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Manhattan Psychiatric Center POLICY AND PROCEDURE MANUAL SUBJECT: ECT SECTION: TX DATE REVISED: 3/17/99 NO.: 1500 Transmittal letter no: 99 M PC 02 Page 1 of 10 Approved by: INTRODUCTION Electroconvulsive therapy is one of the most effective and specific treatments available in any field of medicine. However, in order to employ ECT in a successful, safe and frequently life saving manner, especially in medically ill patients, it is necessary to appreciate the characteristics of the ECT responsive patient, be aware of special considerations and precautions which must be taken into account in the use of ECT and to follow certain approved procedures. Characteristics of the ECT Responsive Patient Clinical Predictors of Responsivity: A. Depression (usually requires 6 to 12 treatments) 1. short duration 2. vegetative signs and symptoms, e.g., motor and mental retardation; sleep disturbance, anorexia and weight loss 3. psychotic element, e.g., delusions 4. history of good therapeutic response to ECT in the patient or first degree relative (indications of a good response are: sustained response, small number (6 or less) treatments required; patient is able to leave hospital shortly after completing a course of ECT) 5. where there has been a therapeutic response to Tricyclic antidepressants but therapy with these agents entails an unacceptable risk because of: a. unacceptable side effects of the drugs b. early pregnancy c. Catatonia (usually requires 8 to 16 treatments). Failure to respond to 1-3 treatments should raise questions about other diagnosis, e.g., central anticholinergic syndrome resulting from psychotropic drugs. d. Mania (usually requires 8-16 treatments. In very acute cases (delire aigu), when response to drugs is inadequate; when drugs cannot be used because of unacceptable side effects or in early pregnancy. e. Psychotic Disorders: Especially those with an affective component and those which fail to show an adequate response to drugs. Special Considerations and Precautions: A. Contraindications: Brain tumors and subdural hematomas are the only absolute contraincidations to ECT. The seriousness of other physical illness and of the psychiatric disorder Manhattan Psychiatric Center POLICY AND PROCEDURE 0 MANUAL SUBJECT:ECT SECTION: TX DATE REVISED: 3/17/99 NO.: 1500 Transmittal letter no: 99 MPC 02 Page 2 of 10 must always be carefully weighed against each other (especially when there has been a myocardial infraction within the preceding six months). B. Factors known to Increase the Risk of ECT: 1. Cardiovascular Disease: € Coronary artery disease, especially when there has bee a myocardial infraction within the preceding six months. € Hypertensive cardiovascular disease especially when the BP is markedly elevated and/or bleeding from intracranial or other sites has occurred within six months. € Uncompensated cardiac failure. € Thrombophlebitis. Cardiac pacemakers: Patients should not be given anticholinergic premedication and the services of a cardiologist familiar with the technical intricacies of the pacemaker in question should be obtained. 2. Significant Obesity 3. Compromised Airway 4. Bronchopulmonary Disease 5. Difficulty with general anesthetic procedures, convulsions, hyperthermia (high fever), prolonged apnea or death occurring in first degree relatives complicating general anesthesia are danger signs. 6. Individuals recently treated with anticholinesterase for myasthenia gravis or glaucoma. Because of the danger that succinylcholine may increase intraocular pressure, phopholine iodine or ecthiophate iodine eye drops are to be given to patients with glaucoma before ETC. 7. Hyperkalemia Prone Individuals: Possibility of a hyperkalemia response to succinylcholine should be considered on patients with upper motor lesions, e.g., spastic paralysis from brain injury and those who have been immobilized for extended periods of time. Manhattan Psychiatric Center POLICY AND PROCEDURE MANUAL SUBJECT:ECT SECTION: TX DATE REVISED: 3/17/99 NO.: 1500 Transmittal letter no: 99 MPC 02 Page 3 of 10 8. Individuals Prone to Malignant Hyperthermia: Patients with history of myotonic or dystonic disorders or family history of death during anesthesia are prone to malignant hyperthermia. Such patients are not to be given ECT at this institution. Dantrolene (Dantrium) is to be available for immediate use should this complication occur. 9. Porphyria 10. Psychotropic Drugs: Psychotropic drugs do not appear to pose a special problem with ECT. However, there are some risks involved with MAO inhibitors and Lithium and Tricyclic Antidepressants. a. A motor hazard appears to be the intensification and prolongation of the actions of catecholamine liberated by the peripheralized seizure process. MAO inhibitors should be stopped for ten (10) days or more prior to ECT. In more urgent situations, ECT may be administered after stopping MAO inhibitors for no less than two (2) days. b. Lithium: There is some evidence that Lithium cannot only prolong the paralytic action of succinylcholine but also intensify the memory dysfunction and confusional state occurring with ECT. Further more, the fluctuating character of the intensified confusional state can be associated with EEG evidence of persistent seizure activity. There is also evidence that the therapeutic response to ECT my be reduced in patients concomitantly receiving Lithium. For the above reasons, Lithium should be discontinued as far in advance of the first treatment as possible. When ECT is administered to patients who have been receiving Lithium, careful monitoring of the post-treatment respiratory tidal volume is advisable. c. Tricyclic antidepressants should be discontinued two (2) days before treatment. C. Anticholinergic Preparation: of the sinoatrial node, minimizes the Cholinergic block by preventing significant vagal inhibition possibility that dangerous cardiac dysrhythmia will occur. D. Multi Monitoring Treatment Method of ECT: A blood pressure cuff is inflated above systolic bp prior to administration of succinylcholine. Thrombollus monitoring of physical secure, which correlates closely with therapeutic effect. EEG monitoring is also done to measure electrical response. Electrode Placement: It should be noted that the therapeutic response to nondominant unilateral ECT may, at times, Manhattan Psychiatric Center POLICY AND PROCEDURE MANUAL SUBJECT:ECT SECTION: TX DATE REVISED: 3/17/99 NO.: 1500 Transmittal letter no: 99 MPC 02 Page 4 of 10 be less than occurring with the bilateral placements. F. Pre-ECT Work Up: The following assessments designed to detect abnormalities which predispose to difficulty with the ECT must be performed prior to the administration of ECT: 1. Medical clearance including physical examination and review of laboratory data 2. Posterior/Anterior radiograph of the chest 3. CBC 4 Electrocardiogram 5. Serum Sodium Potassium, Chloride, COA, SGOT, SGPT, BUN, FBS, Alkaline Phosphatase 6. Special medical considerations in the following categories must be identified to the anesthesiologist: a. Guarded -Risk patients, e.g., very old individuals and those with significant cardiovascular, liver or bronchopulmonary disease. b. Blood relatives of individuals known to have prolonged apnea following succinylcholine. c. Patients who have had or who are expected to have had prolonged apnea after past administration of succinylcholine. d. Patients with recent medical exposure to anticholinesterase, e.g., For myasthmia gravis or glaucoma. It should be noted that a prior normal response to succinylcholine is presumptive evidence that future responses will be normal unless there has been exposure to antichoiinesterase or other agents associated with reduced serum or plasma cholinesterase function. The Physician completes Pre-ECT work-up and obtains appropriate approval for ECT as outlined below Manhattan Psychiatric Center POLICY AND PROCEDURE MANUAL SUBJECT:ECT SECTION: TX DATE REVISED: 3/17/99 NO.: 1500 Transmittal letter no: 99 M PC 02 Page 5 of 10 Q. CLINICAL PROCEDURE Treatments are routinely given three days a week on alternate days at the beginning of a series and may be tapered to once or twice a week nearing the conclusion of a series. Ward Physician 1. Discontinue Lithium, Tricyclic Antidepressants and MAO inhibitors as recommended above, unless indicated otherwise on ECT clearance form (MPC xxx). 2. Writes Pre-ECT orders as follows: -Electroconvulsive therapy (ECT) on day/date/time -NPO after Midnight -Medication, if ordered by anaesthesiologist -The anaesthesiologist is apprised of the nature and amount of medications which the patient had been taking via the patient medication record On Arrival at the ECT Suite: 1. Nurse prepares patient: has patient empty bladder, changes patients into hospital pajamas/gown, removes nail polish, removes hairpins, removes jewelry, removes dentures. 2. Anaesthesiologist gains access to a suitable vein 3. Psychiatrist places ECT electrodes EEG monitors and ensures good contact. 4. Nurse takes vital signs including oxygen saturation 5. Nurse exposes patient's feet and chest 6. Nurse places EKG electrodes 7. Anaesthesiologist administers Methohexital 1 % intravenously. Other anaesthetics may be substituted as indicated. 8. Nurse inflates blood pressure cuff above systolic and locks it. 9. Anaesthesiologist administers Succinylcholine (0.4-0.6 mg/kg) 10. Anaesthesiologist oxygenates patient using an Ambu bag until administration of stimulus 11. Anaesthesiologist inserts bite block into patients mouth 12. Anaesthesiologist holds patient's jaw shut during administration of stimulus 13. Psychiatrist administers stimulus and monitors duration of procedure 14. Nurse monitors vital signs 15. Anaesthesiologist oxygenates patient using an Ambu bag until patient can breathe on own 16. Anaesthesiologist observes patient until patient is stable and reoriented 17. Psychiatrist reassures and reorients patient Manhattan Psychiatric Center POLICY AND PROCEDURE MANUAL SUBJECT:ECT SECTION: TX DATE REVISED: 3/17/99 NO.: 1500 Transmittal letter no: 99 M PC 02 Page 6 of 10 18. Psychiatrist documents procedure in a progress note 19. Psychiatrist schedules next treatment and indicates special orders for same if indicated 20. A clears patient for return to ward when medically indicated 21. Anaesthesiologist notifies ward psychiatrist of any unusual problems with the patient during the procedure 22. Anaesthesiologist makes appropriate entries in the Anaesthesia record WARD NURSE encourages patient to take nourishment upon his/her return Manhattan Psychiatric Center POLICY AND PROCEDURE MANUAL SUBJECT:ECT SECTION: TX DATE REVISED: 3/17199 NO.: 1500 Transmittal letter no: 99 MPC 02 Page 7 of 10 REFERENCE Bidder, T.G.: ECT: Methods of Administration. In Franked, F.H.A., Bidder, T.G., Fink, M. Ectal: Electroconvulsive Therapy (American Psychiatric Association Task Force Report 14). Washington, APA 1978. pp. 92-121. Fink, M.. Convulsive Therapy: Theory and Practice, New York: Raven Press 1979. Kalinowsky, L.B. The Convulsive Therapies, In Freeman, A.M., Kaplan, H.I., and Sadock, B.J., eds.: Comprehensive Textbook of Psychiatry, 30 Ed. Vol. 3 1980. Baltimore, Williams & Williams, pp. 2335-2342. Royal College of Psychiatry Memorandum on the use of Electroconvulsive Therapy. Brit, J., Psychiatry 131: 261-272, 1977. Small, J.G. et al. Complications with Electroconvulsive Therapy combined with Lithium. Biol. Psychiatry 15: pp. 103-112, 1980. Whittaker, M and Berry M. The Plasma Cholinesterase Variants in Mentally III Patients. Brit J., Psychiatry, 130: pp. 397-404, 1977. Youmans, R.C., et al. Electroshock Therapy and Cardiac Pacemakers. American Journal Surgery, 118: pp. 931-937, 1969. Groners, G.A. Malignant Hyperthermia. Anesthesiology 53: p. 395-423, 1980. Cocanitis, D.A., et al. Comparative Study of Atropine and Glycopyrolate on Suxamethonium-induced Changes in Cardiac Rate and Rhythm. Brit. J. Anaesth., 52: pp-291-293, 1980. Manhattan Psychiatric Center POLICY AND PROCEDURE MANUAL SUBJECT:ECT SECTION: TX DATE REVISED: 3/17/99 NO.: 1500 Transmittal letter no: 99 M PC 02 Page 8 of 10 Legal/Procedural Considerations: Electroconvulsive Therapy may be administered to patients only upon their informed written consent. In cases where the patient is not competent to give consent, the appropriate procedure as per the Mental Hygiene Law Section 27.9 must be adhered to. It is unlikely that a court will give permission to use ECT if a patient is competent and refused. However, if the danger to life and limb is imminent in spite of all efforts of staff to project the patient or if there are no reasonable alternative treatments, e.g., in cases of severe cardiac disease, court authorization will be requested, All ECT will be administered in the Medical Services Unit by a psychiatrist credentialed to perform ECT and in the presence of a team consisting of a certified anesthesiologist, a nurse and mental hygiene therapy aide. The limited anesthesia required for the procedure must be administered either by an anesthesiologist, a qualified nurse anesthetist or a physician credentialed to administer same. The following are the principal indications for which ECT may be administered. 1. Psychotic Depression 2. Imminent Danger of Suicide 3. Mania 4. Catatonic Schizophrenia ECT may not be performed for personality disorders and is contraindicated in patients with increased intracranial pressure (brain tumor or subdural hematoma) - (for further details see the Medical Services Manual). Procedure: A. Non-Emergencies - Patient Competent and Consents to Treatment: Treating Psychiatrist: 1. Determines need for ECT; advises the unit chief and super vising psychiatrist indicating patient's competency to give consent. 2. Obtains signed informed consent from patient (see attachment 11). Supervising Psychiatrist 3. Reviews the case for clinical appropriateness and pre-ECT or Medical Unit Chief work up/ consults if necessary with the internist; discusses Manhattan Psychiatric Center POLICY AND PROCEDURE MANUAL SUBJECT:ECT SECTION: TX DATE REVISED: 3/17/99 NO.: 1500 Transmittal letter no: 99 M PC 02 Page 9 of 10 the case with the unit chief and treating psychiatrist; discusses case with the unit chief and treating psychiatrist; discusses the case with the clinical director; documents the decision and/or recommendations in the form of a Progress Note in the patient's record. Clinical Director: 4. Reviews the case, authorizes treatment. Treating Psychiatrist: 5. Notifies MILS when approval has been granted by the clinical director to perform ECT; documents MILS notification in the patient's record; obtains informed written consent from patient' performs work up required for ECT; notifies the associate clinical director/medical, or his designee. If he/she is not to perform ECT he/she notifies the clinical director who designates an alternate, credentialed psychiatrist. Anesthesiologist: 6. Evaluates patient; determines whether patient is medically suitable for ECT; advises psychiatrist in charge of ECT of patient's suitability; administers anesthesia. Associate Clinical Director Medical 7. Is responsible to see that mandated ECT team is in place and present when the procedure is taking place. B. Non-Emergencies - Patient Incompetent or Refuses Treatment: Supervising Psychiatrist: 1. Reviews the case and gives approval to the treating psychiatrist to proceed with court authorization. Treating Psychiatrist: 2. Completes request for Court Authorized Treatment (see Clinical Policy 1099). Reviewing Psychistrist: 3.Examines the patient and completes a Request for Court Authorized Treatment. (see Clinical Policy). Treating Psychiatrist: 4. Submits the completed forms to the Patient Legal Affairs Coordinator. Patient Legal Affairs 5. Prepares affidavits for the signature of the treating Manhattan Psychiatric Center POLICY AND PROCEDURE MANUAL SUBJECT:ECT SECTION: TX DATE REVISED: 3/17/99 NO.: 1600 Transmittal letter no: 99 MPC 02 Page 10 of 10 Coordinator: psychiatrist and reviewing psychiatrist. Clinical Director: 8. Reviews all completed packages; signs the petitions and affidavits. Patient Legal Affairs Coordinator: 9. Submits the completed package to the Attorney General's Office; when served with an Order to Show Cause by the court, serves the patient with the said order; notifies physicians and unit chief of the court date. C. Emergencies: Clinical Director: 1. Notifies MILS, discusses the case with the Executive Director and obtains his written permission to proceed with ECT. Mental Health Legal Services: 2. In all instances where informed consent is obtained, MILS must be given an opportunity to interview the patient before ECT is proceeded with. |
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