X. PREPARATION FOR TREATMENT

A. Prior to the first treatment, the anesthetist will complete the Pre Anesthesia Evaluation (LIPC 31), and indicate whether the patient is a candidate for ECT anesthesia at PPC. The anesthetist should review the ASA( American Society of Anesthesiologists) Classification of Risk (see Appendix V) in making this determination.

B. The treating psychiatrist will write orders for the patient to be kept NPO after midnight prior to treatment. An exception may be made for necessary medications, e.g. antihypertensives, which may be given with a small sip of water. This should be indicated in the physician's orders.

On the morning of treatment, the ward nurse will encourage the patient to void,

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ensure that any dental protheses are removed, and review the medical record to ensure that appropriate documentation is present. (This includes the original consent, and clinical summary for ECT, including the medical, dental and anesthesia evaluation.) In addition the ward nurse will take the patient's vital signs, assess the patient's sensorium and ambulation and document these findings, along with any medications given, in the Pre ECT Progress Note (621 C LIPC); side one.

D. The ward staff wil escort the patient ( along with the medical record ) to the ECT suite, assist in preparing the patient for treatment, and stay with the patient during the pre and post treatment period as directed by the ECT staff.

E. When the patient and the medical record arrive in the ECT suite, the ECT Psychiatrist and Anesthetist will review the record for any changes in the patient's condition or medications which would affect the administration of ECT. If so, then a progress note indicating these changes, and the action taken should be entered into the medical record. The ECT psychiatrist and/or anaesthetist may cancel a scheduled treatment if appropriate procedures have not been followed or if the risk for conducting ECT is deemed unacceptably high.

XI. TREATMENT PROCEDURES

A. Patient Preparation

Intravenous Access: Intravenous access should be established by the anesthetist and maintained until the patient is ready to leave the treatment area. The anesthetist will also administer any prescribed pre-ECT medications.

2. Vital Signs: Vital signs will be taken prior to the administration of ECT and every 2 minutes during treatment by the ECT nurse and recorded on the Nursing ECT Progress Note. Also, the ECT Nurse will apply leads for EKG and pulse oximetry.

B. Monitoring

1 Patient Monitoring: Throughout the time the patient is in the ECT treatment area,the following will occur:

a) Pulse oximetry will be monitored continuously to assess peripheral oxygen concentration

b) heart rate and blood pressure will be recorded every 2 minutes while

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the patient is in the ECT treatment area, and every 5 minutes while in the recovery area. EKG monitoring will begin prior to the administration of anesthesia and will continue until the resumption of spontaneous respiration.

2. Seizure Monitoring: Seizure duration should be monitored to assure an adequate ictal response, to detect prolonged seizure activity and to enable appropriate decisions to be made regarding stimulus dosing strategy. Seizure monitoring generally consists of observation of both the duration of ictal motor activity and ictal EEG activity. The two are used together to obtain the most accurate seizure duration. Motor activity alone may underestimate the length of the seizure, and single channel EEG recordings at times may be difficult to interpret.

a) Ictal Motor Activity: Seizure duration is monitored by timing the duration of convulsive movements. This is done via the "cuff technique". Prior to the administration of a muscle relaxant, a blood pressure cuff is inflated to a level that is substantially above the anticipated systolic pressure during the seizure. This blocks the flow of muscle relaxant to the limb and allows a direct observation of the duration of the ictal motor activity.

If unilateral stimulus electrode placement is used, the occluded limb should be ipsilateral to the stimulated cerebral hemisphere to assure contralateral spread of the seizure activity.

Because ictal movements may persist for a longer time in body regions other than the cuffed extremity, the longest duration of any seizure-related motor activity should be used.

The duration of cuff inflation should be minimized to avoid trauma to blood vessels. Similarly, care should be taken when using this technique in cases where extreme skeletomuscular fragility is present, e.g., severe osteoporosis.

b) Ictal EEG Activity: Since scalp electroencephalographic (EEG) activity provides a more accurate representation of seizure duration than does the convulsive motor response, ictal EEG monitoring will also occur, on at least a one-channel basis.

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EEG recording electrodes should be sufficiently far apart and in good contact with the scalp. The location of EEG monitoring leads should be based upon maximizing the ability detect of ictal EEG activity.

EEG may be monitored either on a visual (i.e., chart recorder or video monitor) or an auditory basis.

The ECT psychiatrist should be aware of the different manifestations of EEG seizure onset and termination as well as artifacts likely to occur during monitoring, e.g., EEG, pulse, myographic activity, and anesthesia effects.

C. Airway and Anesthetic Management

Airway and anesthetic management are the responsibility of the anesthetist. On each treatment day, prior to the first treatment, the anesthetist should ascertain that relevant equipment, (e.g. oxygen delivery system, suctioning system, intubation equipment) is functional and that supplies necessary for resuscitation are available.

The ability to adequately ventilate the patient should be assured prior to administration of the muscle relaxant agent. Intubation should be avoided unless specifically indicated.

Oxygenation by mask( positive presssure at a concentration of 100% 02, flow rate of 5 liters/minute, and respiratory rate of 15-20/minute) will be maintained from the induction of anesthesia until the resumption of adequate spontaneous respirations.

When clinically indicated,(e.g. in patients receiving sympathetic blocking agents, or where the prevention of a vagal bradycardia is medically important), a parasympathetic agent (e.g. atropine or glycopyrrolate) may be given prior to the administration of the anesthetic agent.

When used, the anticholinergic premedication should be administered IV 2-3 minutes prior to anesthesia or, alternatively, IM or SC 30-60 minutes prior to anesthesia induction.

Typical dosages for atropine are 0.3 - 0.6 mg. administered IM or SC, or 0.4 - 1.0 mg. administered IV, and for glycopyrrolate are 0.2 - 0.4 mg. administered IM, SC or IV.

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ECT should be carried out using ultra-brief, light general anesthesia, in a dose that ensures that the patient remains unconscious throughout the procedure. The anesthetic agent generally used is methohexital sodium (Brevital), typically at a dose of 0.75-1.0 mg/kg body weight.

Thiopental, etomidate, or ketamine are typical alternative anesthetic agents, and may be used instead of methohexital when clinically indicated.

Regardless of agent, doses are adjusted at successive treatments to provide the desired effect.

Skeletal muscle relaxants should be used to minimize convulsive motor activity and to improve airway management. Succinylcholine is generally used at a dose of 0.5-1.0 mg/kg body weight. Doses should be adjusted at successive treatment sessions to achieve the desired effect. When clinically indicated other agents, e.g. Atracurium and Curare, may be used.

Relaxants should be administered either following anesthesia induction or soon after injection of the anesthetic agent (rapid sequence induction). The anesthetist should assure that the patient is unconscious prior to respiratory paralysis, and that a patent airway is present.

Although the maximal effect of succinylcholine usually occurs within 60 to 120 seconds, the adequacy of skeletal muscle relaxation will be ascertained prior to stimulation. This will be assessed by the following:

a) the diminution or disappearance of knee, ankle, or withdrawal reflexes;

b) loss of muscle tone, e.g. using the flexibility of the lower jaw.

c) visually observing for muscle fasiculations. (it is unlikely that maximal relaxation has been achieved until after muscle fasciculations have disappeared.) In the event that the state of muscle paralysis is in question, a peripheral nerve stimulatior will be available for use.

7. Based on the patient's response to anesthetic induction, doses of anesthetic, muscle relaxant and anticholinergic agents may be modified at subsequent ECT treatments.

D. ECT Seizure Induction

1. In order to ensure adequate contact between the stimulus electrodes and

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the scalp, the sites at which the ECT electrodes will be placed will be cleansed with acetone or alcohol and gently abraded.

When using circular metal ECT electrodes, conducting gel will be applied to the area under the stimulus electrodes whereas when Thymapad electrodes are used, the approprite conducting solution will be applied.

Stimulus electrodes should be applied with sufficient pressure to assure good contact during stimulus delivery.

When stimulus electrodes are placed over an area covered by hair, a conduction medium, such as a saline solution, should be applied; alternatively the underlying hair may be clipped. Hair beneath the electrodes should be parted prior to application of the stimulus electrodes.

After applying the electrodes, the patient's head will be inspected to verify that the conducting medium has not spread to the hair or scalp between the electrodes.

2. Prior to electrical stimulation, a flexible protective mouth guard (bite-block) will be inserted in the patient's mouth to protect the teeth and other oral structures. When recommended by the dental consultants, a special mouth guard may be used in patients with poor dentition.

3. Electrode impedance will be checked just prior to each ECT stimulus administration.

4. The ECT stimulus will not be administered until:

a) the static impedance is within acceptable range and/or the cause of the exceptional impedance reading is identified and documented AND b) the patient has achieved an acceptable level of anesthesia and muscle relaxation.

ECT wil be administered using a Thymatron ECT device. (A MECTA ECT device is also available as a back up device.)

6. During the passage of the electrical stimulus, the patient's chin will be held to keep the jaw tight against the bite-block and minimize potential oral injury.

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7. EEG monitoring will begin before seizure induction and will continue until there is clear evidence that paroxysmal ictal activity has terminated.

8. The duration of the induced seizure wil be determined and documented according to the following:

a) Motor seizure duration determined by EMG and by visual inspection using the "cuff technique". b) Ictal seizure duration as determined by EEG.

9. If a missed, inadequate or prolonged seizure occurs, the actions delineated in section XV B will be followed.

10. Within a few seconds of seizure termination, the blood pressure cuff on the extremity will be deflated.

11. Decisions about cardiovascular and/or hemodynamic interventions made before, during and after the ECT stimulus will be the responsibility of the anesthetist, in consultation with the ECT psychiatrist. When clinically indicated, medications other than listed above may be administered prior to or following seizure induction.

12. The ECT psychiatrist will document all pertinent aspects of the treatment including stimulus electrode placement, stimulus parameter settings, seizure duration etc, on the ECT Procedure Note, QPQ 155), and indicate the next scheduled treatment, along with any recommendations to the treating psychiatrist on the Pre ECT Progress Note (621 C LIPC side one)

13. The anesthetist will document all pertinent information, including all medications administered in the treatment or recovery area, any treatment complications, and the patient's condition during the time the patient was in the ECT suite, on the Pre Anesthesia Evaluation Form (LIPC31). The anesthetist should also document the patient's condition at the end of his/her stay in the recovery area, and the occurrence and management of any complications during that time.

E. Transfer of Patients from the Treatment Area to the Recovery Area

1. After ECT, patients will be moved from the treatment area to the recovery

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area only after clearance from the anethetist, based on the following criteria:

a) The EKG is in the baseline rhythm b) Oxygen sturation is >95% by pulse oximetry c) Stable vital signs ( baseline within 20%) d) The patient is breathing spontaneously and is respnsive to verbal stimuli.

F. Management of the Patient In the Recovery Area

1 .The patient will be brought to the recovery area by stretcher or bed.

2. Upon admission to the recovery area, the Recovery Nurse will do the following:

a) Assess the color, level of consciousness, orientation and other aspects of the patient's general appearance b) Position the patient so that airway maintenance will be optimal c) Note the patient's respiratory pattern d) Suction the patient as indicated e) Monitor the patient's oxygenation via pulse oximetry Inspect the patient's mouth for loose teeth

3. Under the supervision of the anesthetist, the Recovery Nurse is responsible for the continuous observation and monitoring of the patient. Vital signs will be taken every 5 minutes. The anesthetist will be alerted immediately of any alteration in vital signs or clinical status that may require medical intervention.

4. The patient will be systematically and gently reassured until significant re orientation occurs.

5. Any complications that arise in the recovery area will be managed by the ECT treatment team ( ECT Psychiatrist, Anesthetist, and ECT or Recovery Nurse). Post ictal agitation wil be managed as described in Section XV A.

The Recovery Nurse will document the patient's vital signs and the patient's condition at the end of the recovery period on the Nursing ECT Progress

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Note LIPC 149-95.

7. Patients may be discharged from the recovery area after the following:

a) the patient has been monitored in the recovery area for at least 20 minutes or until a time that is deemed appropriate by the Anesthetist or ECT Psychiatrist. b) the patient is awake and has returned to the pre-ECT mental state. c) vital signs are stable, and have returned to basellne(within 20%) d) nausea and vomiting have subsided or the danger of aspiration has passed.

8. The Recovery Nurse will directly notify the ward nurse of any complications during ECT and any potential problems which may be expected to develop.

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