Mr. N.Loganathan M.Sc (N),

Lecturer,

Dept of psychiatric nursing,

COMS-TH.

Electroconvulsive therapy (ECT), also

known as

is a well established, albeitis a well established, albeitcontroversial psychiatric treatment in whichseizures are electrically induced inanesthetized patients for therapeutic effects.

ECT was first introduced by Italian psychiatrist UgoCerletti and Lucio Bini in April 1938.

Insulin coma therapy and pharmacoconvulsivetherapy were replaced by ECT.

Insulin coma therapy was introduced by the

German psychiatrist Manfred Sakel in 1933.German psychiatrist Manfred Sakel in 1933.

Pharmacoconvulsive therapy was introduced in

Budapest in 1934 by Ladislas Meduna.

In 1974, the APA’s council on research anddevelopment appointed a task force on ECT.

The APA task force on ECT, in 1976, gave its reportwhich provided clear guidelines for use of ECT.

1. “ Artificial induction of a grand mal seizure (tonic

phase 10-15 sec, clonic phase 30-60 sec) throughthe application of electrical current to the brain, thestimulus is applied through electrodes which are

placed either bilaterally in fronto-temporal region orplaced either bilaterally in fronto-temporal region or

unilaterally on the non dominant side.”

or

2. ECT is a physical/somatic therapy in which the help

of two electrodes, current is passed through the

temporal region in between the two hemispheres of

the brain, to produce a grand mal type of seizure.

: 70-120 volts

(The usual amount of currentpassed in ECT is 200-1600mA)passed in ECT is 200-1600mA)

: 0.7-1.5 sec

ECT relief very severe depressive illnesses whenother treatments have failed.

ECT has saved patient’s live because 15% ofpeople with severe depression will killpeople with severe depression will killthemselves.

ECT works faster than all antidepressants drugs.

Major Depression w/ or w/o psychotic features.

Bipolar disorder - manic or depressed phase.

Acute or Catatonic Schizophrenia.

Some studies have shown efficacy in treatingSome studies have shown efficacy in treatingOCD, Delirium, Chronic pain syndromes, andintractable seizure disorders.

AbsoluteIncreased ICP

Relative

1. Cardiovascular problems

Coronary artery disease, HTN, Aneurysms,Coronary artery disease, HTN, Aneurysms,Arrhythmias

2. Cerebro vascular effects

Recent strokes, Space occupying lesions,Aneurysms

3. Severe pulmonary disease

TB, Pneumonia, Asthma

The exact mechanism of action is notnot knownknown.

One hypothesishypothesis statesstates that ECT possiblyaffectsaffectsaffectsaffects thethethethe catecholaminecatecholaminecatecholaminecatecholamine pathwayspathwayspathwayspathways betweenaffectsaffectsaffectsaffects thethethethe catecholaminecatecholaminecatecholaminecatecholamine pathwayspathwayspathwayspathways betweendiencephalon (from where seizure generalizationoccurs) and limbic systems (which may beresponsible for mood disorders), also involvingthe hypothalamus.

DIRECT ECT

In this, ECT is given in the absence ofanesthesia and muscular relaxation.

This is not a commonly used methodnow.now.

Electrodes are placed on the side of apatient’s head just above the temples.

The patient is given anesthetic injectionsand a muscle relaxant to stop muscleand a muscle relaxant to stop musclecontractions that can lead to brokenbones.

A small electric current is passed throughthe brain.

Bilateral

Most common, most effectiveand most cognitivedysfunction.dysfunction.

Each electrode placed 2.5 – 4cm (1-1.5 inches) on themidpoint on a line joining thetragus of the ear and thelateral canthus of the eye.

Unilateral

less cognitive effect,may be clinically lesseffective.

Electrodes are placedonly on one side ofhead usually nondominant side.

ECT is usually given 3 times a week, reduced to

twice a week or once a week once symptoms begin torespond. This limits cognitive problems.

Treatment of depression usually consists of 6-12treatments.treatments.

Psychosis and mania upto (or sometimes more than)

20 treatments.

Catatonia usually resolves in 3-5 treatments.

Psychiatrist

Anesthetist

Trained nurses

Nursing aidsNursing aids

ECT assistant

Inj. Atropine (0.6mg to 1mg)

Inj. Succinylecholine (1mg/kg/b.wt)

Inj. Sodium thiopendothal (3-5mg/kg/b.wt)

A pretreatment medication such as atropinesulfate, glycopyrolate is administered

IM 30 min before treatment, (to decrease

secretion and counteract the effect of vagalstimulation induced by ECT).

A short acting anesthesia (the patient should beA short acting anesthesia (the patient should beunconscious when the ECT is given).

Muscle relaxant (to prevent muscle contractionduring the seizure reduction of possibility offracture or dislocated bone).

Pure oxygen before and after treatment

3 rooms

1. Waiting room

2. ECT room2. ECT room

3. Recovery room

Articles for anesthesia

Suction apparatus

Face mask

Oxygen cylinder

Tongue depressor

Mouth gag

Resuscitation apparatus

Full set of emergency drugs, ECT drugs

Defibrillator

Description of the procedure.

Explain why the procedure isrecommended.�Alternative treatment�Alternative treatment

�Benefits may be transient

�Behavioral restrictions

�Voluntary treatment

�Implies consent for emergency treatment

�Risks major and minor

Time 10-15mit (or more time preparation and recovery)

Intravenous (IV) catheter

Oxygen mask may be givenOxygen mask may be given

Electrodes are placed on the head either unilateral or bilateral

Anesthetic is injected into IV

Unconscious and unaware of procedure

Muscle relaxant is injected into IV

Prevent violent convulsions

BP cuff placed around forearm or ankle.To Prevents muscle relaxant fromparalyzing, so doctor can confirm seizurewith movement of hand/foot.

Electric current is sent through electrodesto brain.to brain.

Seizure lasts 30-60 seconds.

Few min later, anesthetic and musclerelaxant wear off.

• Pre ECT care

• Intra procedure care

• Post procedure care

Informed consent

Fully explain the risks and benefits of procedureand answer questions from patients or relatives.

Information sheets.Information sheets.

Reduce patients anxiety and help establish goodrelationship (nurse-patient, doctor-patient).

Administration of drugs.

Check patient record.

Cont…Explain procedure.

Keep patient on NPO 6-8 hours before ECT.

Discourage smoking just before ECT.

Remove artificial dentures and articles.

Vital signs.Vital signs.

Ensure emergency articles are accessible.

Emotional support.

Transfer patient to ECT room with necessaryrecords.

Checks patients identity.

Check patient is NPO and has emptied their bowels andbladder prior to coming to treatment room.

Check patient is not wearing restrictive clothing andjewellery/dentures have been removed.jewellery/dentures have been removed.

Consult ECT record of previous treatments(includinganesthetic problems).

Ensure consent form is signed appropriately.

Check no medication that might increase or reduceseizure threshold has been recently given.

Check ECT machine is functioning correctly.

Reassurance & support.

Place patient in supine position.

Necessary drug administration.

Mouth gag.Mouth gag.

Apply upward pressure to mandible.

Oxygen administration.

Clean the scalp with normal saline.

Prevent fall, fracture, dislocation

Remove the mouth gag after seizure occurred

Suck the oral secretion & apply O2 mask

Shift client post – procedure room.

Check vital signs every 15 min.

Administer drugs if patient is aggressive / violated /confused.confused.

If respiratory difficulty continue oxygen.

Provide side rails.

Be with the patient.

Documentation.

Reorient the client after recovery.

ImpairmentImpairmentImpairmentImpairment ofofofof cognitioncognitioncognitioncognition

Period of confusion immediately after ECT

May not know where you are or why you arethere

Generally lasts few minutes to several hours

MemoryMemoryMemoryMemory losslosslossloss

May forget weeks/months before treatment, duringtreatment or after treatment has stopped

Usually improves within couple of months

Permanent in relatively rare cases

MedicalMedicalMedicalMedical complicationscomplicationscomplicationscomplications

Heart problems

Small risk of death

PhysicalPhysicalPhysicalPhysical symptomssymptomssymptomssymptoms

NauseaNausea

Vomiting

Headache

Muscle ache

Jaw pain

People with serious mental illness who are at riskof self harm or are thought to be risk to otherpeople can be sectioned under the mental healthact.act.

This means they can be taken to a place ofsafety, usually a secure psychiatric unit, and giventreatment against their will.

They may not consent to the treatment they aregiven and may be held against their will.