Electroconvulsive Therapy

Airway: Nil
Access: 22G or 20G IVC
Pain: May result in post-ictal headache
Position: Supine or sitting
Time: Minutes
Blood loss: Nil
Special: Typically remote setting with paucity of resuscitation staff available

ECT involves transcutaneous electrical stimulation of the brain to produce generalised seizures in order to treat certain psychiatric disorders. ECT is:

Used to treat severe depression, mania, and catatonia
Performed regularly (e.g. twice weekly) for 3-4 weeks, and then usually ceased
Dosing and issues can be reliably deduced from reviewing old anaesthetic charts.
Associated with a significant physiological response
- Arrhythmias and MI are the primary cause of ECT-related mortality
- Initial parasympathetic discharge associated with electrical stimulus
  Bradycardia or, rarely, asystole may occur.
- Subsequent dominant sympathetic response
  Large ↑ in SBP, moderate ↑ in HR, tachyarrhythmias.

Preoperative

Assessment: * CVS Comorbidities * Recent MI
Absolute contraindication if ⩽3 months. * Recent aortic aneurysm, angina, CHF, thrombophlebitis.
Relative contraindications. * Presence of PPM
Magnet should be available. * Underlying psychiatric illness

Intraoperative

Usually can be performed with brief sedation and sub-intubating dose muscle relaxation without a secured airway, e.g.:

Preparation: * Standard ANZCA monitoring * IV access

Induction: * Preoxygenation * Induction with propofol (1-2mg/kg) * Partial relaxation with suxamethonium (e.g. 0.6-1mg/kg)
Adequate muscle relaxation is essential to prevent * Teeth damage from masseter spasm
Most common injury. * Muscular damage or fractures from seizures. * Assisted mask ventilation may be required until spontaneous ventilation resumes * Insertion of bite block

Maintenance: * Labetalol or esmolol may be required for treatment of hypertension * Atropine may be required for treatment of bradycardia

Emergence: * Altered mental status
Non-memory cognitive functions are rarely affected, however common side-effects include: * Confusion * Agitation * Violent behaviour * Amnesia * Headache * Myalgia * Nausea and vomiting * Amnesia
Period of anterograde and retrograde amnesia around seizure. Rarely may become prolonged with long durations of ECT treatment.

Postoperative

Destination: * Recovery management important in off-the-floor areas

Specific: * Postictal headache
Due to dilation of meningeal vessels. * Haemodynamic upset
May last minutes to over an hour post-procedure:

References

Uppal, Vishal, Jonathan Dourish, and Alan Macfarlane. ‘Anaesthesia for Electroconvulsive Therapy’. Continuing Education in Anaesthesia Critical Care & Pain 10, no. 6 (1 December 2010): 192–96. https://doi.org/10.1093/bjaceaccp/mkq039.