ECTPart II

Presented By

Mohamed Abdelghani

ECTIn

Special Groups

Introduction

No absolute medical contraindications to ECT exist.

ECT may be the treatment of choice in some medically ill patients because of its speed of action and safety profile.

Assessment of the risks and benefits of ECT should be undertaken individually.

It includes:1. Consideration of the severity and duration of

the psychiatric illness and its threat to life. 2. The likelihood of therapeutic success with

ECT.3. The medical risks of ECT and the degree to

which these risks can be diminished.4. The benefits and risks of alternative

treatments and of no treatment.

In patients referred for ECT, it is especially important to understand :

The interactions among coexisting medical conditions.

Physiologic events associated with anesthetic induction, electrical stimulation of the brain, and induced seizure activity.

ECT in special groups must be preceded by:

Pre-ECT evaluation

Additional laboratory evaluation

Specialist consultations

ECT In

Elderly

ECT has a special role in the treatment of late-life

depression and other psychiatric conditions in the

elderly.

Although 1.12 persons per 10,000 in the general

adult population were treated with ECT, the rate

was 3.86 persons per 10,000 among people aged

65 years and older.

Age does not constitute a particular indication for

ECT.

Indication of ECT in elderly

1) Intolerance to antidepressant

medications.

2) The presence of medical conditions,

esp. cardiovascular disease.

3) Medication resistance “may be age-

related”.

4) Rapid and full clinical response is

needed e.g. “Severe inanition, refusal

to eat, psychosis, and suicidality”.

Problems of ECT in the elderly

Seizure threshold may rise with increasing age. So, The clinician should consider:

Reducing or withdrawing sedative/hypnotic or other anticonvulsant agents (including benzodiazepines).

Replacing prophylactic lidocaine with another antiarrhythmic medication.

Minimizing doses of barbiturate anesthesia. Ensuring adequate ventilation. Because of altered metabolism in the elderly,

dosages of all medications used with ECT may need to be reduced.

Preadministration of intravenous caffeine augments ECT not reduces seizure threshold, and may be associated with cardiovascular side effects.

Problems of ECT in the elderly

Elderly patients are at greater risk for more cognitive impairment during and after ECT: Relative to younger patients, older patients with

depression had more severe anterograde and retrograde amnesia immediately following the end of the ECT course.

So, The clinician should: Carefully assess the cognitive status. Electrode placement, stimulus intensity, and

treatment frequency (e.g., twice instead of three times weekly) should be modified to minimize adverse cognitive effects.

ECT During

Pregnancy

Recent data supports the use of ECT as a treatment

with low risk and high efficacy in the management of

psychiatric disorders in all three trimesters of pregnancy.

APA practice guidelines for major depressive

disorder and bipolar disorder endorse the safety and

efficacy of ECT and suggest ECT as a primary treatment

for these disorders during pregnancy.

Severe postpartum depressive or manic states, with

or without psychosis, are also responsive to ECT.

Pregnancy is a challenge…Why?!!!! During the first trimester of pregnancy, the risk of

teratogenicity must be considered when patients require

pharmacologic treatment.

Teratogenic risks were identified for benzodiazepines,

antipsychotics, lithium, and other mood stabilizers.

Specific teratogenic risks have not been identified with

tricyclic antidepressants and selective serotonin

reuptake inhibitors.

During later stages of pregnancy and particularly near term, neonatal toxicity has been reported with chronic administration of all major classes of psychotropic agents: Neuroleptics may cause tremor, motor

restlessness, abnormal movements and hypertonicity in neonates.

Benzodiazepines may cause hypotonicity, apnea, and impaired temperature regulation.

Chronic treatment with antidepressants has been associated with anticholinergic symptoms in the neonate as well as withdrawal syndromes consisting of jitteriness, irritability, and convulsions.

Use of lithium in the third trimester is associated with premature labor, polyhydramnios, and neonatal hypothyroidism or lithium toxicity .

From the standpoints of teratogenicity and neonatal

toxicity

ECT is considered relatively safe

Why?!!!

The risks to the fetus from anesthetic agents are

likely to be less than those of psychopharmacologic

alternatives.

Succinylcholine has a relatively low ratio of

placental transfer.

Methohexital and thiopental do not suggest any

increase in teratogenesis, as it is largely a function

of exposure duration.

Precautions during Pregnancy Informed consent which includes discussions of

potential neonatal toxicity and teratogenic effects. An obstetrician should be consulted prior to ECT. Assessing risk factors for spontaneous abortion,

preterm labor, abruption, and uteroplacental insufficiency.

To maximize delivery of oxygen to the fetus, patients should be well oxygenated during the ECT.

Hyperventilation should be avoided because this can diminish fetal oxygenation by decreasing placental blood flow and by reducing the dissociation of oxygen from hemoglobin.

Before each treatment, intravenous hydration with a non–glucose-containing solution.

Because of the increased risks of gastric reflux and aspiration, pregnant women should be premedicated with a nonparticulate antacid such as sodium citrate, cimetidine, ranitidine, and metoclopromide.

Beyond 24 weeks of gestation and near term: Consider intubation with each ECT

treatment. When an anticholinergic agent is indicated in

the pregnant patient, glycopyrrolate is usually preferable because its placental transfer rate is more limited than that of atropine as it decreases the tone of the lower esophageal sphincter and may augment aspiration risk .

For post-ECT headache and muscle soreness during pregnancy, acetaminophen is the treatment of choice.

Aspirin and nonsteroidal anti-inflammatory agents should not be administered especially in the 3rd trimester of pregnancy, because they may contribute to altered maternal and fetal hemostasis and to early closure of the fetal ductus arteriosus.

When gestational age is more than 14–16 weeks, fetal heart rate should be measured before and after each treatment.

After 24 weeks or with suspected fetal heart rate abnormalities, some specialists recommend a non-stress test with a tocometer (a 30- to 60-minute fetal heart rate strip) before and after each treatment.

 

ECT During

Breastfeeding

Virtually all known psychotropic agents enter breast milk to some degree.

At therapeutic maternal dosages, serum levels of tricyclic antidepressants are generally low or undetectable in the nursing infant.

Other antidepressants, antipsychotics and benzodiazepines have categorized by the American Academy of Pediatrics as being “of special concern when given to nursing mothers for long periods”.

In terms of mood-stabilizing agents, valproic acid is compatible with breastfeeding, whereas lithium should be avoided.

In general, breastfeeding need not be interrupted during a course of ECT.

However, the informed consent process should discuss the potential impact of ECT.

Infant exposure to succinylcholine is minimal and absorption of succinylcholine from GIT is poor.

For methohexital, the relative infant exposure from breast milk has been estimated to be less than 1% of the maternal dose.

 

Precautions during Breastfeeding Acetaminophen, codeine, or nonsteroidal anti-

inflammatory drugs may be used to treat headache or muscle soreness after ECT.

However, Aspirin is contraindicated because of its association with Reye’s syndrome in children.

Exposure of breastfeeding infants to medications may be lessened if the mother delays the feeding for a period of several hours after an ECT treatment.

Another strategy is to collect and store the breast milk prior to ECT for administration by bottle during the 24-hour period after an ECT treatment.

ECT In

Children & Adolescents

Few studies address the use of ECT in children and

adolescents.

First-line use of ECT in children and adolescents is

particularly rare.

Despite this low utilization, evidence indicates that

when an affective disorder is well defined, the

response to ECT is likely to be favorable.

Seizure thresholds in children and adolescents are

likely to be considerably lower than those in adults.

Precautions during ECT The consent process, including discussion of the

risks and benefits of ECT, should involve the parents or guardians of the child.

Use of empirical dose titration with low initial dosage settings is particularly encouraged in this age group.

Because of the possibly increased likelihood of prolonged seizures in children and adolescents, the treatment team should be prepared to intervene with appropriate medication to terminate the seizure.

ECT In

Patients With

Neurologic Disorders

Space-occupying cerebral lesions: If small or chronic minimal increased risk

unless associated with increased intracranial pressure or other signs of a mass effect.

Increased intracranial pressure: To diminish this risk with ECT use potent

antihypertensive agents, steroids, diuretics, and hyperventilation.

Recent strokes or cerebral aneurysms: The acute ECT-related hypertensive surge should

be pharmacologically blunted when ECT is given to patients at risk for a bleed.

Epileptic patients: ECT may be associated with an improvement

in seizure control. However, Anticonvulsant medications may

complicate ECT by raising seizure threshold. Thus, o Dosage should be kept as low as clinically feasible

during ECT.o the use of a stimulus dose-titration procedure at the

time of the first treatment is desirable because it allows the most accurate assessment of the patient’s actual seizure threshold.

History of brain trauma: Carries risk for increased cognitive changes

with ECT. Stimulation over a skull defect should be

avoided. Modified stimulus electrode placement should

be used.

Myasthenia gravis: Associated with an increased resistance to

and slow recovery from depolarizing muscle relaxants. Thus, a decrease in dosage should be considered.

A switch to a nondepolarizing agent may be problematic because of increased sensitivity.

Idiopathic Parkinson’s disease: ECT often has beneficial, although transient,

effects. Patients with Parkinson’s disease may have

greater cognitive dysfunction after ECT. This may be minimized by the use of

unilateral ECT.

Multiple sclerosis: Generally tolerate ECT without experiencing

major adverse effects. Neuroleptic Malignant Syndrome:

ECT is used to treat mental disorders in patients with current or past NMS.

It has been suggested that two seizure inductions in a single ECT session may hasten the time to recovery in severe NMS.

Patients with a history of NMS generally do not require specific changes in the ECT or anesthetic protocol.

However, switching to a nondepolarizing relaxant agent should be considered in those with NMS symptoms, because of the risk of hyperkalemia after succinylcholine administration.

Neuroleptic Malignant Syndrome: In such patients, dopamine blocking agents

such as neuroleptics, metoclopramide, prochlorperazine, and promethazine should be avoided.

It is important for patients with active NMS symptoms to be observed for metabolic or cardiovascular instability throughout the ECT course.

ECT In

Patients With

Cardiovascular Disorders

The cardiovascular risks of ECT derive primarily from the marked changes in heart rate and blood pressure that typically occur during and immediately after ECT.

Individuals at increased risk with ECT include: Recent myocardial infarction. Unstable angina. Uncompensated congestive heart failure. Severe valvular heart disease. Clinically significant cardiac arrhythmias. Fragile vascular aneurysms. Uncontrolled hypertension. High-grade atrioventricular block.

Precautions1) Cardiac consultation includes:

i. Cardiopulmonary history and examination.ii. Careful medical evaluation.iii. Electrocardiogram (ECG) prior to ECT. iv. A chest radiograph and measurement of serum

electrolyte levels are optional.

2) Current medications likely to diminish cardiovascular risk should be continued.

Such agents include, but not limited to, sympatholytic medications, short-acting nitrates, other antihypertensive drugs, and anticholinergics.

3) Iatrogenic hypotension should be avoided during and after the ECT treatment.

4) ECT may convert atrial fibrillation to sinus rhythm, So:

Some practitioners recommend routine anticoagulation to diminish risk of embolism from mural thrombi.

5) If cardiac function is normal, patients who have undergone cardiac transplant do not present a specific cardiac risk during ECT.

6) In patients with implanted cardiac pacemakers : To prevent unnecessary pacemaker triggering

at the time of ECT, some practitioners choose to convert a demand pacemaker to a fixed mode (using a magnet).

ECT In

Patients With

Other Disorders

Diabetes:

Dosing of antidiabetic agents depends on:

The fasting period prior to each ECT treatment.

The typical hyperglycemic effect of ECT.

Blood glucose should be monitored closely during the

ECT course especially the hour before each treatment to

allow hypoglycemic states to be detected and treated.

Endocrinologic or medical consultation should be

considered for individuals whose diabetes is unstable or

insulin dependent.

Hyperthyroidism : Hyperthyroidism substantially increases risk of

thyroid storm at the time of ECT. The assistance of specialty consultation, and β-

blocking agents should be used at the time of ECT unless contraindicated.

Hypothyroidism: Has not been reported to be problems with ECT.

Pheochromocytoma : Can be minimized with α-blockers, β-blockers, and

blockers of tyrosine hydroxylase.

Metabolic disorders Hyperkalemia:

Are at increased risk of cardiotoxic effects because of the transient rise in serum potassium with succinylcholine.

If serum potassium cannot be normalized prior to treatment, a switch to a nondepolarizing muscle relaxant.

Hypokalemia: Should be corrected before starting treatment

to avoid prolonged paralysis and apnea. Hyponatremia :

Should be corrected prior to ECT to avoid spontaneous seizures.

Patients with porphyria: Intolerant to barbiturates and must be

switched to an alternative anesthetic agent. Patients undergoing renal dialysis:

Electrolyte imbalance is common. Monitoring of electrolyte levels is mandatory. ECT treatments should be scheduled on the

day after dialysis when possible. Patients with COPD:

Should receive any prescribed bronchodilators as well as preoxygenation at each ECT treatment.

Theophylline should be discontinued or reduced to minimize the risk of prolonged seizures.

Patients with Eye Diseases: Open-angle glaucoma:

Most practitioners administer antiglaucoma medications before each treatment.

Long-acting anticholinesterase ophthalmic solutions, such as demecarium and echothiophate, could greatly prolong succinylcholine-induced apnea and therefore should be replaced by alternative agents for an appropriate time period prior to ECT.

Closed- or narrow-angle glaucoma: Medical emergency and represents a greater risk

with ECT. Acute or evolving retinal detachment:

Ophthalmologic consultation should be considered. Avoid unnecessary movement of the head during

ECT. Pharmacologically blunt the acute hypertensive

surge associated with ECT.

Liver Transplant Recipients: Depression in these patients is a life-threatening emergency. ECT is an important consideration when suicide is imminent

or the patient has not responded to pharmacotherapy trials. Adrenal suppression and immunosuppression require special

attention. Immunosuppressed status and the relatively rare rate of fever

secondary to ECT need full workup. Key to the patient’s treatment was:

Psychiatric consultation and management while he was in the transplantation unit.

Followed by intensive transplantation service management while he was in the psychiatric unit.

With close collaboration of psychiatry and transplantation teams, ECT can be administered safely.

Patients with Bone Diseases: Patients with joint or bone disease, including

moderate to severe osteoporosis, often need an increased dosage of muscle relaxant.