A case study presented at the 2nd International Brain Stimulation in Barcelona. Cite as: Gad, M., & Elaghoury, A. (2017). Risk of pulmonary aspiration with the outpatient electroconvulsive therapy: Case report. Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation, 10(2), 419. http://dx.doi.org/10.1016/j.brs.2017.01.244

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Introduction
CASE REPORT
A. During providing outpatient ECT, consider suicidal behavior and ambivalent attitude as
causes behind NPO breaking, besides the typical causes of pulmonary aspiration during ECT.
B. There is higher risk for non compliance with pre ECT fasting protocol following the initial 3 or 4
sessions because of increased self-assertion due to an ECT-induced increase in arousal and
psychomotor reactivation.
C. Equally, consider the effects of psychotropics and mental disorders to the risk of gastric
retention and gastroparesis .
D. The balance between the anticipated risk and benefit of outpatient ECT should judge how to
provide the ECT course: outpatient, inpatient or combined.
E. Airway management tools are of particular relevance to the practice of outpatient ECT and
because of this applying ECT in a highly qualified hospital with well equipped ICU and a
planned system for aspiration management could be life saving especially with higher
incidence of aspiration in outpatient ECT .
Recommendations
References
1.American Psychiatric Association. (2001). Committee on Electroconvulsive Therapy., Weiner RD. The Practice of
Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging: a Task Force Report of
the American Psychiatric Association. A task force report of the American Psychiatric Association.
2.Fink, M., Abrams, R., Bailine, S., & Jaffe, R. (1996). Ambulatory Electroconvulsive Therapy: Report of a Task
Force of the Association for Convulsive Therapy. The Journal of ECT, 12(1), 42-55.
3.Waite, J., & Easton, A. (2013). The ECT Handbook (Vol. 176). RCPsych Publications.
4.Guidelines: ECT minimum standards of practice in NSW. Mental Health and Drug and Alcohol Office, NSW Dept
of Health, North Sydney, N.S.W New South Wales. Dept. of Health. Mental Health and Drug and Alcohol Office
(2010).
5.Ghaziuddin, N., & Walter, G. (Eds.). (2013). Electroconvulsive therapy in children and adolescents. Oxford
University Press.
6.Hasler, W. L., Wilson, L. A., Parkman, H. P., Nguyen, L., Abell, T. L., Koch, K. L., ... & Tonascia, J. (2011). Bloating
in gastroparesis: severity, impact, and associated factors. The American journal of gastroenterology, 106(8),
1492-1502.
7.Hasler, W. L., Parkman, H. P., Wilson, L. A., Pasricha, P. J., Koch, K. L., Abell, T. L., & Unalp-Arida, A. (2010).
Psychological dysfunction is associated with symptom severity but not disease etiology or degree of gastric
retention in patients with gastroparesis. The American journal of gastroenterology, 105(11), 2357-2367.
8.Kurnutala, L. N., Kamath, S., Koyfman, S., Yarmush, J., & SchianodiCola, J. (2013). Aspiration during
electroconvulsive therapy under general anesthesia. The Journal of ECT, 29(4), e68.
9.Olié, E., Travers, D., & Lopez-Castroman, J. (2016). Key Features of Suicidal Behavior in Mental Disorders. In:
Understanding Suicide (pp. 199-210). Springer International Publishing.
10.Simon, R. I., & Hales, R. E. (Eds.). (2012). The American Psychiatric Publishing Textbook of Suicide assessment
and management. American Psychiatric Pub.
11.Tavares, A., & Volpe, F. M. (2016). Attempted Suicide by Breaking Pre-Electroconvulsive Therapy Fasting. The
Journal of ECT, 32(2), e2.
12.Berrios, G. E., & Sage, G. (1986). Patients who break their fast before ECT. The British Journal of Psychiatry,
149(3), 294-295.
Authors contacts
A 34-year-old male patient presented to our clinic with severe depressive symptoms in the
form of low mood, loss of interest, social withdrawal, irritability and easily provocation. Upon
examining the patient, he looks appropriate for age, lacking self-care with disheveled hair and
beard, coherent speech, depressed and restricted affect, no perceptual abnormality detected,
no formal thought disorder detected. Regarding the thought content, he had death wishes, and
the patient denies any suicidal ideation. The patient was insightful to his illness.
Despite the patient was supported by his parents and brother, he was suffering after divorce
within the last two months. He had a history of recurrent depressive episodes for the past ten
yrs. In additions, he has positive family history of schizophrenia in one of the first degree
relatives.
The patient was admitted to our hospital and ECT decision was made, and he received the
following medications:
Paroxetine 25 mg od, midazolam IVI at a rate of 1mg per hour to relieve the patient anxiety.
The patient received 4 ECT sessions through the first week upon which the patient shows
improvement concerning mood, irritability and death wishes. Accordingly, the treating doctors
decide to use combined protocol and upon that the patient was discharged to continue his ECT
sessions in the out-patient setting.
On the first day of the outpatient ECT (9 AM), both the patient and his brother signed a
document confirming the observance of pre-procedure fasting, but upon starting the
procedure of ECT the patient developed severe vomiting and aspiration upon that a call for
aspiration team was done and the patient was intubated and transferred to ICU for further
management .
In the ICU an endoscopic bronchoalveolar lavage was made to prevent complications of
aspiration. Blood gases and chest x-ray were ordered. The patient stayed in the ICU for two
days for close observation then transferred to a regular ward and put on his previous
treatment.
Risk of pulmonary aspiration with the outpatient electroconvulsive
therapy: case report
1.Mahmoud H Gad, MD Associate consultant psychiatrist, Saudi-German Hospital, Jeddah, Saudi Arabia
2. Ahmed E Elaghoury, MD Psychiatrist at Abbassia Mental Hospital, Cairo, Egypt
• The practice of outpatient electroconvulsive therapy (ECT) is traditional since its start (1),
with documented guidelines (2). This practice is related to multiple factors in patient
condition, living settings or healthcare facility (3 and 4).
• When the whole course of ECT is given as an outpatient, it is termed “ambulatory ECT.” A
typical example is the continuation/maintenance ECT (1, 3, 4).
• The “index course” may be given as ambulatory or as combined with the transition from
inpatient to outpatient care with the taper-down schedule (1, 5).
• Key advantages of outpatient/ambulatory ECT are the lesser cost of the inpatient care,
minor disruption to the daily life of patients, and consequently lesser stigma in the
community. Also, it improves the rapport between treating psychiatrist and the patient.
• One of the greatest challenges while practicing the outpatient ECT is the assurance that
patients are adhering to the instructions regarding the night prior to the session, particularly
fasting, which has been documented as a suicide-related behavior (9, 10). So, breaking of
NPO state before ECT sessions (11), esp. in outpatient settings may be a sign of suicidal
behavior. However performing the ECT in the inpatient settings; as the only routine
practice; is considered of high cost, especially in low-income countries.
• Typical causes of airway difficulty during ECT sessions are obesity, late pregnancy, and
pulmonary diseases (1, 3, 4).
• Adverse effects of psychotropic drugs e.g. SNRI antidepressants (6) or psychological
dysfunction e.g. depression (7 and 8) may contribute to the degree of gastric retention in
patients with gastroparesis, a known risk factor for pulmonary aspiration.
• The number of previous ECT sessions and age of patient were suggested to correlate with
breaking of NPO state (12).
Dr.Mahmoud gad: drgadmahmoud@gmail.com
Dr. Ahmed Elaghoury: dr.aghoury@gmail.com