8/17/2019 Guide to ECT 2015

1/25

  uide to Electroconvulsive Therapy

Revised for 2015

 by

Conrad M. Swartz, Ph.D., M.D.

2014, 2015 Conrad Swartz

Individual copies available solely by registration with Somatics!ther distribution not authorized

Table of Contents

Documentation 2ECT Physical Setup 2

Patient Selection 2Informed Consent 3Pre-ECT Evaluation 3Sleep Medication Common !nesthetic !"ents # Doses Electrode placement $Initial Stimulus Dose %Pulse &idth' (re)uency # Current *+outine ,rders +eassurin" and E.aminin" the Patient !d/ustin" Stimulus Dose 0Physical preparation of the patient 0

!nesthesia 11Stimulus delivery 12Monitorin" the Patient 13Printed report and pro"ress note 1$Mana"in" common complications 1%ECT Session +ecovery 1%Postictal !"itation 1%Postictal Delirium 1*Tardive Seiure 1*Dischar"e (rom the ECT !rea 1Methods to Potentiate ECT Seiure 1Minimiin" Co"nitive Side Effects 1

&hen to Stop the !cute ECT Course 2Evaluation after ECT Course 2Preventin" +ecurrence 214uality !ssurance Monitors 21+eferences 22

Self-!ssessment 4uestions 2

1

8/17/2019 Guide to ECT 2015

2/25

In eletroonv!lsive thera"y #$C%& a ontrolled seiz!re is "rod!ed with a s'all a'o!nt ofeletriity. In the $C% seiz!re brain ne!rons fire in ylial waves, releasin( ne!rotrans'itters.

 )or'ally this seiz!re is self li'itin(, onl!din( after 20*+0 seonds. %his seiz!re is lar(elyres"onsible for the thera"e!ti benefits fro' $C% in 'aor de"ression and other disorders. %here is

no definitive 'ehanis' of ation for $C%, or for any biolo(ial "syhiatri treat'ent.

Perha"s the seiz!re re"laes "atholo(ial "atterns of ne!rotrans'itters with nor'al "atterns. In any ase, thera"e!ti $C% has seletive effets and is not a (eneral "!r(e. -hen (iven

 "ro"erly to s!itable "atients it !s!ally brin(s re'ission fro' s"eifi "syhiatri diseases, with sideeffets that are ordinarily 'inor or less. s with other linial "roed!res, reliably (ood o!to'e

for $C% re/!ires both diret e"eriene and s!bstantial tehnial infor'ation. %his (!ide ai's to "rovide the basi tehnial infor'ation needed by "ratitioners. Please he yearly for "ossible

!"dates to this (!ide.

DOCUMENTATION FOR ECT

avin( a written a""roved $C% "oliy do!'ent in "lae hel"s 'aintain strai(htforward

o''!niations between "syhiatrists and anethesiolo(ists. S!h a "oliy desribes $C%indiations and "roed!res and ty"ially ites the latest 3%as 4ore Re"ort on the Pratie of

$letroonv!lsive %hera"y fro' the 'erian Psyhiatri ssoiation #P, 2001&. %he "oliyalso !s!ally desribes the redentials for $C% "rivile(es and the res"etive res"onsibilities of

 "syhiatrists, anesthesiolo(ists, and n!rsin( staff in the "roed!re.

Several for's are !s!ally !sed in do!'entin( $C% treat'ents, as for6 1& lo((in(treat'ents and identifyin( 'ediation doses and $C% sti'!li, 2& 'edial reord "ro(ress notes, 7&

shed!lin( !"o'in( "hysial ea's and lab tests for o!t"atients, and 8& billin(.

PROCEDURES AND ARRANGEMENTS BEFORE STARTING ECT

ECT Physical Setup

$C% is o''only (iven in either a "ost*s!r(ery reovery area or a s"eifi roo'. In a "ost*

s!r(ery area the %hy'atron devie is !s!ally e"t on a wheeled art that has drawers for s!""lies

and for's. If a s"eifi roo' is !sed for $C%, it sho!ld be adaent to roo's for "re*$C% waitin(

and "re"aration, and for "ost*$C% 'onitorin( and reovery.

4or the $C% "roed!re an oy(en s!""ly, s!tion, oi'eter, laryn(oso"es and laryn(eal

airways sho!ld be at hand. nearby sin is onvenient. res!sitation art with defibrillator

sho!ld be /!ily aessible, altho!(h its !se sho!ld be etre'ely rare.

Patient Selection

%he offiial 4D indiation for $C% is 'aor de"ression. %raditionally this is de"ression

that resists 'ediation, inl!des atatonia or "syhosis, is 'ied with 'ania, or re/!ires !r(ent

res"onse. 9r(eny orres"onds to s!iidal behavior, inanition, 'edial instability, or a(itation. In'aor de"ression o'"leted s!iide is assoiated with "reo!"ations or del!sions involvin(

hy"ohondria or ho"elessness #Shneider et al., 2001&. $C% an be the safest reliable treat'ent

2

8/17/2019 Guide to ECT 2015

3/25

available when the "atient:s 'edial ondition 'aes 'ediation risy. $ffetive res"onses to $C%o!r in "syhoti de"ression, atatoni de"ression, or with si(ns of lassial 'elanholia.

Classial 'elanholia inl!des low "syho'otor ativity, little faial e"ression besides onern,virt!ally no initiation of new tho!(ht, di'inished 'ental reativity, i'"aired "roble' solvin(, an

affet of siness or ab!lia, and so'eti'es !n"rovoed a(itation #e.(, a'ilton, 1+;+&.

video "ro(ra' 3Infor'ed $C% for Patients and

4a'ilies is hel"f!l in o''!niatin( with fa'ilies. It "laes $C% in "ers"etive as an ordinarytreat'ent. It i'"liitly o!nters e"loitative 'isre"resentations of $C% in 'ovies. Infor'ation

 broh!res for fa'ilies and "atients are available (ratis fro' So'atis, written in a si'"le /!estion*

and*answer for'at #bra's ? Swartz, 1+;;&.

Pe#ECT E$aluationRo!tine "re*$C% eval!ation inl!des "syhiatri history, 'ental stat!s and "hysial ea's,

review of syste's, $C% and labs. @abs ty"ially inl!e ser!' eletrolytes, %S, a liver f!ntion

7

8/17/2019 Guide to ECT 2015

4/25

enzy'e, and a he'o(lobin level or o'"lete blood o!nt. y"erale'ia is a onern bea!ses!inylholine te'"orarily raises ser!' "otassi!' levels. y"o'a(nese'ia an res!lt fro' lon(*

ter' "roton "!'" inhibitors s!h as o'e"razole or heavy drinin(A it lowers seiz!re threshold anda!ses ardia arrhyth'ias, aniety and '!sle s"as's. @oose teeth and dent!res sho!ld be

re'oved before $C%. Patients of bla rae sho!ld have a "revio!s or !rrent sile ell test res!lt.

Medial disorders that 'ay involve s"eialty ons!ltations inl!de or(an fail!re #e.(.,ardia, renal, he"ati, "!l'onary, thyroid&, reent MI or stroe, !nstable 'edial ondition #e.(.,

hy"ertension, arrhyth'ias, eletrolyte abnor'ality, thro'bi, se"sis&, seiz!re disorder, de'entia, "or"hyria, osteo"orosis, inreased intraranial "ress!re, erebral neo"las', and fa'ilial 'ali(nant

hy"erther'ia.

8/17/2019 Guide to ECT 2015

5/25

(ood /!ality or whose "ro(ress stalls with other narosis a(ents. Pro"ofol alone #1 '((& shortens$C% seiz!res 'aredly, b!t less so when o'bined #0.=5 '(( with re'ifentanil #1 '((&

#adoi ? Saito, 2015&.

$C% '!sle "aralysis is (iven to "revent hy"oia and '!s!loseletal in!ry. fter the

narosis 'ediation dose, a s!inylholine 27 '(( bol!s is ty"ially (iven. @ean or '!s!lar

 "atients 'ay need lar(er doses.

8/17/2019 Guide to ECT 2015

6/25

In ir!'stanes of hi(h ris or intense sr!tiny #e.(., ative s!iidality, self in!ry,'ali(nant atatonia, forensi hos"italization, assa!ltiveness&, when o(nitive side effets do not

wei(h heavily, bite'"oral $C% is "robably the 'ost defensible 'ethod. -hen there is no s!h risor e'er(eny, b!t o(nitive side effets are of stron( onern, traditionally ri(ht !nilateral $C%

sho!ld be onsidered. 

Initial Sti!ulus Dose

%he $C% eletrial sti'!l!s dose is not an a'o!nt of har(e or ener(y bea!se any a'o!ntan be delivered slowly eno!(h to be i'"al"able. %he sti'!l!s ener(y re"resents the a'o!nt of

heat it ontains, 'ost of whih is liberated in the sal" #Swartz, 1+;+&. Char(e is !rrent '!lti"lied by d!ration of !rrent flow, and it re"resents the n!'ber of eletrons in the sti'!l!s. ltho!(h

har(e has traditionally been re(arded as the dose, the 'ini'!' har(e needed to ind!e seiz!revaries stron(ly with the sti'!l!s !rrent #Swartz et al., 2012A Swartz, 200+&.

Rather, the sti'!l!s dose is re"resented by the a'o!nt of seiz!re foi (enerated. Physial

'odelin( identifies sti'!l!s dose as har(e '!lti"lied by !rrent !bed #Swartz, 2018&. -ith the

%hy'atron $C% devie the !rrent is always +00 ', so that statin( the har(e always s"eifiesthe dose. 4or $C% devies with ad!stable !rrent s"eifyin( the dose re/!ires al!latin( har(e

'!lti"lied by !rrent !bed.

%here are two o''on ways to selet the initial eletrial sti'!l!s dose, a(e based andseiz!re threshold based. -ith both the initial sti'!l!s dose de"ends on whether the eletrode

 "lae'ent is ri(ht !nilateral or bilateral. Both 'ethods identify a dose that is ty"ially hi(h eno!(h

for (ood effiay b!t not so hi(h as to a!se !nd!e o(nitive side effets. %he 'ini'!' dose to

ind!e seiz!re is alled the seiz!re threshold, b!t is not a distint harateristi s!h as bodyte'"erat!re bea!se 'eas!rin( it alters it #Swartz, 2018&. %he a(e based 'ethod is fo!nded on the

rise of seiz!re threshold with a(e, b!t does not involve 'eas!rin( this threshold.

(e based dosin( re/!ired 25 fewer $C%s for the sa'e linial i'"rove'ent as titration

 based #"J0.02& dosin(, in a "ros"etive st!dy of =+ "atients #ten et al., 2015&. Post*$C% MDRS

sores avera(ed +.5 with a(e*based and 11.H with titration. MMS$ sores avera(ed 2; for both. $C%s

were (iven with a %hy'atron Syste' IG at 0.25*0.5 'se "!lse widths.

4or the three bilateral "lae'ents #bifrontal, bite'"oral, @R%& the initial sti'!l!s dose is

set in the sa'e way. -ith the a(e based 'ethod the %hy'atron $ner(y dial is set to half the

 "atient>s a(e. %his sets a har(e of 2.5 'C "er year of a(e at +00 ' !rrent. -ith a different $C%

devie at ;00 ' !rrent, a har(e of 7.5 'C "er year is a""ro"riate. -ith threshold based dosin(

the initial dose is ty"ially set 50 to 150 above seiz!re threshold. 4or the vast 'aority of "atients

initial doses set by the a(e based 'ethod are within this sa'e ran(e #Swartz ? Mihael, 2017&.

 Choosin( an initial dose for ri(ht !nilateral $C% is analo(o!s to hoosin( an anti"syhoti

dr!( dose. If everyone reeives the sa'e hi(h dose, "atients who wo!ld res"ond to lower doses wille"eriene !nneessary side effets. bo!t half of "atients who wo!ld res"ond to bilateral $C% will

res"ond as well to low dose ri(ht !nilateral $C%, aordin( to re"orted res"onse rates #Saei' etal., 2000&. ltho!(h st!dies have not been done to identify "atients who will res"ond to low dose

!nilateral $C%, these "atients "robably show lear 'otor ton!s, hi(h "ea heart rate d!rin( theseiz!re #ty"ially over 180 b"'&, and intense $$K ativity at low doses. Rationally, ri(ht !nilateral

H

8/17/2019 Guide to ECT 2015

7/25

$C% 'ay be started with a hi(h dose with the dose ad!sted at later sessions aordin( to thesesi(ns of seiz!re stren(th, as desribed in the 3Benh'ar Method below.

-ith the a(e based 'ethod the initial dose in %hy'atron $ner(y !nits for ri(ht

!nilateral $C% is set to the "atient:s a(e. %his (ives a har(e of 5 'C "er year of a(e at +00 '

!rrent. -ith a different $C% devie at ;00 ' !rrent, a har(e of = 'C "er year is a""ro"riate.

4or ri(ht !nilateral $C% by the threshold 'ethod the dose is 7 to = ti'es seiz!re threshold.

In the threshold based 'ethod the seiz!re threshold is 'eas!red in the first $C% session.

low sti'!l!s dose is (iven. If it does not ind!e seiz!re, "ro(ressively lar(er doses are (iven atintervals of 20 to 70 se !ntil seiz!re o!rs. %raditionally '!lti"le se/!ential sti'!li are re(arded

as inde"endent of eah other and the seiz!re threshold is the final sti'!l!s dose. owever, sti'!lise"arated by less than 2 'in are !'!lative #Swartz, 2018&. ordin(ly, when 'ore titration

sti'!li are (iven the res!lt is less a!rate.

Settin( the ste"s for titration sti'!li aordin( to a(e a""ears to re/!ire fewer sti'!li than "revio!s titration 'ethods #Swartz ? Mihael, 2017&. In fe'ales !nder H5 years of a(e the first

titration sti'!l!s #in $ner(y !nits& is one /!arter a(e with later titration sti'!li as needed of 7;,L, 5;, , 1 and 1.2 ti'es of a(e. In older fe'ales the first sti'!l!s is 7; a(eA later titration sti'!li

are L, 5;, , 1 and 1.2 ti'es a(e. In 'ales the initial sti'!l!s is 7; a(e, with later titration sti'!li

of , 1, and 1.25 ti'es a(e if needed. %o onvert fro' $ner(y !nits to 'C '!lti"ly by 5 'C "er

$ner(y !nit at +00 ', or = 'C "er $ner(y !nit at ;00 '. 4or ea'"le, the initial titrationdose for a 80 year old fe'ale is N a(e, whih is 10 $ner(y and orres"onds to 50 'C at +00 '.

4or a 80 year old 'ale the initial titration dose is 7; a(e, whih is 15 ener(y and orres"onds to=5 'C at +00 '.

8/17/2019 Guide to ECT 2015

8/25

%he sti'!l!s !rrent affets the dose 'ore stron(ly than its har(e. %he effet of !rrent isso stron( that it is "referable to ad!st the sti'!l!s dose by han(in( the har(e and leavin( the

!rrent onstant. %he %hy'atron instr!'ent !ses +00 ' !rrent. @ower !rrents are !sed in

e"eri'ents on laboratory ani'als bea!se their brains are '!h s'aller than those of h!'ans.

%he har(e rate is the a'o!nt of har(e delivered "er seond of sti'!l!s, o!ntin( (a"s

 between "!lses. @ower fre/!eny and narrower "!lsewidth (ive lower har(e rate.

PROCEDURES FOR ECT TREATMENT

Ro!tine $C% orders inl!de no intae by 'o!th #)P

8/17/2019 Guide to ECT 2015

9/25

8/17/2019 Guide to ECT 2015

10/25

$letrode sites are washed with soa" and water, and dried. etone is not !sed bea!se

re"eated e"os!re is toi to "ersonnel. Sti on dis"osable 'onitorin( eletrodes #So'atis

Q$$DS& re'ain in "lae, are /!ily a""lied, involve only 'ini'al lean!", and avoidonta'ination a'on( "atients.

8/17/2019 Guide to ECT 2015

11/25

handle. Sti'!l!s ables and 'onitorin( eletrode lead wires are onneted. Shortly before "ressin(

the %hy'atron treat b!tton ond!tive (el is a""lied to the onave eletrode s!rfae of the steel

eletrode. ""lyin( (el sooner "redis"oses to aidental (el s"ill.

headstra" with steel "late eletrodes, and ond!tive elly an be !sed instead. andles

an be s!bstit!ted for the headstra". andles with a re'ote treat b!tton are available for !se with

the %hy'atron devie. 9se of these eletrode 'ethods involves leanin( away ond!tive elly

 between "atients. -ith @R% and the other bilateral eletrode "lae'ents dis"osable sti'!l!s

eletrodes an be !sed el!sively, 'ini'izin( lean!". -ith ri(ht !nilateral $C% the verte

eletrode involves leanin( !nless the site is free of hair and a %hy'a"ad sti on sti'!l!s

eletrode an be a""lied. If yo! "refer, the re'ote treat b!tton on a handle an be !sed with%hy'a"ad sti*on eletrodes, si'"ly for the re'ote treat b!tton f!ntion.

fter the sti'!l!s eletrodes are "laed, and the sti'!l!s able and 'onitorin( leadwires

are onneted, stati i'"edane is tested. I'"edane testin( 'eas!res the /!ality of eletrial

onnetion to the "atient. $essively hi(h i'"edane #e.(., over 7000 oh's& s!((ests ino'"lete

eletrial onnetion or inade/!ate ontat between eletrode and sin. Sin ontat an be

i'"roved by ea'inin( eletrodes for ino'"lete ontat and by "ressin( on the ba of theeletrodes with a dry nonond!tive obet, s!h as a "lasti handle.

If the "rinted $$K line is !n!s!ally thi or noisy, this s!((ests a "artially broenonnetion in the leadwire. %his is the thin wire that onnets the reordin( eletrode to the thi

'onitorin( able. @eadwires ty"ially last fro' 7*12 'onths and are ine"ensive.

Anesthesian atro"ini 'ediation if any is then inf!sed #if not "revio!sly (iven intra'!s!larly&,

i''ediately followed by a narosis a(ent s!h as 'ethoheital. -hen the "atient beo'es !nable

to res"ond, the narosis is !s!ally s!ffiient. Inhibition of the eyeblin refle o!rs at a dee"er

level of anesthesia than needed to ahieve a'nesia for the $C% "roed!re. 'o!th "rotetor isthen inserted to hel" "revent in!ry to teeth, ton(!e and 'o!th wall. %he dis"osable Gentil* 'o!th "rotetor "rovides an air hannel thro!(h the li"s to "er'it ventilation, while "rotetin( teeth and

ton(!e. %he le( blood "ress!re !ff is then inflated above systoli as the '!sle "aralyti a(ent

#e.(., s!inylholine& is (iven.

%he "atient:s li'bs are bared for view and 'onitored for '!sle fasi!lations as a si(n of

s!inylholine effet. 4asi!lations !s!ally be(in aro!nd the eyes and "ro(ress down the body. few "atients show no fasi!lations. %o 'onitor for "aralysis a wei(hty refle ha''er is desirable,

e.(., lar(e head !een S/!are ha''er #htt"6'edea'tools.o'r1*'e(a.ht'&. %he o''ontaylor to'ahaw ha''er an not (ather eno!(h 'o'ent!'. n eletrial "eri"heral nerve

sti'!lator set to a train of fo!r "attern an be !sed in "lae of a refle ha''er. %he (oal is one or 

two twithes to the fo!r "!lsesA 'ore twithes s!((ests ins!ffiient relaation. -hen refleesdisa""ear and '!sle tone at the nee oint li(htens the "atient is !s!ally ready for the sti'!l!s.

tive hy"erventilation with oy(en by 'as is (iven after the '!sle relaant#s!inylholine& is (ive bea!se hy"eroia and hy"oarbia failitate the seiz!re. D!rin( the

seiz!re ventilation ontin!es, with brief interr!"tions as needed for observations s!h as to identify

that the $$K seiz!re ended. Gentilatory s!""ort witho!t hy"erventilation ontin!es !ntil the "atient

 breathes on his own, !s!ally7 to 8 'in!tes after the $C% sti'!l!s.

11

8/17/2019 Guide to ECT 2015

12/25

Sti!ulus "eli$ey

Before deliverin( the sti'!l!s the $C% dose settin( is verified to be as intended. -ith the

%hy'atron devie the sin(le $ner(y dial sets the sti'!l!s doseA with other devies several

nobs eah ad!st the sti'!l!s dose and eah '!st be heed. %he "!lsewidth, fre/!eny, and

total d!ration of the $C% sti'!l!s are a!to'atially set by the %hy'atron

 instr!'ent to onfor'to the dose set with this $ner(y dial. %he "!lsewidth and fre/!eny settin(s for eah $ner(y

sti'!l!s dose on a %hy'atron instr!'ent are referred to as a "ro(ra', and several different

 "ro(ra's are b!ilt in to eah. %he defa!lt "ro(ra' !ses 0.5 'se "!lsewidth at every dose with the

fre/!eny a!to'atially hosen so that the sti'!l!s is abo!t ; se lon(, ee"t at the few lowest

doses. %he %hy'atron devie identifies this "ro(ra' as 3@

8/17/2019 Guide to ECT 2015

13/25

Monitoin% The Patient-hen the eletrial sti'!l!s starts the "atient>s '!sles enter a state of tetany. %his reflets

diret eletrial sti'!lation of the 'otor orte and it does not indiate seiz!re. %he '!sles

!s!ally show a short s!dden 'ove'ent as the tetany transitions into ton!s at the end of thesti'!l!s. So'eti'es the 'otor seiz!re be(ins a few seonds after the sti'!l!s ends. Seiz!re onset

an be(in 15*H0 seonds after the sti'!l!s, b!t this is !n!s!al. -hen a 'otor seiz!re does not startwithin a few seonds after the sti'!l!s, inreasin( heart rate and $$K a'"lit!de are heed for to

see if a seiz!re is brewin(. If these si(ns do not o!r onsider deliverin( another sti'!l!s abo!t 70

se after the first. It is not neessary for this seond sti'!l!s to be hi(her than the first bea!se the

effets of the two sti'!li oin to(ether. If the seond sti'!l!s fails onsider raisin( the sti'!l!sdose s!bstantially, s!h as by 50. If the third sti'!l!s fails, onsider raisin( the sti'!l!s a(ain,

 "erha"s by 50 or 100.

In seiz!re 'onitorin( the o!rrene of 'otor ativity indiates basi effiay, and $$K isea'ined to (enerally ass!re that the seiz!re ends. Motor ativity is !s!ally 'onitored in the !ffed

ri(ht le(. C!ffed refers to "lae'ent and inflation of a blood "ress!re !ff aro!nd the ri(ht alf to

above systoli "ress!re. %he !ff is inflated when the '!sle "aralyti a(ent #e.(., s!inylholine&

is (iven. (ood si(n of 'otor seiz!re is ton!s lastin( at least 7 se and a total d!ration of ton!s andlon!s lastin( at least 1; se. If 'otor ativity is less than this, onsider resti'!lation at a hi(her

eletrial dose.

$$K seiz!re is ty"ially abo!t 50 lon(er than 'otor seiz!re. @istenin( to the !dible

$$K of the %hy'atron instr!'ent an re"lae looin( at the $$K "rinto!t d!rin( the treat'ent.

%he !dible $$K seiz!re end"oint is heard as a steady tonal "ith that lasts for at least one seond.

%his orres"onds to the flattenin( of the "rinted $$K at the end of the seiz!re. So'eti'es the $CKis visible in the $$K train(, es"eially if an $$K eletrode was "laed on the 'astoid. If the $$K

seiz!re d!ration etends to 100 E 120 se d!ration onsideration sho!ld be (iven to sto""in( theseiz!re with intraveno!s "ro"ofol #e.(., 0.5 * 0.= '((& or 'idazola' #2*8 '(&. n identifiable

seiz!re end"oint on the "rinted or !dible $$K is !sef!l b!t not definitive evidene that the seiz!resto""ed. %his is bea!se seiz!re an ontin!e in brain re(ions far away fro' the $$K eletrodes

#Swartz, 1++H&. Still, it is standard "ratie to !d(e that the seiz!re ended by observin( an $$K

end"oint and ea'inin( the "atient:s behavior.

Shortly after the seiz!re starts the heart rate !s!ally aelerates, reahin( its 'ai'!'

d!rin( that seiz!re in 15 to 70 se. "ea heart rate !nder 170 b"' !s!ally indiates a weatreat'ent, !nless a ardia ondition or 'ediation interferene is "resent. %he "ea heart rate

d!rin( a (ood /!ality $C% seiz!re is si'ilar to b!t ty"ially hi(her than in a ardia tread'ill test

#Swartz ? Shen, 200=&. few seonds after the $$K seiz!re a""ears to end, "ress the "rint

3startsto" b!tton. %he end of treat'ent re"ort is then "rinted by the %hy'atron instr!'ent.

Printin( then a!to'atially sto"s.

%he "ea $$K a'"lit!de in a vi(oro!s seiz!re !s!ally o!rs H to 12 se after the $C%

sti'!l!s. n $$K si(n of intense seiz!re ativity is hi(h a'"lit!de ro!nded waves #7 to 5 "er

seond& with s'aller faster waves ridin( on it. $$K flattenin( at the end of the seiz!re is also a si(n

of intense seiz!re ativity and thera"e!ti effiay #z!'a et al., 200=&. %his flattenin( re"resentss!""ression of eletrial ativity, and so is alled "ostital s!""ression. 4latter 'eans (reater

s!""ression. %he %hy'atron instr!'ent end of treat'ent re"ort inl!des a 'eas!re'ent of

 "ostital s!""ressionA this 'eas!re'ent orres"onds to seiz!re intensity #Porter et al., 200;&.

17

8/17/2019 Guide to ECT 2015

14/25

4i(!re above6 %y"ial early $C% seiz!re. $$K6 to" 2 lines. $MK6 line 7. $CK6 botto' shows

slowin( after $C% sti'!l!s to rate of 70 b"' with /!i ret!rn to abo!t 100 b"'.

4i(!re above6 %y"ial 'iddle seiz!re. $$K shows hi(h a'"lit!de 7 z waves with hi(h

fre/!eny waves on to". %he heart rate reahes abo!t 185 b"'.

18

8/17/2019 Guide to ECT 2015

15/25

4i(!re above6 %y"ial end of 'otor seiz!re seen on $MK. $$K seiz!re ontin!es.

4i(!re above6 %y"ial $$K seiz!re end"oint with stron( "ostital s!""ression #flattenin(&.

$CK is visible on the flattened $$K. R dereases to abo!t 100 b"'. %hese fo!r fi(!res arefro' the sa'e $C% treat'ent.

If the "atient a""ears delirio!s or !n!s!ally disoriented after $C% it is "ossible that o!lt

seiz!re ativity is o!rrin(, and ad'inistration of "ro"ofol or 'idazola' sho!ld be onsidered to

 better ass!re ter'ination of the seiz!re. %he 3"ro"ofol interr!"tion 'ethod desribed below ai'sto "revent ontin!in( o!lt seiz!re ativity ro!tinely.

waenin( fro' the $C% treat'ent ty"ially o!rs (rad!ally, with ret!rn to f!ll

orientation in 10 to 15 'in!tes. !ier awaenin( after $C% with f!ll alertness and orientations!((ests that the (eneralized seiz!re was not ahieved, and that effiay is less than e"eted.

Pinte" epot an" po%ess note

%he end of treat'ent re"ort "rinted by the %hy'atron instr!'ent lists date, ti'e, sti'!l!s

har(e, !rrent, fre/!eny, "!lsewidth, d!ration, and i'"edanes. It also lists "hysiolo(ial

'eas!re'ents inl!din( baseline and "ea heart rates, 'eas!re'ents of seiz!re d!ration fro' $$K

and $MK reordin(s, and several $$K 'eas!re'ents.

15

8/17/2019 Guide to ECT 2015

16/25

fter the $C% treat'ent a "ro(ress note is written in the 'edial reord. So'e of this is

inl!ded in the %hy'atron end of treat'ent re"ort, e.(., sti'!l!s harateristis, $$K seiz!re

d!ration, "ea heart rate. %he end of treat'ent re"ort "rinted by the %hy'atron devie is

so'eti'es savedA the rest of the "a"er "rinto!t is ty"ially disarded after ins"etion.

 Mana%in% co!!on co!plications

-hen an ee"tionally lon( seiz!re o!rs #e.(., lon(er than H0 se 'otor or 120 se $$K&onsider seiz!re ter'ination with an intraveno!s inf!sion of 'ethoheital 80*50 '(, "ro"ofol 0.5 E 

0.= '((, or 'idazola' 1*8 '(.

Post*$C% hy"ertension or tahyardia is o''only 'iti(ated with labetalol #5*10 '(& ores'olol #abo!t 1 '((& intraveno!sly i''ediately after the $C% seiz!re ends. Both di'inish

hy"ertension and tahyardia b!t there are differenes. $s'olol wors in 1*2 'in!tes, and 'orestron(ly on blood "ress!re than heart rate. @abetalol ats in 2*5 'in!tes, and 'ore stron(ly on heart

rate than blood "ress!re. C)S*ative beta*bloers have antionv!lsant effets and both these dr!(sweaen $C% seiz!re when (iven before the sti'!l!s #Gan den Broe et al., 1+++&. Still, so'e

fra(ile "atients 'ay re/!ire 'ediation before the $C% seiz!re ends or even before it starts.

Post*$C% headahe and '!s!loseletal "ain is o''only 'ana(ed by oral )SID oraeta'ino"hen, or with etorola 15*70 '(. eat and 'assa(e also hel". 4!rther a""earane is

 "revented by (ivin( )SID or aeta'ino"hen 2 hrs "rior to $C% with a si" of water, or etorolaIG shortly before $C%.

 )a!sea or vo'itin( "ost*$C% is o''only treated with ondansetron 8 '( IG. 4!rther

o!rrene is "revented by (ivin( this 'ediation 10*70 'in!tes before $C%.

%ro!bleso'e "ain fro' inf!sion of the narosis a(ent #e.(., 'ethoheital& is re"orted by a

few "erent of "atients. %his is !s!ally "revented by inf!sin( 5*10 '( of lidoaine i''ediately "rior to the narosis dr!(. lar(er lidoaine dose before $C% weaens the seiz!re and treat'enteffiay.

ECT Session Reco$ey

fter the $C% seiz!re, heart rate, blood "ress!re, res"irations, level of onsio!sness,

orientation, and a(itation level are 'onitored !ntil all ret!rn to stable safe levels. S!"ervision is

(iven to eah "atient while in the $C% area, before and after treat'ent. %o "revent as"iration, the "atient is ro!tinely t!rned on his side after $C% !ntil reovery is o'"lete. In"atients are esorted

 ba to the ward, and visits are "ost"oned !ntil at least fo!r ho!rs after $C%.

Postictal A%itation

%he syndro'e of "ostital a(itation ty"ially lasts for several ho!rs. -hen severe it

inl!des yellin(, flailin(, and de'ands to (et !" fro' the ot.

8/17/2019 Guide to ECT 2015

17/25

s!betively if not visibly, leaves "atients !no'fortable for the rest of the day, and te'"ts the' toref!se f!rther $C%. So, it is essential to identify and treat "ostital a(itation /!ily, "revent

re!rrenes, and learly reass!re "atients that it sho!ld not ha""en a(ain.

I''ediate treat'ent of "ostital a(itation in the $C% area is !s!ally with "arenteral

'idazola' #1 E2 '(&. -hen the "atient beo'es able to swallow, this is followed by a dose of oral

al"razola' or oaze"a'. -ith 'idazola' inf!sion the "ossibility of s!dden a"nea is aref!lly'onitored for. -hen "ostital a(itation is 'ild and disovered when the "atient has re(ained the

ability to drin water, an oral benzodiaze"ine with reass!rane !s!ally s!ffies on that day.

8/17/2019 Guide to ECT 2015

18/25

Discha%e Fo! the ECT Aea

Dishar(e fro' the $C% area !s!ally o!rs when the "atient ret!rns to f!ll alertness andorientation , shows re"eated vital si(ns in nor'al ran(e, wals in a stable 'anner, and shows no

new behavioral dist!rbane s!h as "ostital a(itation or deliri!'. %his is ty"ially 20 to 70

'in!tes after the $C% session. Intraveno!s lines sho!ld be re'oved before the "atient leaves the

$C% area.

Metho"s to Potentiate ECT Sei+ue

@isted below are ste"s to onsider when the $C% seiz!re beo'es wea or short, or if no

seiz!re develo"s. %he first five ste"s are ro!tine for all "atients. Ste"s si and hi(her are in order of "riority.

1. Disontin!e antionv!lsant 'ediation, in the absene of e"ile"sy.

2. Disontin!e sedative hy"noti a(ents. Krad!al ta"er over 2*7 wees is needed if the "atient

is "hysially de"endent or had !sed daily for a 'onth or lon(er.7. Mini'ize other ono'itant 'ediations. So'e 'ediations have little nown

antionv!lsant effets, e.(., allo"!rinol, M< inhibitors, detro'ethor"han, beta*bloers.

8. Identify and treat hy"othyroidis', on(estive heart fail!re, "!l'onary ins!ffiieny andother 'edial "roble's that a""arently affet oy(enation and 'etaboli rate.

5. Prevent hy"other'ia. y"other'ia is o''on in the elderly.

H. void "ro"ofol. Mini'ize doses of barbit!rate narosis a(ents, e.(., 'ethoheital.=. Inrease the sti'!l!s !rrent if "ossible

;. Inrease the sti'!l!s har(e if "ossible.

+. Consider narosis with eto'idate #0.15 E 0.7 '((& or re'ifentanil #0.8 * 0.; '((&instead of barbit!rate. Seiz!re thresholds are lower and seiz!res are lon(er with these

#S!llivan et al., 2008A vra'ov et al., 1++5&.

10. Consider narosis with eta'ine #0.5 E 1 '((& or a 'it!re of eta'ine with anothernarosis a(ent. eta'ine is risy with e"ile"ti "atients bea!se it an "rovoe seiz!re.

Metho"s of Mini!i+in% Co%niti$e Si"e Effects Fo! ECT

Co(nitive side effets inl!de disorientation, orbital*frontal syndro'e #so'eti'esinorretly identified as $C% ind!ed hy"o'ania or 'ania&, for(ettin(, and deliri!'. -hen

disorientation o!rs it is ty"ially not notieable !ntil after three or 'ore $C%s #Calev et al.,

1++1&. %he orbital*frontal syndro'e ty"ially inl!des disinhibition, intr!siveness, overfriendliness,

i'"atiene or indisreet behavior. Disorientation and orbital*frontal sy'"to's a!'!late(rad!ally and ty"ially disa""ear (rad!ally and o'"letely. If side effets are 'ore linially

s!bstantial than benefits, this is a s!((estion that $C% 'ay not be /!ite a""ro"riate for this "atient,or that the $C% 'ethod 'ay be "rod!in( !nneessarily intense seiz!res, s!h as by !sin( a hi(h

sti'!l!s dose or eta'ine narosis.

4or(ettin( !s!ally inl!des "ersonal infor'ation s!h as "hone n!'bers and na'es.

4or(otten 'e'ories !s!ally rea""ear (rad!ally b!t so'e "atients re"ort that so'e details are

 "er'anently for(otten and need to relearned. Patients who o'"lain of for(ettin( after $C%ty"ially e"eriened 'ore o(nitive defiienies before $C% #Sobin et al., 1++5&.

1;

8/17/2019 Guide to ECT 2015

19/25

Co(nitive side effets vary widely a'on( "atients. Both a!te and "ersistent o(nitivedefiits an be a!sed by "syhiatri illness and "syhotro"i 'ediations, "arti!larly

 benzodiaze"ines and dr!(s with antiholiner(i effets. If o(nitive sy'"to's develo" d!rin( $C%,they are liely to worsen with f!rther $C%s, altho!(h han(in( the $C% 'ethod an so'eti'es

hel". If no o(nitive sy'"to's have o!rred fro' $C%s reeived in the "resent o!rse, it is

reasonable to e"et little to none fro' the net $C%. $C% shed!lin( an be 'ore fleible and

fre/!ent for "atients who show ne(li(ible to no side effets. Patients who have e"erienedo(nitive side effets fro' $C%s, and those who need to avoid even te'"orary 'ild o(nitive side

effets, are andidates for the 'ethods in the net "ara(ra"hs.

Disontin!in( or ta"erin( on!rrent "syhotro"i 'ediations sho!ld dereaseo'"liations fro' $C%. Benzodiaze"ines, antiholiner(is #e.(., triyli antide"ressants&, and

lithi!' an eaerbate o(nitive side effets. ntionv!lsants weaen the $C% seiz!re and "robably its effiay. Do"a'ine bloers s!h as anti"syhotis "redis"ose to as"iration. %hey an

also hide "syho"atholo(y that $C% ai's to re'ove, e.(., de"ressive or 'ani sy'"to's, andthereby onfo!nd eval!ation.

So'e $C% 'ethods !s!ally "rod!e less o(nitive side effets. Bifrontal $C% and theasy''etrial "lae'ents of ri(ht !nilateral and @R% $C% (enerally have fewer side effets

!nless eessive sti'!l!s doses are !sed. Garyin( eletrode "lae'ents a'on( two of these or allthree 'ay have still lower !'!lative side effets. %he "!lsewidth of 0.5 'se showed "arti!larly

low side effets, even with bite'"oral "lae'ent #-arnell ? Swartz, 2011&.

9ltrabrief "!lsewidths of 0.25 or 0.70 'se sho!ld also have low side effets, "erha"s evenlower than with 0.5 'se. owever, a 'aor shorto'in( to ro!tinely !sin( !ltrabrief $C% is that

its effiay has not been learly established o'"ared to brief "!lse $C% #0.5 E 1.0 'se "!lsewidth&.

8/17/2019 Guide to ECT 2015

20/25

 AT T,E CONC-USION OF T,E ECT COURSE

&hen to Stop the Acute ECT Couse

%he "syho"atholo(i si(ns of illness that ori(inally led to $C% treat'ent are 'onitored

alon( the o!rse. 4or de"ression this 'ay be "syho'otor retardation, low s"ontaneity andres"onsiveness, withdrawal fro' interatin( with other "eo"le, a""earin( si or eha!sted, ab!lia,aner(ia, and obsessions abo!t siness. %he $C% o!rse is !s!ally ontin!ed !ntil si(ns of illness

disa""ear, or !ntil f!rther i'"rove'ent does not o!r over the last three $C%s.

%he o"inions of fa'ily and lose visitin( friends abo!t the "atient>s ret!rn to !s!al

 "ersonality and sills an be hel"f!l, b!t te'"orary side effets fro' $C% an interfere with this.

sin( the "atient for how de"ressed he feels does not distin(!ish between de"ression anddys"hori aniety or "ersonal sit!ations, b!t if the "atient feels ha""y and well this an onfir'

re'ission.

%he ordinary 'ini'!' n!'ber of $C%s in a o!rse is si. If a "atient ahieves o'"lete

re'ission by the third $C% and the illness inl!ded no violene or s!iidality it is reasonable toonsider onl!din( after five $C%s. If the "atient was severe, hroni, or "syhoti onsidertreatin( to 'ai'!' i'"rove'ent in what yo! see, then addin( two 'ore $C%s. Co!rses are

(enerally lon(er with !nilateral $C% and with !ltrabrief $C%.

%he lon(est o!rses 'ay be with very elderly "atients, with bi"olar "atients who swith "hase fro' de"ression to f!ll 'ania d!rin( the o!rse, and with atatoni "atients who have

o'orbid oarse brain disease #e.(., tra!'ati brain in!ry, develo"'ental disorder&. ty"ial

o!rse is H to 10 treat'ents. If yo!r avera(e is hi(her than this, onsider seein( an e"lanation.

E$aluation Afte ECT Couse

fter $C% it is hel"f!l to ea'ine for o(nitive dysf!ntion, aniety disorder, and resid!al "atholo(y fro' the ondition $C% was (iven to treat, e.(., 'aor de"ression. Co'orbid dys"hori

aniety disorders are o''on in "atients with 'aor de"ression, even those with 'elanholia or bi"olar disorder. -hen "resent an aniety disorder needs a treat'ent "lan that is se"arate fro'

$C%. Dys"hori aniety has 'any of the sa'e s!betive sy'"to's as 'aor de"ression, inl!din(

low 'ood, loss of "leas!re, inso'nia, worry, hy"er"ha(ia, feelin(s of siness, fati(!e, re'orse,

and s!iidality. S!iidality in aniety disorders is several fold 'ore fre/!ent than in the nor'al "o"!lation #Ra'sawh et al., 2018A Sareen et al., 2005&, so its "resene does not distin(!ish between

'aor de"ression and aniety disorders. Dys"hori aniety disorder is a o''on reason fora""arently ino'"lete res"onse to $C% or early rela"se. Identifyin( and treatin( o'orbid

dys"hori aniety disorder is essential to ahievin( re'ission fro' o'"laints of de"ression.

If the "atient o'"lains of de"ression after $C%, whether i''ediately or within a 'onth, b!t yo! do not see the "syho"atholo(i si(ns of illness that were "resent before $C%, dys"hori

aniety disorder is a liely a!se. Detetion of aniety disorders after $C% involves ea'inationafter both 1*7 wees and 8*H wees "ost*$C%, not !st shortly after the $C% o!rse. %his is bea!se

aniety disorders ty"ially res"ond so'ewhat to $C% for a few days and !" to a 'onth. Si(ns ofaniety disorder inl!de bein( !"set at s'all thin(s, ventilatory behavior, wantin( to enoy life b!t

feelin( fr!strated, and dissatisfation with relationshi"s and sit!ations rather than !st feelin( ill.

20

8/17/2019 Guide to ECT 2015

21/25

Basi o(nitive eval!ation inl!des reall of "ersonal bio(ra"hial infor'ation, orientation,

reall of details of !rrent news events, self*are s!h as hy(iene and dress, and !d('ent abo!tret!rnin( ho'e and res!'in( wor. fter an $C% o!rse the "atient sho!ld re'ain !nder

s!"ervision by others for two to fo!r wees. Maor life deisions sho!ld be avoided d!rin( this

 "eriod #e.(., 'arital, lar(e invest'ent, ho!se "!rhase or sale&, and the "atient sho!ld not drive or

o"erate 'ahinery.

Pe$entin% Recuence

fter the $C% o!rse a "lan is started to "revent re!rrene of the illness. Mediation an

 "revent e"isodes of 'elanholia, "syhoti de"ression, or 'ania that it is not able to treat. 4or'aor de"ression with lassial 'elanholia or atatonia onsider b!"ro"ion, nortri"tyline, or hi(h

doses of a S)RI, e.(., 150*700 '(day of venlafaine, 120 '(day or 'ore of d!loetine. @ithi!'

'ay be added for f!rther "rotetion or if the "atient is bi"olar. Patients with a 'ood disorder that

has resisted "revention with 'ediation an benefit fro' a'b!latory 'aintenane $C%, ty"ially(iven one every 7 to 8 wees. t its start a'b!latory 'aintenane $C% is so'eti'es (iven weely

fre/!ently and then (rad!ally slowed.

.UA-IT/ ASSURANCE MONITORED ASPECTS4or /!ality ass!rane "!r"oses yo! 'ay wish to identify as"ets of the $C% "roed!re for

'onitorin(. Monitorin( so'e trends listed below 'ay be !sef!l. %hey are listed only as s!((estionsand ill!strations.

Proed!re effiieny. Perenta(e of days in whih the avera(e ti'e needed by the $C% dotor

eeeded 15 'in!tes "er "atient. Reord total ti'e fro' when yo! be(an worin( in the $C%

area !ntil yo! o'"leted ti'e, divide by n!'ber of $C% "atients seen.

Keneral effiay. Perenta(e of "atients whose a!te $C% o!rse eeeded 12 treat'ents. ninitial (oal 'i(ht be less than 10.

Co'"liation inidene. Perenta(e of "atients whose $C% o!rses are sto""ed before linial

 "latea! is reahed, alon( with reason, e.(., onf!sion, onsent withdrawn, 'edial

o'"liation, finanial li'itation, hos"ital environ'ent.

Seiz!re ind!tion s!ess. Perenta(e of "atients whose $C% o!rses are sto""ed bea!se

seiz!res of ade/!ate /!ality were not obtained.

Consent. Perenta(e of "atients who withdrew onsent for $C% after (ivin( it, alon( with when

it was withdrawn, e.(., before first $C%, before both "atient and dotor identified re'ission,

 before !st dotor identified re'ission, after re'ission, after o!rse.

Medial o'"liation inidenes6 headahe, na!sea, hy"ertension or tahyardia lastin( over 2

'in!tes after $C%, "ostital a(itation, "ostital deliri!', delayed awaenin(, other.

niety disorder inidene "ost*$C%6 Perenta(e of "atients ea'ined for aniety disorder at

end of $C% and 7*; wees later. Perenta(e of "atients with new dia(nosis of aniety disorder

fo!nd at end of $C% and 7*; wees later.

21

8/17/2019 Guide to ECT 2015

22/25

Pro"hylais6 Perenta(e of $C% "atients with de"ression "laed on S)RI, triyli, b!"ro"ion,

lithi!', or Mor de!ression. 4 EC 13+ 1?#%*887.Fster0aard S2, (olwi0 , /etrides . No causal association between EC and death. 4 EC 13:+ ;3#:%*19;7:./orter R, (ooth 2, ra"

8/17/2019 Guide to ECT 2015

23/25

Ramsawh !7article7swartz.!d$ Swartz CM. Stimulus Electrode /lacement. Cha!ter 1? )n* Swartz CM, editor* DElectroconvulsive and Neuromodulation

hera!iesD, New Yor'* Cambrid0e niversit" /ress, 133-b, !!. :;37:9.Swartz CM. Electricit" and Electroconvulsive hera!". Cha!ter )n Swartz CM, editor* DElectroconvulsive and

Neuromodulation hera!iesD, New Yor'* Cambrid0e niversit" /ress, 133-c, !!. 79.Swartz CM. ens A=, Mulder /, Kusuma A, (rui>n 4A. &ow dose esmolol bolus reduces seizure duration durin0

electroconvulsive thera!"* a double7blind !lacebo7controlled stud". (r 4 Anaesth ---+ ;#1%*1?7:.Warnell R&, Swartz CM, homson A. /ro!o$ol interru!tion o$ EC seizure to reduce side7e$$ects* a !ilot stud". /s"chiatr"

Research 133+ ?8*:78.Warnell R&, Swartz CM, homson A. Clinicall" )nsubstantial Co0nitive Side E$$ects o$ (item!oral EC at 3.8 msec /ulsewidth.

 Annals o$ Clinical /s"chiatr" 13+ 1;#:%*18?791.Yalcin S, A"do0an

8/17/2019 Guide to ECT 2015

24/25

Self-!ssessment 4uestions5

1 "hen the electrical stimulus is delivered to the patient you may #eel the it i# $choose one%& ' (ou touch the hospital cart the patient is on) (ou touch the patient*s head with your hand

C (ou hold the patient*s shoulder and leg+ (ou press the -reat )utton while touching the patient. /one o# the above

2 .C- patients may see other patients receiving .C- because they will #orget it later& $-rue or alse%&

"hat is the main purpose o# suppressing consciousness with anesthesia at .C- $chooseone%&

 ' So the patient will not #eel the electricity

) So the patient will not remember anything about the treatmentC 3rotecting the patient+ So the patient will not remember the muscle paralysis

4 'n ordinary and desirable pea heart rate during .C- under anesthesia with methoheital,thiopental, or etomidate is in which range&

 ' 'bove 10 bpm) 120610 bpmC 1106120 bpm+ under 110 bpm

5 'n ordinary and desirable heart rate 10 minutes a#ter the .C- session is in which range& ' 'bove 15 bpm) 120610 bpmC 1106120 bpm+ under 110 bpm

7 "hen the electrical stimulus is applied, what may be in the patient*s mouth $choose onebest%&

 ' +entures) ' compressible mouth protector 

C /othing+ ' plastic 8uedel airway. 'n endotracheal tube

28

8/17/2019 Guide to ECT 2015

25/25

9 '#ter .C- treatment but be#ore awaening the patient yells and #lails -his is probably&$choose one%&

 ' 'n ordinary reaction to .C-) 3ostictal agitationC 3ostictal delirium+ ' nightmare during anesthesia

. -ardive seizure

: '#ter the .C- seizure each patient is routinely turned on his side $-rue or alse%&

; '#ter the .C- seizure all the #ollowing are routinely monitored #or return to baseline be#orethe patient leaves the .C- area ecept $choose one%&

 ' evel o# consciousness and orientation. -emperature

10 "hen given #or sleep these medications should inter#ere with .C- e##icacy ecept& ' 3romethazine $3henergan%) ?olpidem $'mbien%C .szopiclone $>unesta%+ -emazepam $=estoril%. lurazepam $+almane%

 '/S".=S >IS-.+ ).>!"

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ Answers*. C. ouchin0 the !atient with 1 hands ma'es a circuit throu0h "our bod".1. =alse

;. 2:. A8. 29. (. eeth must be !rotected?. (. rue-. E3. A

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@