ECT: Anesthesia Considerations

Updated July 28, 2014
Author: N Boulanger

Description: Evaluation & patient management for patients having ECT


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Cardiac Co-morbidities

Patients with the following cardiac conditions must have a cardiology consult as well as a formal anesthesia pre-operative consult which is signed off by a member of the anesthesia staff prior to having ECT:

ECT treatments should be delayed a minimum of six weeks after a patient sustains a myocardial infarction

Reference: ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery 2007


Anticoagulants (warfarin, etc.)

Patients on chronic warfarin therapy should maintain a PT INR within their therapeutic range, with a maximum acceptable INR of 3.0 for undergoing ECT.

Reference: Mehta, et al. Safety of electroconvulsive therapy in patients receiving long-term warfarin therapy. Mayo Clin Proc. Nov 2004;79(11):1396-1401.


Gastric Outlet Obstruction, Gastroparesis

Any patient being scheduled for ECT who have a history of gastric outlet obstruction must have a GI consult prior to starting ECT treatment.

New pts. carrying a diagnosis of gastroparesis must have a gastric emptying study done prior to having ECT treatment. The lower limit of normal gastric emptying is 90% empty at four hours. Should the potential ECT pt. fall below that, then intubation with RSI for ECT treatments is recommended.


Dialysis Patients & ECT

Patients should have: a K+ of 5.5 or less, measured on the morning of ECT treatment. dialysis within the past 48 hours. a single dose only of succinylcholine should be given. Do not give succinylcholine for ECT to a patient. with acute hyperkalemia for any reason without first correcting the hyperkalemia.
Reference: Thapa, et al. Succinylcholine-induced hyperkalemia in patients with renal failure: an old question revisited. Anes Analg 2000;91:237-41.


DNR (Do Not Resuscitate) Order Suspension Policy for ECT Patients

When consenting most patients who have a DNR Directive, we would have a discussion with the patient and family about perioperative suspension of DNR status, and leave the choice to the patient. ECT patients however, present a unique set of issues (see note from G. Prentice MD 2013).

Therefore, going forward, when obtaining the 6 month anesthesia consent for ECT in a patient who has a DNR directive, please advise the consentor (patient or patient's POA) the policy of the Department is to suspend the DNR Directive for the treatment period.


MAO Inhibitors

MAOI's may be continued during ECT therapy if their use is believed to be clearly beneficial to the patient. Patients should be informed of the small risk of severe hypertension that can occur when patients on MAOI's undergo anesthesia. Anesthetic drugs to avoid: meperidine, ketamine. If one needs to give epinephrine or norepinephrine the dose should be decreased by at least 75%.

Reference: MAOI

 


ECT Candidate Checklist (used by Psychiatrist to determine eligibility)(MS-Word)

Nancy Boulanger 12/12/2013

Beginning mid-December 2013 we're going to begin a system of pre-opping P6 inpatient who will be starting ECT treatments. The P6 psychiatrists will have a checklist (click on highlighted text to open in MS Word) that was developed by Dr. Bokat and her team (with our input) to screen potential ECT patients.

The P6 psychiatrists will be responsible for getting various specialty consults as appropriate using the checklist guidelines. Once they have completed the screening they will call Ann Taylor and give her the pt's name and information, which she will then relay to one of the residents (probably the OB resident, as they will be fielding pre-ops under the new resident night float system).

We've been told this will amount to about 1-2 patient pre-ops per week, since their pre-ops and consents are good for 6 months.
If anyone has any thoughts about items that should be added or changed on the checklist, please let me know.