adversely affect the efficacy of the ECT
treatments.

12.  Thiopentone sodium (2–4 mg/kg) is used due to
wide availability though Methohexital (0.5–1.0
mg/kg), is 'gold standard'.
 Ketamine (1.5–2 mg/kg) and Etomidate (0.15–0.6
mg/kg) might seem preferable to other agents in
the light of their lack of anticonvulsant properties,
however, other aspects such as drug's safety
require consideration.

13.  Ketamine-propofol mixture (“ketofol”) and
ketofol-dexmedetomidine combination
(ketofol-dex mixture) can be used as
alternative induction agents.
 Sevoflurane (5%–8% for induction) It is
preferred in patients not cooperative for IV
access. It has the advantage of attenuating
uterine contractions ,is used in the third
trimester of pregnancy.
 Opioids, such as remifentanil in higher
doses, can be used as a sole agent in
patients refractory to seizure induction.

14.  To prevent myalgias , as well as more serious
musculoskeletal complications (e.g., bone
fractures or dislocations)
 Succinylcholine (0.5 to 1.5mg/kg) remains
the most commonly used muscle relaxant
due to shorter duration of action.
 Alternatives like Mivacurium ( 0.15–0.25
mg/kg IV) , Rapacuronium (0.6–0.8 mg/kg),
Atracurium( 0.5 mg/kg IV) can be used .

15.  Anticholinergic drugs are used to block the
parasympathetic responses i.e. bradycardia
and increased secretions .
 Glycopyrrolate (.1 to .3 mg iv ) lacks central
nervous system activity so it is used to reduce
oral secretion and bradycardia during ECT
without producing post-ECT side effects

16.  Acute sympathetic responses are attenuated
with β-blockers, calcium channel blockers, α2
agonists, and direct-acting vasodilators

17.  Inj. Glycopyrollate 0.2mg
 Inj.Thiopentone sodium 70-150 mg
 Inj. Succinylcholine chloride 25-40 mg

18. Before ECT
 Consent is taken .
 Pre assessment clinical examination is done
which include fundoscopy for
papilloedema,ecg etc
 Patient is asked to be kept npo from midnight
from the day of procedure

19. During ECT
 Patient is placed in supine position
 Premedication with inj. Glycopyrollate to
prevent bradycardia ; inj Thiopentone sodium
for induction of anesthesia than inj Scoline is
given for muscle relaxation.
 After Necessary Drug administration upward
pressure is applied to mandible and oxygen
is administered.
 Than mouth gag is inserted and after
occurrence of seizure mouth gag is removed
and suction is done for oral secretion and
again oxygen is administered.

20. POST ECT
 Patient is shifted to the recovery room and
monitored for an hour .