IM, Intramuscular; IV, intravenous.
Adapted from Ding Z, White PF. Anesthesia for electroconvulsive therapy. Anesth Analg 2002; 94:1351-1364; White PF. Perioperative Drug Manual. 2nd ed. Philadelphia: Saunders. 2005; Wagner KJ, Möllenberg O, Rentrop M, et al. Guide to anaesthetic selection for electroconvulsive therapy. CNS Drugs 2005;19:745-758.
A thorough preanesthetic assessment must be performed, with consideration given to the possible great physiologic hemodynamic responses generated by the induced seizure activity. The box on pg. 384
lists the possible physiologic effects as a result of ECT.
Possible Physiologic Effects as a Result of Electroconvulsive Therapy
Parasympathetic response during the tonic phase of seizure
Sympathetic response during the clonic phase of seizure
Increased cerebral blood flow (increase of 100% to 400% above baseline are possible)
Increased intracranial pressure
Increased intraocular pressure
Increased intragastric pressure
Adapted from Lee M: Anesthesia for electroconvulsive therapy. In Atlee JL, editor: Complications in Anesthesia. 2nd ed. Philadelphia: Saunders; 2007:903-905.
Adult patients about to undergo ECT should follow fasting guidelines of at least 6 hours for solids and 2 hours for liquids. Necessary bronchodilators may be taken. Oral medications, such as antihypertensives, cardiac medications, anticoagulants, and thyroid medications, may be taken with a sip of water up to 1 hour before the procedure.
Patients may have results of laboratory studies, a pharmacologic regimen, and ECG readily available because of their psychiatric hospitalization. Informed consent is obtained whenever possible from the patient or legal guardian. An IV catheter is inserted in a peripheral vein.
The patient is monitored with a pulse oximeter, ECG, noninvasive blood pressure monitor, temperature-monitoring device, and peripheral nerve stimulator. Use of etco2
monitoring has been suggested because hypercarbia and hypoxia shorten seizure duration.
Suction, oxygen, a positive-pressure Ambu bag and face mask, and rubber bite protectors must be present, as well as necessary airway and cardiovascular resuscitation equipment (including a laryngoscope and ETT with stylet), medications, and supplies because ECT is usually performed in a dedicated psychiatric suite or special treatment room.
The patient is preoxygenated before induction. Anticholinergics may be administered as an antisialagogue or to prevent asystole.
The induction agent is administered intravenously. Propofol, etomidate, and ketamine have also been used, although an enhanced hemodynamic response and increased ICP is possible after using ketamine. Succinylcholine (0.25-0.5 mg/kg) is usually given and is the drug of choice because of its short duration.
Positive-pressure ventilation is applied to the patient via the positive pressure breathing bag and a face mask and is continued until after treatment is completed and spontaneous respirations resume.
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