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Psychiatry

ECT Nurse Education

A.   Review PRE-OP anesthesia work-up results and complete checklist.

  • Patient needs to have BMP, Ca, Mg, CBC, urinalysis, CXR (60+ years old), EKG (40+ years old) completed.  Some may require cardiology consult and clearance before starting ECT.
  • UTIs need to be treated.  Infections have profound psychiatric implications including confusion and delirium.
  • Consent for ECT 

There are specific legal parameters that protect patients from having ECT against their will.  Patients must give informed consent for themselves; families cannot give permission even if they have medical power of attorney.  If patients are unable to provide consent, then families or physicians can petition for court-ordered ECT.

  • The patient will be NPO after midnight.
  • IV access must be obtained, preferably the left arm. Patients with ports need to have port accessed with running IVF’s on call.
  • Elderly patients:  Consider IVF of NS or LR
  • Diabetic patients:  Consider D51/2 NS.  We would need to know their 6am accu-check.
  • No gum.  This increases gastric secretions and increases aspiration risks.
  • Remove dentures but let patients come with glasses to aide in signing anesthesia consent.
 

B.   Pre- operative ECT Issues

  • The night before ECT, medications with anticonvulsant properties should NOT be given after 5pm (i.e., valium, ativan, xanax, restoril, ambien, depakote, dilantin).
  • The morning of ECT nurse will pre-medicate with liquid Tylenol or Motrin at 8am.  ECT headaches are common so treat prophylactically. Patients who should be given daily cardiac/antihypertensives should be administered such at 8am with sips of water.
  • Our outpatients are done before inpatients; call unit for your patient’s approximate treatment time. We call for patient 20 minutes beforehand and we appreciate a prompt transport to our area.
  • AICDs must be temporarily turned off prior to treatment.  We will work with the EP lab in our treatment area to accomplish this. Please notify us if this applies.
  • Questions can be answered by calling 412-858-2707.
 

C.   What Can My Patient Expect?

Treatment room

  • Patient will sign an anesthesia consent each treatment day

  • Patient is connected to dinemap, pulse oximetry and EKG monitor
  • Nerve stimulator is applied to left leg.  This allows nurse to know when patient is sufficiently paralyzed.
  • Manual blood pressure cuff is applied to right leg to provide a tourniquet effect (no anectine will reach the right foot and motor seizure will be visible).
  • Paddles are applied to patient’s head (size of a quarter) and are held in place by a strap that is wrapped around patient’s head. There are 3 different placements that describe the area of the brain experiencing the seizure.  These are: right unilateral, bi-frontal, and bi-temporal.  Most inpatients receive bi-frontal or bi-temporal
  • Patient verification is completed.
  • Sleeping agent is given, usually Brevitol.  Patients often report that the Brevitol burns going in the IV.
  • Anectine is the paralyzing agent we use.  Rapid onset, short duration.
  • Intubation is not necessary since the patient is paralyzed for less than 5 minutes, a bag and mask system are utilized.
  • Seizure quality - not duration - determines efficacy of therapy.  We monitor patient’s EEG during treatment.
  • Once the patient is breathing effectively on their own we move them to the recovery room.

 

Recovery room

  • Patients are monitored for at least 30 minutes
  • Discharge criteria include: B/P within 20% of baseline, room air saturations at baseline, following commands, no post-op nausea, and oriented to person, place and time.
  • Some patients experience incontinence while having their seizure.  You may be asked to apply a diaper to your patient.
  • Some patients experience a post-seizure delirium in the recovery room.  This can encompass crying and restlessness to a more extreme agitation. This is treated with versad and haldol.

 

D.   POST-OP

  • Safety concerns:  Patient at fall risk for the next hour.  Patient will need to be supervised their first time OOB.
  • Somatic complaints:  Headaches, stomach upset and muscle soreness are common post- procedure complaints. Utilize prn medications as needed.
  • Be supportive, especially if patient is experiencing cognitive changes.  Notify us if your patient becomes confused or delirious.  Treatments might need to be postponed.  Risk of confusion increases based on placement.  Right unilateral causes the least amount of confusion, bi-frontal can create more, bi-temporal has the most probability of confusion and memory loss.  Conversely bi-temporal works faster than bi-frontal or RUL.    
  • VSS every 30 minutes x3
  • Resume previous diet.
  • Bedside report will be given.
  • Most patients receiving ECT will also be managed with antidepressants.

 

References

  1. Krishnan KR, Hays JC, & Blazer DG (1997).  MRI defined vascular depression  Am J Psychiatry 154:497-501.
  2. Krishnan KR (2002).  Biological risk factors in late life depression.  Biol Psychiatry 52:185-92.
  3. Alexopoulos GS (2005).  Depression in the elderly.  Lancet 365:1961-70.
  4. Mayberg HS (2003).  Modulating dysfunctional limbic cortical circuits in depression, toward development of brain based algorithms for diagnosis and optimized treatment. Br Med Bull 5(197):193-207.
  5. APA Task Force (1987).  Dexamethazone suppression test: An overview of its current status in psychiatry.  Am J Psychiatry 144:1253-1262.
  6. Stahl S (2008).  Depression and bipolar disorder.  Essential Pharmacology; March.
  7. Depression Guideline Panel. (1999).  Depression in primary care. Vol. 2 Treatment of major depression. Clinical Practice guidelines. No. 5 Rockville, MD Agency for Health Care Policy and Research.
  8. Freeman MP (2009).  Antenatal depression: Navigating the treatment dilemmas.  Am J Psychiatry 164:1162-1166.
  9. Green MF (2007).  Serious concern or much ado about little?  N Engl J Med  356:2732-2733.
  10. Toh S, Mitchell AA, & Louik K (2009).  SSRI use and risk of gestational hypertension.  Am J Psychiatry 166:328.
  11. Parsing D (2009).  Risk for the use of SSRI in Pregnancy.  Am J Psychiatry, 166:3.
  12. Winer KL, Sit D, Hanusa BH, Moses-Kolko EL, Bogen DL, & Hanker DF (2009).  Major depression and antidepressant treatment: Impact on pregnancy and neonatal outcomes.  Am J Psychiatry 166: 557-566.
  13. Kessler RC, Berglund P, Demler O, Jin R, & Koretz D (2003).  National comorbidity survey replication: The epidemiologic major depressive disorder: Results from National Comorbidity Survey Replication. JAMA 289:3095-3105.
  14. Refhuis J, Rasmussen SA, & Friedman JM (2006).  SSRI and persistent pulmonary hypertension of newborns; reply of Chambers C, Hernandez-Diaz S, & Mitchell AA.  N Eng J Med  354:2188-2190.
  15. Parry BL (2009).  Assessing risk and benefit: To treat or not to treat major depression during pregnancy with antidepressant medications. Am J Psychiatry 166:5.
  16. Andersohn F, Schade R, Suissa S, & Garge E (2009).  Long-term use of antidepressants for depressive disorders and the risk of diabetes mellitus.  Am J Psychiatry 166:591-598.
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