Electro convulsive therapy
By
Ms. Deepika.K,
[Link] (N)- I Year,
Dept Of Psychiatric Nursing,
KGNC.
DEFINITION
ECT is a type of somatic treatment in which
electric current is applied to the brain through
electrodes placed on the foreheads of the patients.
ECT is the artificial induction of a grandmal
seizure through the application of electrical
current to the brain.
HISTORY
In 1938, Italian psychiatrist UgoCarletti and
Lucio Bini, Rome for the first time administered
ECT to a man of 39 years old man.
INDICATIONS
Major severe depression
Severe catatonic stupor
Severe psychosis
Mania
Schizophrenia
Schizo-affective
Postpartum psychosis
Organic mental disorders.
CONTRAINDICATIONS
Absolute
Increased intra cranial pressure
Relative
Severe hypertension
Recent myocardial infarction
Cerebro vascular accident
Severe pulmonary disease
Retinal detachment
Brain tumors
Pneumonia
Person with pacemaker
Meningitis
Encephalitis
METHODS
Direct ECT
Absence of muscular relaxation and general
anesthesia, other than this all the procedures are
same.
Indirect ECT(Modified ECT)
ECT is modified by drug induced muscular
relaxation and general anesthesia.
TYPES /ATTACHMENT OF ELECTRODES
Bilateral ECT:
In bilateral ECT electrodes are placed on each
side one inch above the midpoint of an imaginary
line connecting the outer canthus of the eye and
tragus of the ear.
Unilateral ECT:
The electrodes are placed only on one side of the
head, usually non- dominant side (right side of
head in right handed individual and vice versa).
Unilateral ECT is safer with much fewer side
effects particularly those of memory impairment.
SIDE EFFECTS
Memory impairment
Drowsiness, confusion and restlessness
Poor concent6ration, anxiety
Headache, weakness/fatigue, backache, muscle
aches
Dryness of mouth, palpitation, nausea, vomiting.
Unsteady gait
Tongue bite and incontinence
PROCEDURE
Administration:
It is usually administered in hospitals, clinic or in nursing
homes.
It is usually administered in the morning hours.
Consent
Informed consent for ECT must be obtained from patients,
preferably in writing.
If patient’s psychological state does not permit, thus consent
may be obtained from patient’s legal guardian.
Parameters of electrical current applied
Voltage: 70 to 120 volts
Duration: 0.7 to 1.5 seconds
CONTD….
Types of seizure produced
Grandmal seizure- tonic phase lasting for 10 to 15 seconds
Clonic phase lasting for 30-40 seconds
Frequency and total number of ECT
Frequency: 3 times per week or as indicated.
Total number: 6 to 10; up to 25 may be preferred as
indicated.
Treatment facilities
A pleasant, comfortable waiting room- pre ECT room.
ECT room which should be fully equipped.
A well-equipped recovery room.
EQUIPMENTS NEEDED
ECT machine
ECG machine
Anesthetic instruments such as boyle’s apparatus
Laryngoscope and suction apparatus
Pulse oximeter
Defibrillator
Beds with side rails
Monitor and Addition cables and electrodes
Electrode jelly
Bite blokes
Assorted airways
Masks
ECT TEAM
Psychiatrist
Anesthetist
ECT nurses
Trained attenders
MEDICINE TRAY AND INJECTABLE TRAYS
Sodium penthanol 1-5 mg/kg body weight (150-200mg)
Suucinyl choline 0.75 mg/kg body weight (30-50 mg)
Anti-cholinergic drug- inj. atropine sulphate 0.6 mg
IV fluids such as NS, RL, etc,
Tourniquet
Autoclaved syringes and needles
Spirit swab
Pre ECT Preparation
Check the record for recent physical examination and a routine
laboratory work.
Check for signed consent form
Involve the family as much as possible to inform them and about
their fears and anxieties.
Communicated positive feelings about the procedure to the family
and patient
Discourage cigarette smoking just before the procedure to avoid
increased difficulty in managing pulmonary secretions during
treatments.
Ensure the liquid and solids are not taken 6 hours before treatment
Remove dentures, metal hair clips, glasses, jewelries from the
patient and dress them in loose clothing.
CONTD,,,
Have client evacuate bowel and bladder.
Fitness for ECT is evaluated by the anesthetist before
the procedure
Withhold anticonvulsants before ECT
Cerebral dominance is decided by the preferred hands,
legs and eyes.
Lithium should be stopped before ECT to prevent
cognitive morbidity.
Patient should be advised to keep the scalp oil free.
PROCEDURE
The patient lies supine on the table. The clothing is
loosened; oxygen (100%) is given through a face mask.
The anesthetic agents (thiopentine 3-5mg/kg body
weight) and atropine are injected followed by muscle
relaxant using separate syringes.
During anesthesia, oxygenation is maintained by
intermittent positive pressure ventilation until
resumption of spontaneous and regular respiration.
A bite block is inserted prior to situation, to protect the
tongue.
CONTD….
The chin of the patient is held up to keep the jaw tight
against the bite block.
Vital signs should be monitored.
Pulse oximeter helps to determine adequate ventilation
and oxygenation before and after the procedure.
Excessive secretion should be cleared by suction.
The patient is then shifted to the recovery room and
should be remain under observation till the patient is
ambulant.
ROLE OF THE NURSE
Pre-treatment evaluation
Detailed medical and psychiatric history,
including history of allergies.
Assessment of patient's and family's knowledge
of indications, side-effects, therapeutic effects
and risks associated with ECT.
An informed consent should be taken. Allay any
unfounded fears and anxieties regarding the
procedure.
Assess baseline vital signs.
Patient should be on empty stomach for 4-6hours
prior to ECT.
CONTD…
With hold night doses of drugs, which increase seizure
threshold like diazepam, barbiturates and
anticonvulsants, Withhold oral medications in the
morning.
Head shampooing in the morning since oil causes
impedance of passage of electricity to brain.
Any jewelry, prosthesis, dentures, contactless, metallic
objects and tight clothing should be removed from the
patient's body.
Empty bladder and bowel just before ECT.
Administration of 0.6 mg atropine IM or SC30 minutes
before ECT, or Adjust before ECT.
INTRA-PROCEDURE CARE
Place the patient comfortably on the ECT table in supine
position.
Stay with the patient to allay anxiety and fear.
Assist in administering the anesthetic agent(thiopental
sodium 3-5 mg/kg body weight)and muscle relaxant
(1mg/kg body weight ofsuccinylcholine).
Since the muscle relaxant paralyzes all muscles including
respiratory muscles, patent airway should be ensured and
ventilator support should be started.
Mouth gag should be inserted to prevent possible tongue
bite.
The place(s) of electrode placement should be cleaned
with normal saline or 25 percent bicarbonate solution, or
a conducting gel applied.
Monitor voltage, intensity and duration of electrical
stimulus given.
Monitor seizure activity using cuff method.
100 percent oxygen should be provided.
During seizure monitor vital signs, ECG ,oxygen
saturation, EEG, etc.
Record the findings and medicines given in the patient's
chart.
POST-PROCEDURE CARE
Monitor vital signs.
Continue oxygenation till spontaneous respiration starts.
Assess for post-Ictal confusion and restlessness.
Take safety precautions to prevent injury (side lying
position and suctioning to prevent aspiration of
secretions, use of side rails to prevent falls).
If there is severe post-Ictal confusion and restlessness,
IV diazepam may be administered.
Reorient the patient after recovery and stay with him
until fully oriented.
Document any findings as relevant in the patient's
record.
