Ect part 3

Under supervision
Of
DR: AMR KAMAL

The purpose of the electrical
stimulus in ECT is to induce a
generalized grand mal type of
seizure.
The seizure produced is not an all-
or-nothing phenomenon.

seizures can be monitored both by
observing
the ictal motor response
(convulsion)
monitoring ictal EEG activity
(the electrophysiological activity of
the brain occurring during the
Seizure) , ( use muscle relaxant)
EEG seizure activity is typically 10–20
seconds longer
.

The intensity of convulsive motor
activity is influenced by two factors:
 the dose of muscle relaxant (generally
succinylcholine)
 intensity of the electrical stimulus

Most physicians use a practice
known as the cuff technique to allow
the motor convulsion to be monitored
after giving muscle relaxant

the cuff technique to allow the motor
convulsion to be monitored.
Just before the muscle relaxant is
administered, a blood pressure cuff
is placed on a distal extremity(wrist
or ankle) and inflated well above
the systolic pressure (about 200 mm
Hg).
This activity procedure prevents the
flow of muscle relaxant distal to the
cuff and enables unblocked muscles
to manifest convulsive

.
The ECT stimulus and the induced
seizure both exert cardiovascular
,effects
primarily through the direct neuronal
transmission fromthe hypothalamus
to the heartvia parasympathetic tracts
(the vagus nerve)and sympathetic
tracts (primarily in the spinal cord).
The activation of the parasympathetic
system causes adecrease in blood
pressure and heart rate. t

The cardiovascular response pattern
can best be described
as a four-stage process,
involving shifts from parasympathetic
to sympathetic to parasympathetic
to sympathetic phases The
activation of the sympathetic system
produces opposite effects: blood
pressure, venous pressure, and heart
rate increase, resulting in an overall
acceleration of cardiac output

MISSED SEIZURE
INADEQUATE SEIZURE
PROLONGED SEIZURE

Missed Seizures
when no motor and ictal evidence of
seizure activity is seen following the
electrical stimulus,

Causes
 Insufficientstimulus intensity
 Premature termination of stimulus
 Poor electrode contact with the skin
 Patient’s high intrinsic seizure
threshold
 Hypercarbia due to hypoventilation

NB the patient should be
restimulated within 20–30 seconds,
using a 25%–125% increase in
stimulus intensity

Seizures of “inadequate” duration

 Restimulation (should be delayed for
30–60 sec)

 Evidence suggests that missed or inadequate
seizures occurring at maximum stimulus
intensity decrease the likelihood that the
patient will respond to treatment.
 When these phenomena occur, efforts should
be directed at:
 Decreasing the seizure threshold
 Increasing the seizure duration
 or both
(Krystal et al. 2000).

Presently, four methods of seizure
enhancement are commonly used:
 Decreasing the anesthetic dosage (if possible
and if the agent used has anticonvulsant
properties)
 Hyperventilation (inducing hypocarbia)
 Caffeine (and other adenosine receptor
antagonists)
 Ketamin anesthesia

(Weiner et al. 1991).

Seizure activity lasting longer than 3 minutes
(American Psychiatric Association 2001).

1) At the first treatment
2) During benzodiazepine withdrawal
3) In patients in whom proconvulsant
medications (e.g., caffeine,
theophylline) and lithium
4) In patients who have epilepsy or
preexisting paroxysmal EEG activity

 Inaddition to making the decisions of ECT,
the practitioner must also make a
determination of:
 How frequently the seizures should be induced
(i.e., the interval between treatments)
 How many treatments should be administered in
the treatment course.

 Most ECT treatments are given three
times a week whereas in other
countries they may be administered
twice weekly.
 Increased frequency is associated
with a more rapid response, it may
also be associated with increased
cognitive side effects
 A three-times-weekly schedule
appears to be an acceptable

A total number of treatments averaging
between six and twelve but no exact number

 The number of treatments will vary
according to the individual and severity of
medical condition.

After the conclusion of a course of ECT, three
options are available for continued
treatment:
r Administration of applicable psychotropic
medications (e.g., antidepressant,
antimanic, and/or antipsychotic agent)
r Administration of continuation ECT
f Psychotherapy combined with either
medication or continuation ECT.

A fourth option, involving the use of both
continuation medication and ECT, may be
necessary for patients with a history of
failure of prophylaxis with either treatment
alone.

Multiple psychiatric disorders respond to
maintenance ECT including:
 major depressive disorder
 psychotic depression
 bipolar disorder
 and schizoaffective disorder
(Birkenhager et al. 2005).

 Use of maintenance ECT in the geriatric
population is also well documented
(Thienhaus et al. 1990).

 Particular
forms of schizophrenia
(catatonia, refractory positive symptoms)
may also be responsive to the
combination of ECT and antipsychotic
medication
(Shimizu et al. 2007; Suzuki et al. 2006)

A typical arrangement would involve weekly
ECT for 4 weeks, then incremental increases
in the interval between ECT treatments to
once a month over the next few months
(Clarke et al. 1989).

‫‪ ‬مــادة )03( :‬
‫ل يجوز إجراء العلج الكهربائى اللزم لحالة المريض‬
‫النفسى إل تحت تأثير مخدر عام وباسط للعضلت ،‬
‫ويتعين الحصول على موافقته على ذلك كتابة بناء‬
‫على إرادة حره مستنيره وبعد إحاطته علما بطبيعة‬
‫هذا العلج والغرض منه ،والثار الجانبيه التى قد‬
‫تنجم عنه، والبدائل العلجيه له، فإذا رفض المريض‬
‫الخاضع لجراءات الدخول والعلج اللزامى هذا النوع‬
‫من العلج وكان لزما لحالته فرض عليه بعد إجراء‬
‫تقييم طبى مستقل.‬

Ect part 3

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Ect part 3