Overview of Anesthetic Considerations in Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is a treatment method often used for individuals who have not seen improvements in their condition with medication. It’s commonly used for a range of mental health challenges such as severe depression, a state of excessive activity or restlessness known as catatonia, bipolar disorder, and other psychiatric issues. The most common reason for someone to receive this treatment is depression.
The concept of ECT was introduced in the 1930s. The treatment involves giving the patient a general anesthesia, meaning they will be unconscious. Then, an external device gives off an electric signal to one or both parts of the patient’s brain to trigger a generalized seizure. This may sound scary, but many patients see positive changes in their mental health following these procedures.
The goal of inducing anesthesia for ECT is threefold – firstly, it helps to keep the patient’s blood flow and heart rate stable. Secondly, it provides amnesia so the patient doesn’t remember the procedure. Finally, it relaxes the muscles, letting the patient undergo the ECT treatment effectively.
Anatomy and Physiology of Anesthetic Considerations in Electroconvulsive Therapy
During electroconvulsive therapy (ECT), a procedure used to treat certain mental health conditions, a special machine is used to create a controlled seizure or electric shock while the patient is asleep from general anesthesia. The length of these seizures can vary. Seizures cause a lot of activity in our automatic nervous system, which is the part of the nervous system that controls functions such as heart rate and digestion.
At first, the part of the automatic nervous system that helps our body rest and digest (called the parasympathetic nervous system) is activated. This can slow down the heart rate, and in some cases, the heart may even temporarily stop beating. This slow heartbeat doesn’t last for long and is quickly followed by a surge in activity from the opposite part of the automatic nervous system (the sympathetic nervous system), causing high blood pressure and an increased heart rate. This can continue for about 5 to 10 minutes after the electric shock has triggered the seizure.
The electric shock and the seizure itself may increase the blood flow to the brain and how quickly the brain uses oxygen, leading to a higher pressure inside the skull. It can also lead to increased pressure inside the eyes and stomach. A medication named Esmolol can be given to counter these effects.
Having seizures does come with some risks. For instance, if the heartbeat becomes too slow or lasts for too long, it could lead to a shortage of blood supply to the heart. There is also the risk of heart events due to the increased demand on the heart and more oxygen use caused by the fast heartbeat and high blood pressure during the seizure. A medication named Glycopyrrolate can be given to slow down the slower heart rate.
Unfortunately, this medication can also make the heart beat too fast, which gets worse during the period of the high heart rate. Patients may also experience post-seizure confusion resembling stroke symptoms or find it hard to think clearly. This can be difficult to distinguish from the effects of the anesthesia used to put the patient to sleep for the procedure.
Why do People Need Anesthetic Considerations in Electroconvulsive Therapy
Electroconvulsive therapy (ECT) always needs general anesthesia in most parts of the world. However, in some developing countries, they might do it without anesthesia because there’s not enough equipment or people with the right training. ECT is a well-established treatment for some mental health conditions.
If someone is dealing with severe psychiatric symptoms or is at risk of suicide, ECT can be used as a first-choice treatment. It can also be a good option when severe depression has led to someone being unable to eat or drink, or becoming very slow and inactive. ECT can offer quick relief for these problems if it works well. For instance, one report suggests that for cases of severe depression, ECT can lead to significant improvement in up to 90% of patients within two weeks.
ECT can also be used for a condition called Neuroleptic malignant syndrome, a rare and life-threatening reaction to certain medications. Another situation where ECT can be particularly useful is when a pregnant woman suffers from severe depression or psychosis, and medications might harm her or her unborn child.
And, if medications are not improving the patient’s symptoms or if the symptoms are getting worse, doctors might turn to ECT as a second-choice treatment. In some instances, ECT can also be used as a potential experimental treatment for conditions like epilepsy, Parkinson’s disease (which affects movement and brain function), depression accompanied by shaking movements, and Tourette syndrome (a condition involving repeated, uncontrollable movements or unwanted sounds).
When a Person Should Avoid Anesthetic Considerations in Electroconvulsive Therapy
Sometimes, a person can’t have ECT (Electroconvulsive Therapy), a type of treatment that involves inducing a seizure under anesthesia, for several reasons. These reasons may require special consideration by the anesthetist, the doctor who makes people sleep during operations, as the induced seizure could affect the patient’s other health problems.
For instance, if someone has a condition called pheochromocytoma, which is a rare tumor of the adrenal glands, or increased pressure in the skull due to a mass, these are absolute reasons why they can’t have ECT.
Other times, conditions that increase eye or brain pressure, like having a brain mass, a detached retina (damage to the back of the eye), or brain aneurysms (bulging blood vessels) could make ECT too risky because their bodies may not accommodate the pressure changes very well.
Patients with heart problems, irregular heartbeats, blood clotting disorders, and pheochromocytoma may also have a hard time coping with the extreme changes in heart rate and blood pressure that can happen during ECT.
Equipment used for Anesthetic Considerations in Electroconvulsive Therapy
Electroconvulsive therapy (ECT), a treatment that involves sending small electric currents into the brain, requires several important preparations. One of the major organizations in this field, the American Society, highlights the importance of several procedures to ensure a patient’s safety during the treatment.
One of these measures is consistent health monitoring. This includes tracking the rhythm of the heart with a device called an electrocardiogram, keeping tabs on the heart rate, oxygen levels, breathing, and blood pressure.
Another measure is using a tourniquet (a device used to apply pressure) on one of the limbs of the patient. This prevents a drug used to relax the muscles during the procedure from affecting that limb. This allows doctors to monitor how effective the convulsions are during the treatment. Convulsions are muscle movements that happen when your brain has a burst of abnormal electrical signals.
Doctors will also use an electroencephalogram (EEG) or processed EEG to track the brain’s activity during these convulsions. An EEG is a test that detects electrical activity in your brain using small, flat metal discs attached to your scalp.
As a safety precaution, emergency breathing equipment should always be on hand. A soft object, known as a bite block, is also used inside the patient’s mouth. This prevents injuries to the tongue and teeth since these types of injuries can occur even when the muscles are relaxed during a convulsion.
Also, tools should be available to provide the patient with oxygen if needed. This could be a simple oxygen face mask or a bag-valve mask, a device that can both provide oxygen and create pressure to stimulate the lungs. Lastly, a suctioning device is also required. This is used to remove any secretions or liquids from the patient’s airway to help them breathe easier. Preparing properly for ECT, like with any other procedure, is crucial for ensuring a safe and successful treatment.
Who is needed to perform Anesthetic Considerations in Electroconvulsive Therapy?
For a procedure like ECT (Electroconvulsive Therapy), which is used to treat certain mental disorders, several medical professionals are needed. These include a psychiatrist (a doctor who specializes in mental health), a nurse, and a healthcare provider trained to do general anesthesia (this person essentially helps you safely “sleep” through the procedure). However, the team involved can change depending on where you live because different states and their specific healthcare authorities have varied rules for who needs to be present.
How is Anesthetic Considerations in Electroconvulsive Therapy performed
Before undergoing a medical procedure that involves anesthesia, a small plastic tube (an intravenous catheter, or IV) is placed in a vein to deliver the anesthesia and any other necessary medication. As the patient breathes in pure oxygen, their vital signs like heart rate and blood pressure are continuously monitored by the healthcare team. Next, the anesthesia medication is given, and the patient’s breathing is increased to lower cerebral blood flow (blood supply to the brain) and make the brain more susceptible to a seizure. A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements, feelings, and levels of consciousness.
Once the patient is fully asleep from anesthesia, a muscle relaxant drug is given. This is to stop the muscles from hurting and to stop muscle injuries during the seizure. To study the motor portion of the seizure (the part of a seizure that causes muscle contraction) in real time, one of the patient’s legs is temporarily blocked from receiving the muscle relaxant with a tourniquet (which is like a strong, elastic band).!
Then, a soft piece is placed between the patient’s teeth to ensure the patient does not damage their mouth during the seizure. After these preparations are done, an electrical stimulus is given to spark a seizure. The goal is to lead the seizure to last anywhere from 25 to 75 seconds. If the seizure lasts less than 15 seconds, it’s usually considered too short. After the procedure, the patient is observed in a recovery area until they are ready to go home or back to their hospital room.
The drugs used to control anesthesia and relax muscles can be different depending on patients’ needs. One common anesthetic is Methohexital, which works on the brain’s receptors to sleep for about 4 to 7 minutes. This time window is ideal for stimulating seizures as a treatment for certain mental health conditions. Another substance is Propofol, used when seizures induced by previous sessions have been excessively long, or when the procedure needs to start as quickly as possible. However, it may decrease the length of the seizure.
Furthermore, doctors prefer using a muscle relaxant named Succinylcholine for this kind of procedure. This drug produces enough muscle relaxation to safely put a breathing tube into the patient’s mouth or nose and down into the windpipe. It generally lasts 5 to 8 minutes, offering extra safety by keeping the muscles relaxed in case of a prolonged procedure.
Rocuronium is a suitable alternative to Succinylcholine. This medication works over longer periods, around 35 minutes, and is an excellent choice if a longer procedure is needed. Regardless of the specific drugs used, the medical team will always strive to use the lowest effective doses to ensure patient safety.
Possible Complications of Anesthetic Considerations in Electroconvulsive Therapy
Although they are not common, complications can sometimes occur during Electroconvulsive therapy (ECT), a procedure often used to treat certain psychiatric conditions. That’s why it’s important that a healthcare professional oversees the patient throughout the procedure. The most typical side effects from ECTs are headaches and difficulties with thinking or remembering things, but these issues usually go away after a while. It can be harder to think clearly right after ECT because of the anesthesia used during the procedure, the underlying mental health issue, and the controlled seizure that is part of the treatment.
With ECT, there’s also a risk of having a seizure that lasts too long, a situation known as status epilepticus. This is a medical emergency and needs quick treatment using medicines like benzodiazepine or propofol until the seizure stops. This type of extended seizure is more likely if a drug called theophylline is used to lengthen the seizure during the treatment.
In some cases, it might be tough for the medical team to help the patient breathe using a mask after they’ve been put to sleep and their muscles have been relaxed for the procedure. Depending on the drugs used, it might be best to let the patient wake up and start breathing on their own again. But in some cases, a tube might need to be put into the windpipe to make sure the patient gets enough oxygen.
There can be issues after the procedure as well, while the patient is in the recovery room. Problems like a heart attack or a stroke are possible although not common. Patients will be closely monitored and if anything unusual is noticed, specialists like a cardiologist or a neurologist will be asked to take a look. Sometimes, people might feel agitated or in pain as they’re waking up from the anesthesia. Other side effects could include temporary paralysis or extreme happiness or excitement, also known as mania.
Also, patients who have certain medical devices in their body need extra care. People with something called a deep brain stimulator, which is used for certain neurological conditions, might need to have their device switched off because it can interfere with the electric current used in ECT. We’ll most likely want to talk this over with a specialist in deep brain stimulation. People with pacemakers or other heart devices can usually have ECT quite safely, and they’ll be monitored with an electrocardiogram (ECG) throughout the procedure. The risk of the electric current from the ECT interfering with the heart device is very low, but we’ll have a magnet on hand in case of emergencies. We will also talk to the patient’s cardiologist to evaluate the severity of their heart condition and assess the risk of giving them general anesthesia.
What Else Should I Know About Anesthetic Considerations in Electroconvulsive Therapy?
Electroconvulsive therapy (ECT) is a treatment approach used when medication is unable to help with serious mental health disorders like depression. The treatment starts to work quickly, though multiple sessions might be required for some people. This therapy has been given under general anesthesia (a state where the patient is put to sleep) since the 1950s. The purpose of anesthesia in ECT is to create a safe setting for an induced seizure to occur.
The perfect anesthesia for ECT should facilitate forgetfulness for the procedure, without seriously affecting the body’s stability or the duration of the seizure. In some instances, an anesthetic that does impact the length of the seizure could be useful if a patient’s previous seizure during ECT was too short or too long. A muscle relaxant protects the patient’s muscles and bones from the intense muscle contraction and relaxation phases of an induced seizure.
There are plenty of options for anesthesia during ECT to accommodate most patients’ needs. Changes can be made by the anesthesiologist, who is trained to respond to potential reactions, patient discomfort, and side effects. Nowadays, it’s rare to give ECT without general anesthesia, except in some developing countries. Uncontrolled seizures during ECT without anesthesia could lead to muscle injuries and post-traumatic stress disorder. Anesthesia prevents physical damage and patient distress, making it safer for the person to undergo a procedure that significantly benefits their mental health condition.
