The use of ECT still generates significant controversy.

Electroconvulsive therapy (ECT) has been demonstrated to be an effective and safe treatment for many psychiatric disorders.

ECT has been viewed as harmful by the general public and psychiatric patients.

Despite such debate, approximately 100,000 patients annually receive ECT in the United States

Introduction

Modern Electroconvulsive Therapy (ECT) Machines

It is treatment modality in which an electric current passed through

The brain for 0.5 to 2 seconds with an

electric current of 70 to 150 micro volts,

Causing grand mal epileptic seizer .

Definition of E.C.T :

a. Epileptic cry : It literally sounds like a gradual scream/yell.

b. Tonic phase : characterized by muscle rigidity, eye fixed, pubic dilated, it last for few seconds.

c. Colonic phase : Rhythmic contraction and relaxation of all body muscle especially face muscle.

d. Relaxation phase :Muscles start to be relax .

Phases of convulsion :

The exact mechanism of action of ECT

is not fully known. ECT affects multiple

central nervous system components,

including hormones, neuropeptides,

and neurotransmitters

Mechanism of action :

* Neurotransmitter theory

It was suggested that E.C.T acts like tricycle

antidepressants by enhancing deficient

neurotransmission in monoaminergic system ,

especially it is thought to improve

serotoninergic and adrenergic

neurotransmission

Mechanism of action :

Neuroendocrine theory :

It suggests that E.C.T release prolactin,

thyroid stimulating hormones , pituitary

hormones but the specific hormone

responsible for the therapeutic effect is not

known .

It is suggested that E.C.T treatment exert

a profound anti-convulsive effect on the

brain that result in an Anti-depressant

effect .

Anti-convulsive theory :

Frequency of treatment A series of about 6-15 treatments are

scheduled three times a week. Six treatments are needed to observe a sustained improvement of depressive symptoms. Maximum effect or benefit is achieved in 12 to 15 treatments.

 

I. According to techniques:

A. Modified E.C.T :The patient given some form of

medication before E.C.T :1. Anticholinergic : atropine 0.5mg

Intramuscular until pulse increased by 10% to decrease risk of arrhythmias ,cardiac arrest and aspiration.

Types of E.C.T

The dosage should be adjusted to minimum effective amount because higher dosage will increase the seizure threshold and prolonged the period of apnea .

3. Muscle relaxants : succinylcholine or anectine.

2. Anesthesia :

ECT gives without anesthesia , but it has a disadvantage of more “adverse reaction” .

II .According to site :Bilateral and Unilateral ECT .

B. Unmodified ECT :

It is used for severely ill patient .Electrodes are placed bilateral in the two

temporal sites, but it has more cognitive side effect more disorientation and more memory impairment .

A. Bilateral ECT :

It's more recently have been used , it has been reported that pt. have fewer cognitive side effect and induce less disorientation , fewer memory impairment , and few pathological ECT changes .

It is given to the patient at right or left side according to the patient – in the “ non- dominant area “.

B . Unilateral ECT :

Major depression( Suicide ideation, refusal of food, not respond to treatment)

Acute Mania ( Excitement ) patients who do not respond to another form of drugs.

Schizophrenia especially catatonic stupor or excitements. Patients who cannot tolerate pharmacotherapy due to side effect. Patients with history of poor drug response. patients in whom treatment response is urgently needed, such as

patients who are suicidal or those who are refusing food and are nutritionally compromised.

ECT may be efficacious in patients with rapid cycling bipolar disorder ECT is effective for symptoms of acute schizophrenia but is not

effective for chronic schizophrenia. ECT is not recommended for the treatment of

obsessive-compulsive disorder (OCD) but may be considered for treating comorbid disorders such as major depressive disorder, mania, and schizophrenia in patients with OCD

Indications of ECT:

Pregnant clients can also undergo an electroconvulsive therapy. The treatment poses no harm or injury to the fetus. Thus, pregnant self-destructive women may undergo ECT to provide quick relief of depression and self-directed violence.

Can pregnant women undergo ECT?

Generally, geriatric patients with depression have better outcomes with ECT than do younger patients

Seizure threshold may rise with increasing age, and effective seizures may be hard to induce.

Cognitive adverse effects are the major limitations to the use of ECT.

This effects are observed with a brief period of confusion, disorientation and impairments in attention, and memory. This effects reverse over time and modifications such as switching to unilateral ECT, lowering the stimulus dose, increasing the time interval between treatments, may decrease cognitive adverse effects.

Anterograde and retrograde amnesia may result from ECT. After ECT, anterograde amnesia resolves rapidly(temporary) . With retrograde amnesia are greatest for events closest to the time of treatment. Postictal delirium may occur in a minority of patients/

Geriatric patients may be at a higher risk for persistent confusion and greater memory deficits during and after ECT.

Systematic effect, Fatigue, Headache, muscles aches nausea, anorexia . Headache is common. It can be treated with medications such as aspirin,

Side Effects

Prolonged seizures and status epileptics may be more likely when patients receive medications that lower seizure threshold. Prolonged apnea is rare but may occur .

complication Fracture and dislocation Arrhythmia Tongue injury Aspiration

ECT stimulates a seizure episode to occur, however it does not cause a seizure disorder and patient with a seizure disorder may undergo the therapy.

No absolute contraindications are noted with ECT but a few conditions have been associated with morbidity and mortality rate which includes the following:

recent myocardial infraction sever hypertension presence of intracerebral mass recent cerebro-vascular accident (stroke)

Contraindications and precautions

Preparation before ECT Preparation of equipment

Treatment device and supplies including electrodes past and gel gauze pads alcohol saline suction device, Stretcher with firm matter with side rails

Ventilator equipment, Intravenous and vein puncture

Nursing Interventions

Psychological preparation Physical preparation

Preparation of patient

Complete blood count Electrocardiography Chest X ray Urine analysis Remove dentures metal hairpins shoes or slippers before treatment. The regular use of benzodiazepine for night time sedation should be

eliminated because of its ability to raise the seizer threshold Atropine should be given as order one hour before treatment or intravenous Informed consent should be signed. NPO post-midnight. Remove fingernail polish. IV line initiation.

Patients in late pregnancy should lie on their left side during ECT to ensure adequate blood flow to the fetus.

Psychotropic drugs, especially antidepressants and antipsychotics, may give rise to some concern in clinical practice because of their known ability to reduce seizure threshold and to provoke epileptic seizures

*

*During ECT

Accompanied the patientsExplain the procedureAdministration of short-acting anaesthetic.Administration of a sedative or muscle relaxant(succinylcholine). Atropine is also given to decrease bronchial secretions which could block the airways during seizures.Let the client void before the procedure.Place electrodes on the client’s head on one side (unilateral) or both (bilateral).Brain monitoring through electroencephalogram (EEG).Air way is inserted into mouth Hold his arm at his sides to prevent uncontrolled thrashing.Electric impulses is given with up to 150 microvolt. .

Positions Oxygen administration with an Ambu-bag Assess client for the return of gag reflex. Ensure his safety. When the client is awake, reorient the client. Obtain vital signs. Allow the client to eat (with a positive gag reflex).

After ECT

GOOD LUCK