Anesthesia for Electroconvulsive Therapy - Aim, Guidelines, Drugs Used and Risk

Introduction:

Electroconvulsive Therapy (ECT) is a treatment option for patients with certain mental health conditions like depression that don't respond well to medication. It has been used since the 1930s and involves the patient being given anesthesia and receiving an electrical shock to the brain. This shock causes a seizure, and many patients find that their mental health improves after undergoing these procedures. The anesthesia ensures the patient's safety and comfort during the treatment by keeping their body stable, helping them forget the experience, and relaxing their muscles.

What Are the Anesthetic Drugs Used for ECT?

For people with certain mental health issues like depression that don't react well to medicine, ECT is a therapy option. Different types of medications are used to induce anesthesia and muscle relaxation during ECT. The prevalent ones are Methohexital, Etomidate, Propofol, Ketamine, and Sevoflurane.

1. Methohexital is a barbiturate that helps produce anesthesia for around 4 to 7 minutes. It is considered the standard choice for ECT because it doesn't affect the duration of the seizure and has a minimal effect on the heart.

2. Etomidate is another drug that activates certain receptors in the brain and produces anesthesia for about 5 to 10 minutes. It tends to prolong the seizure, so it's often used with other medications to regulate the heart rate.

3. Propofol also affects the same receptors in the brain but tends to shorten the seizure. It is used when previous seizures are too long and when a rapid onset of anesthesia is needed.

4. Ketamine is a different type of drug that has analgesic properties. It is not commonly used in ECT because it can increase the length of the seizure and stimulate the heart indirectly. However, it is being studied for its potential antidepressant effects.

5. Sevoflurane is an inhaled anesthetic sometimes used to induce anesthesia in ECT. It has a slow onset compared to other drugs but quick recovery. It shortens seizure length more than other drugs but doesn't control the heart rate so additional medications may be used.

What Is the Aim of Anesthetic Management for ECT?

• The patient should have a pleasant and stress-free environment for patients who return for multiple treatments.

• Safety.

• Significantly minimal interference with seizure activity.

• Quickly induce unconsciousness and reduce excessive physical responses.

• Quickly regaining normal breathing and waking up after the procedure.

• Minimizing excessive body movements during the seizure prevents harm by maintaining the ability to observe and assess the seizure's activity.

Who Are Currently Recommended for ECT?

ECT is currently used to treat various mental health conditions, which include:

• Bipolar major depression, including depressed or mixed type.

• Atypical psychosis with unusual symptoms.

• Schizophreniform or schizoaffective disorder has symptoms similar to schizophrenia.

• Major depression, both single or recurrent episodes.

• Schizophrenia, which is a psychiatric disorder distinguished by distorted thoughts and emotions.

• Catatonia is a state of unresponsiveness and abnormal mobilization.

• Other psychiatric conditions like Obsessive-Compulsive Disorder (OCD), severe postpartum depression, pregnancy depression, and psychosis.

There are also some miscellaneous conditions where ECT can be used:

• Parkinson's disease, which affects movement.

• Status epilepticus, prolonged seizure.

• Dementia with behavioral disturbances.

• Segawa syndrome (Dopa-responsive dystonia) is a movement disorder.

• Delirium, a state of confusion and disorientation.

• Neuroleptic malignant syndrome is a life-threatening condition caused by medication.

• Secondary catatonia, caused by an underlying condition.

• Self-injurious behavior in autism.

What Are the Guidelines to Follow in Using ECT?

Patients must adhere to specific rules before receiving Electroconvulsive Therapy (ECT).

• They can consume clear liquids and take medicines prescribed up to two hours before the surgery, but they should avoid solid food for at least eight hours before.

• Patients may be given aspirin, acetaminophen, or ketorolac before ECT to reduce muscle pain.

• During ECT, a mask is used to aid breathing, and a breathing tube may be used in specific situations.

• Obese patients with sleep apnea may benefit from an oral airway to assist breathing.

• Blood pressure, oxygen levels, heart activity (electrocardiography), and carbon dioxide levels (capnography) are all monitored while ECT is administered.

• The duration of muscle activity is measured using either a tourniquet or electromyographic monitoring.

• A bite block protects the teeth and reduces the risk of tongue injury due to muscle contractions during the procedure.

• Vital signs and oxygen levels are monitored for 15 to 30 minutes following ECT.

• A little midazolam or dexmedetomidine may be administered to calm patients down if they become restless or agitated after awakening.

Do Specific Patient Groups Receive General Anesthesia During ECT?

1. For Children and Adolescents:

   1. ECT is generally not commonly used in children and adolescents due to potential risks to their developing nervous system.

   2. Increase the use of ECT in some instances like severe depression, bipolar disorder, schizophrenia, catatonia, autism, and refractory status epilepticus.

   3. When ECT is performed on children, specific considerations are taken into account, such as using medications like dexmedetomidine for anxiety before the procedure. Methohexital is the preferred anesthetic, but ketamine, propofol, and sevoflurane are options.

2. For Pregnant Women:

   1. ECT is effective and safe in treating conditions like depression, bipolar disorder, and schizophrenia during pregnancy.

   2. Aspiration and early labor are two dangers that could affect the mother and the fetus.

   3. Methods like laryngeal mask airway or endotracheal intubation can help with breathing difficulties in certain situations.

   4. The administration of specific anesthetics may decrease the likelihood of uterine contractions.

   5. Emergency cesarean sections may be required in exceptional circumstances.

3. COVID-19 Era:

   1. ECT units have experienced difficulties with screening, wearing personal protective equipment, and upholding a safe environment during the COVID-19 outbreak.

   2. During the procedure, controlling the patient's airway has proven to be the most challenging difficulty.

   3. ECT involves close supervision and can increase the risk of spreading the virus through the patient's oral and airway secretions.

   4. To avoid this, ECT is performed without mask ventilation and using specialized airway devices with filters to reduce the risk of viral transmission.

Who Is at Risk in Using ECT?

• Pheochromocytoma (a type of tumor) and elevated intracranial pressure with a mass putting pressure on the brain.

• Increased pressure in the brain or eyes is also not well tolerated in patients with conditions like intracranial mass, retinal detachment, or intracerebral aneurysms.

• Patients who suffer from pheochromocytoma, cardiac arrhythmias, bleeding disorders, or heart issues may not withstand the changes in blood pressure and heart rate during ECT.

Conclusion:

The anesthesia used during ECT plays a crucial role in its effectiveness and safety. ECT is a reliable and safe treatment for various mental health conditions, and its approved uses have expanded over time. During ECT, the anesthesia should ensure deep sleep, relax muscles to prevent injury, have minimal impact on seizure duration, and allow for quick recovery. The patient's needs and health conditions will determine which anesthesia option is best for them.