ECT - Exam 6 Flashcards by Liz Jarzembowski

ECT
-PNS response

-bradycardia
-HoTN
-bradydysrhythmias

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ECT
-SNS responses

-tachycardia
-HTN
-tachydysrhythmias

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ECT
-cerebral responses
-misc responses

-increased cerebral blood flow
-increased ICP

-increased IOP
-increased intragastric pressure
-hypoventilation

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Acute ETC pts receive _ treatments per week

-can need several treatments until reaching maintenance phase

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T/F Clinical improvement is usually seen with ECT within first few treatments

true

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ECT
-indications

-mania
-MDD resistant to other treatments
-catatonia
-vegetative dysregulation
-inanition
-suicidal drive
-schizophrenia with affective disorders
-some Parkinson’s disease conditions

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3 positions of electrodes in which ECT is performed

-right unilateral
-bitemporal (bilateral)
-bifrontal

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Which kind of current is sent through the electrodes during ECT?

alternating current (AC)
-not DC lol

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Theories for MOA of ETC involve enhancements of _, _, and _ neurotransmission as well as release of _ and _ hormones, causing antidepressant and _ effects.

-dopaminergic, serotonergic, adrenergic
-hypothalamus and pituitary
-anticonvulsive

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T/F ECT produces anticonvulsive effects

TRUE
-raises seizure threshold
-decreases seizure durations

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ABSOLUTE CI for ECT

-pheochromocytoma
-recent MI (<4-6wk)
-recent CVA (3 months or less)
-recent intracranial surgery (3 months or less)
-intracranial mass lesion
-unstable C spine

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Relative CI for ECT

-angina
-CHF
-cardiac rhythm management device (PPM, AICD)
-severe pulm disease
-major bone fracture
-glaucoma
-retinal detachment
-thrombophlebitis
-pregnant

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Meds used for ECT
-Anticholinergics

-Atropine
0.4-1mg IV or IM

-Glycopyrrolate
0.0005mg/kg IV or IM

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Meds used for ECT
-Anesthetics

-Etomidate
0.15-0.3mg/kg IV

-Ketamine
0.5-1mg/kg

-Methohexital
0.5-1mg/kg

-Propofol
0.75-1.5mg/kg IV

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Meds used for ECT
-DMR

-Sux
0.5-1mg/kg IV

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Meds for ECT
-NDMR

-Cisatracurium
0.15-0.25mg/kg IV (onset 1-2min)

-Rocuronium
0.3-0.9mg/kg IV (onset 1-2min)

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T/F Hypercarbia and hypoxia lengthen seizure duration

false
-shorten

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Monitoring devices necessary for ECT:

-EKG leads
-NIBP
-Pulse ox
-temp
-peripheral nerve monitoring
-highly suggested : EtCO2

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Goals of giving anticholinergics for ECT

-antisialagogue
-prevention of asystole

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How should you assess patients first time for ECT? (thorough, focused)

Thorough preop assessment
-Airway
-Neurologic
-Cardiac disease
-Retinal disease
-Renal disease
-Recent long bone fractures
-GERD/HH

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If a patient has cardiac disease, what must they have before ECT?

Clearance from internist or cardiologist
12 lead pre-procedure
Heart sounds
Hx: CHF, valvular heart disease, recent MI (<6 months), thoracic/aortic aneurysm, pacemaker/AICD, require monitoring

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When should you intubate an ECT patient?

HH/GERD
Full beard
Obesity
Difficult mask fit
Pregnant

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Typical airway mangement for ECT?

Mask
Bite block
Ventilation device (Jackson reese or bag valve mask)

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Should you switch up induction agents between the same patient’s cases?

no, stay consistent

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What drug blunts baroreceptor reflex?

propofol

Why is ketamine problematic for induction for ECT?

-enhanced hemodynamic response -increased ICP

How often do you take the blood pressure in ECT?

Q 1 min

Procedure for ECT

induce tourniquet paralyze ventilate stop for seizure resume ventilation await spontaneous respirations

Side effects of ECT

Muscle aches -NSAIDs Confusion and short-term memory loss Nausea Headache Post-procedure myalgia -Toradol young -Tylenol old

Profound myalgia prevention?

higher dose of sux for next treatment

Pt with Afib must be on a/an _ for ECT

anticoagulant`

Number 1 Cause of problems from ECT

laryngospasm (pulmonary)

What should you do with AICDs for ECT?

turn them off

Typical MR of choice for ECT?

sux

ECT seizure lasts _ - _ sec

30-90

T/F For ECT, you can tell how long a seizure lasts by watching the motor seizure a pt experiences

false, motor seizure is a shorter duration than what is seen on the EEG

What will the patient typically start doing at the end of the ECT seizure?

breathing spontaneously

T/F Hyperventilation increases duration of seizure

true!! -high CO2 and hypoxia SHORTEN seizure duration

Adult fasting guidelines for ECT:

6+ hrs for solids 2 hr liquids

RSI for ECT for _ and _ _ pts

GERD Hiatal hernia

Meds that PROLONG ECT seizure duration

-Alfentanil with Prop -Aminophylline -Caffeine -Clozapine -Etomidate -Ketamine (proconvulsant)

Conditions that PROLONG ECT seizure duration

hyperventilation / hypocapnia

Meds that SHORTEN ECT seizure duration

-Diltiazem (Cardizem) -Diazepam -Fentanyl -Lidocaine -Lorazepam -Midazolam -Propofol -Sevo

Meds that are safe for seizure for ECT (doesn't affect)

-clonidine -precedex -esmolol -labetalol -nicardipine (cardene) -NTG -nitroprusside (nipride)

1st type of cognitive/memory impairment seen after ECT:

postictal confusion -transient restlessness, confusion, agitated -lasts ~30 mins after ECT

3 types of cognitive/ memory impairment seen after ECT:

-postictal confusion -anterograde memory dysfunction -retrograde memory dysfunction

Anterograde memory loss occurs with forgetting _ information

new -for ECT, may forget information for a few days after

Retrograde memory loss occurs with forgetting _ information

old -for ECT, could forget information from weeks/months prior

T/F IV benzo or propofol and/or restraints are appropriate management techniques for postictal agitation

true

Factors influencing cognitive/memories changes seen after ECT:

-frequency of ECT -number of ECT treatments -quantity of energy used -placement of electrodes -type of anesthetics used

Cardiovascular stimulation from ECT may result in:

increased CRMO2 arrhythmias transient ischemic changes

Transient cardiac changes BEFORE ECT should be managed by:

-anticholinergics -IV LA (Lidocaine) -IV narcotics (Remifentanil)

Transient cardiac changes AFTER ECT can be managed with:

-beta blockers -CCB -other antihypertensives

HA/ muscle aches from ECT can be treated with:

-acetaminophen -NSAIDs -ASA

Nausea from ECT can be treated with:

-ondansetron -dolasetron -granisetron -metoclopramide

What electrode placement is associated with fewer cognitive side effects of ECT?

R UL

How strong and long is the current of electricity used for ECT?

70-130 volts for 0.1-0.5seconds

What are the two phases of the ECT treatment and how long does each phase last? How does each phase correlate with autonomic nervous system function

Tonic Phase: 10-15 seconds, PNS Clonic Phase: 30-60 seconds, SNS -longer is better!

What kind of patients should have additional monitoring during ECT?

CHF, Valve disease, MI<6 months, Aneurism, AICD

Goal ETCO2 for ECT

Seizure lasts _______, cumulative treatment time lasts______. What is the normal treatment period?

Seizure: 30-90seconds Treatment: 200-1000 seconds 3 times a week for 2 months

Which is longer, the motor seizure or the seizure seen on EEG?

EEG

How do tricyclic antidepressants work and what are some anesthetic considerations for ECT?

Block re-uptake of catcholamines Sympathomimetic drugs may have an exaggerated effect

How do MAO-I antidepressants work and what are some anesthetic considerations for ECT?

Inhibit the breakdown of catecholamines causing accumulation of them in the nerve terminal Indirect sympathomimetics (ephedrine) can have an exaggerated effect! PICK NEO

How does lithium work and what are some anesthetic considerations for ECT?

Inhibits Na-K-ATPase pump May cause nephrogenic DI Prolongs recovery from GA and NMBDs Can cause EKG changes

How do SSRI antidepressants work and what are some anesthetic considerations for ECT?

Inhibit the reuptake of serotonin only, causing accumulation in the nerve terminal Can cause SIADH with anesthetics

What is a possible treatment for headaches pre-ECT?

Caffeine (prolongs seizure) 5-hydroxytyramine-1 agonist (Sumatriptan)

What are some things that can cause nausea from ECT?

stress and anxiety Anesthetic agent/ seizure itself Air in stomach

What is the preferred induction agent and why? What is the dose?

Methohexital because it potentiates the seizure and has a lower incidence of dysrhythmias 0.5-1mg/kg

What is the second choice induction agent and what is the dose? Possible side effects?

Propofol, 0.75-1.5mg/kg May cause bradycardia and asystole!

What is the dose of penothal?

1.5-3mg/kg

What is the ECT dose of etomidate? What are some positive and negative side effects of it?

0.15-0.3mg/kg Positive: longer seizure, cardiac stable Negative: increased PONV

What NMBD is used if succ is contraindicated and what is the dose?

Mivacurium 0.08mg/kg

What is the ECT does of precedex and what would it be used for?

1mcg/kg over 10 minutes to help control BP without changing seizure duration

Postictal confusion may be caused by increased plasma levels of what? What should be changed to avoid this for the next treatment?

Lactate Increase paralytic dose

What happens to vital signs AFTER ECT?

Decrease for 10-15 seconds first (brady and asystole possible) Then 1 to 5-7 minutes after they increase

After ECT, how much does BP increase? When does heart rate and myocardial oxygen consumption peak? At what point could you see LV dysfunction?

SBP: 30-40% HR/ O2: peaks 3-5 mins LV: 6 hours after

ECT patients should be monitored in PACU for how long?

30 min

When patients die after ECT, what are the common causes? CV and Respiratory

CV: Arrhythmia, MI Resp: aspiration and laryngospasm

Major depressive disorder may be associated with dysfunction in what part of the brain? How does ECT work in this area?

Dorsolateral prefrontal cortices It doesnt! Neither do meds

What is rTMS? How does it compare to ECT?

repetitive transcranial magnetic stimulation Delivers rapid magnetic pulses to specific areas of the brain Vs. ECT: scalp and skull are transparent, fewer cognitive side effects, faster recovery

What is MST? How does is compared to rTMS and ECT?

Higher intensity, frequency, and duration magnetic pulses than rTMS. It can stimulate a seizure in more localized regions. Does NOT produce jaw contractions, DOES produce vital sign changes Faster recovery Increases auditory threshold (earplugs)

What is vagus nerve stimulation

Surgical implant of stimulator into chest - for MDD patients who have failed 4 meds

What is the most common adverse event associated with ECT?

Memory impairment

How does Theophylline impact the seizure threshold?

It lowers it

Why are muscle relaxants used in ECT?

To protect patients from musculoskeletal injury

Which beta blocker is preferred after ECT and what is a possible side effect?

Esmolol Dose dependent bradycardia

If a patient repeatedly has headaches and severe muscle aches, what change may be necessary?

Increased dose of paralytic

Which induction agent is preferred if there is inadequate seizure activity with maximal current?

Etomidate

Which type of muscle relaxants do not offer benefit for ECT?

Non-steroidal muscle relaxants (-onium)

If clonidine is used for BP control with ECT, what is the dose and timing?

0.3-0.5mg 60-90 minutes before

For ECT patients with cerebral anuerysm, which meds should be considered and why?

Nitroprusside (decreases CBF) Atenolol

For patients with SDH or intracranial mass, where should electrodes be placed and what should they be treated with?

Unilateral away from lesion Steroids and diuretics

What is recommended for patients with CAD receiving ECT?

Pre-treatment with beta blockers

What should be done for patients with an AICD prior to ECT?

Temporary fixed rate pacing Deactivate AICD

How does aminophylline affect seizure activity?

Increases duration

What should be considered for pregnant women before ECT?

B2 agonist (tocolytic) Sevo instead of brevitol

ECT - Exam 6 Flashcards

(97 cards)