Electroconvulsive Therapy (ECT)

Anesthesia Implications

Position: Supine
Time: 5-30 min (very short)
Blood Loss: Zero
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: Yes

Be prepared – Keep LMA and ETT available at bedside if needed. Have oral or nasal airway readily available

Induction – A quick acting anesthetic (Brevitol) and paralytic (succinylcholine) is given on induction. If the patient is anticipated to have a short (sub-therapeutic) seizure, you’ll also be giving caffeine at this junction to prolong the seizure. After giving Brevitol, obtain a baseline EEG before administering succinylcholine. Then hyperventilate using the mask/ambu bag to decrease CO2. This will hyperoxygenate the patient.

Sympathetic Response – Electro-stimulation of the brain will produce a brief parasympathetic response, and then a more prolonged sympathetic response. Esmolol (20-50 mg) and/or labeolol (5-15 mg) is typically given directly after induction.

Bite Block – After induction, place a rubber or foam bite block before electro-stimulation.

Get Clear – After induction and placement of the bite block, get clear of the patient to avoid shock.

Post-seizure – Resume airway management and assist the patient back to spontaneous ventilation. Continue to monitor for hypo or hypertension, bradycardia (rare), tachycardia (most common), or any dysrhythmia. Have all emergency drugs at bedside.

Common medication lineup – Bevitol (0.75-1.5 mg/kg), Succinylcholine (0.3-1 mg/kg), Robinul (0.2 – 0.4 mg) OR Atropine, Caffeine (120-600 mg), Esmolol (20-50 mg) and/or labeolol (5-15 mg).

ECTs (Electroconvulsive Therapy) is typically indicated for for the relief of Major Depressive Disorder (MDD) or other mental disorders that have not responded to traditional medical treatment. The procedure involves sending an electrical current through the brain which causes a brief seizure. The actual duration of the seizure is determined by the surgeon, but generally anticipate a longer duration if previous induced seizures were sub-therapeutic.

Absolute Contraindications – Recent craniotomy, recent MI (less than 3 months ago), recent stroke (less than 1 month ago), Intracranial mass, and increased ICP.

Relative Contraindications – angina, CHF, significant pulmonary disease, bone fractures, osteoporosis, pregnancy, glaucoma, and retinal damage

Consult – Patients with COPD, CHF, unstable angina, and glaucoma are at increased risk for complications during ECT. The anesthesia provider should consult with the patient’s doctors following these conditions.

Post-seizure myalgia – Patients are likely to have post-succinylcholine myalgia pain.