Anesthesiology considerations for eletroconvulsotherapy

Anesthesiology on ECT

Abstract

Introduction

Electroconvulsive therapy (ECT) is a procedure irreplaceable for severe mental illness. However, ECT is performed under general anesthesia due to adverse effects. This work aims to describe anesthesia patient care to optimize and increase patient safety and ECT efficiency.

Methods

A narrative literature review with the following terms added to the term “electroconvulsive therapy” such as “anesthesiology”, “sedation “, “electroencephalogram”, “pacemaker”, “brain stimulation”, “vagal nerve stimulation” was conducted in different electronic data bases such as MEDLINE, EMBASE, Cochrane Library, and SciELo. We included articles in Portuguese and English after reviewing the abstracts.

Results

ECT promotes a seizure which may lead to fractures, bradycardia, hypertension, hemodynamic decompensation, nausea, vomiting, headache, and confusion. The anesthesiology must provide patient care to warrant 1) an medical history review, 2) select the most appropriate pharmacy to induce general anesthesia, and 3) minimize the most common adverse effects during and after ECT. A previous consult to ECT is recommended and should include a hemogram, leucocytes, coagulation, electrocardiogram, and a recent head computerized tomography should be available to exclude structural central nervous system disorders. Chronic medication doses adjustments of anticonvulsants, antidepressants, antihypertensive, beta-blockers, and insulin therapy may be needed. Pregnants or holders of implantable electronic devices urge for special care. Anesthesia is performed using either propofol or ketamine with remifentanil/alfentanil using a neuroblocking agent such as succinylcholine or rocuronium.  The management of the airway should be made using a conventional mask-bag system in low-anesthetic risk patients. However, in the presence of difficult airway preditors or increased risk of aspiration, orotracheal intubation may be anticipated. During ECT, monitoring is made using an electroencephalogram, electrocardiography, arterial pressure, respiratory plethysmography, capnography, and pulse oximetry. Nausea and vomiting are preventable with ondansetron, headache with paracetamol or ketorolac. Delirium and seizure recurrence should be monitored after ECT.

Conclusion

Anesthesia patient care must anticipate adverse effects of the ECT to warrant appropriate airway management, avoid hemodynamic decompensation and optimize treatment efficiency.