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XV. CLINICAL MANAGEMENT OF POTENTIAL ADVERSE EVENTS A. Management of Post Ictal Agitation 1 Post ictal agitation occurs in a small proportion of patients following ECT and is a self-limited phenomenon, lasting from a few minutes to an hour. 2. Management of patients exhibiting post-ictal agitation will include: a. Supportive management with reduction of external stimuli, quiet PILGRIM PSYCHIATRIC CENTER issue Date: 10/1/97 Revision Date: 2/20/2001 Facility Policy Reviewed Date:2/20/2001 Page 32 of 58 Issuing Office: Clinical Services Subject: ELECTROCONVULSIVE THERAPY (ECT) reassurance and if indicated, wrist ankle restraint to prevent the compromise of medically necessary post-procedure monitoring and IV access. b. Intravenous diazepam (generally in doses of 2.5-20 mg.) Or intravenous lorazepam (generally in doses of 0.5-2.0 mg) , or additional methohexital. If no intravenous access is present, intramuscular medications such as lorazepam (0.5-2.0 mg) may be administered. 3. At subsequent treatments, the ECT Psychiatrist will determine whether strategies to prevent post-ictal agitation are indicated. These strategies include: a. Intravenous administration of a higher dose of anesthetic or muscle relaxant before the seizure elicitation. b. Prophylactic administration of diazepam, or lorazepam immediately following seizure elicitation. B. Missed, Abortive, Inadequate, or Prolonged Seizures. A subconvulsive or missed seizure is defined as having no EEG or motor evidence of seizure activity other than some contraction of the temporal muscles with the delivery of the electrical stimulus. In the absence of seizure activity, the patient should be restimulated at a higher intensity (e.g., 25-100% increase). In general, up to a total of four stimulations, if necessary, may be administered within a single treatment session. Each restimulation should be preceded by a 2040 second delay to take into account the possibility of delayed seizure onset. Although additional doses of anesthetic or relaxant agents are not generally required in such cases, these drugs may occasionally need to be re-administered. b. Premature termination of the stimulus, poor electrode contact, disconnection of the stimulus cable, and device malfunction may each result in missed or abortive seizures. Some devices provide information as to such events, but in any event, the electrical continuity of stimulus cables and electrodes should be checked prior to restimulation. No more than 4 subconvulsive stimuli will be administered in a single treatment session. PILGRIM PSYCHIATRIC CENTER Issue Date: 10/1/97 Revision Date: 2/20/2001 Facility Policy Reviewed Date:2/20/2001 Page 33 of 58 Issuing Office: Clinical Services Subject: ELECTROCONVULSIVE THERAPY (ECT) 2. An abortive or inadequate seizure is defined as having a motor seizure duration of less than 15 seconds or EEG activity less than 15 seconds. a. Inadequate seizures should be followed by restimulation at a higher intensity, (usually at least 25 % more than the initial stimulus.) Because of the presence of a relative refractory period, a longer time interval (e.g., 45 seconds) should be used before re-stimulation. This prolonged waiting period increases the likelihood that additional doses of anesthetic or relaxant agents will be necessary. b. Patients will not be re-stimulated after a second abortive seizure, even if the seizure duration remains below the cut offs for motor or EEG duration. C. Situations Where Increases In Stimulus Dosage Are Insufficient to Elicit an Adequate Seizure The following techniques, alone or in combination, should be considered as means of prolonging or otherwise augmenting seizures (no specific order of importance is implied). a. Diminish dose of anesthetic agent. b. Diminish or omit doses of any concomitant medications with anticonvulsant action, especially benzodiazepines. c. Provide vigorous hyperventilation prior to and during the induced seizure. d. Insure adequate patient hydration. e. Use an alternative anesthetic agent with less effect upon seizure threshold and/or duration, e.g., ketamine or etomidate. D. Prolonged Seizures A prolonged seizure is defined as a seizure with motor manifestations lasting longer than 180 seconds by motor and/or EEG criteria. The presence of prolonged seizures may only be apparent with EEG monitoring. (However, the practitioner must be convinced in such situations that seizure activity rather than artifact is present.) 2. Prolonged seizures should be terminated pharmacologically. This is usually accomplished via the intravenous administration of a benzodiazepine or barbiturate. PILGRIM PSYCHIATRIC CENTER issue Date: 10/1/97 Revision Date: 2/20/2001 Facility Policy Reviewed Date:2/20/2001 Page 34 of 58 Issuing Office: Clinical Services Subject: ELECTROCONVULSIVE THERAPY (ECT) Oxygenation should be maintained during and immediately following prolonged seizures. Intubation should be performed in cases of respiratory compromise. Cardiovascular monitoring should be continued throughout to detect the presence of adverse cardiovascular changes. 4. Repeat doses of relaxant agents should be given if convulsive motor activity persists or recurs. 5. Appropriate medical consultation should be considered if difficulties are experienced in terminating a prolonged seizure, if spontaneous seizures occur, or if neurologic or other medical sequelae appear to be present. In such cases, ECT should be resumed only after any treatable conditions known to increase the likelihood of prolonged seizures have been corrected and an assessment of applicable risk/benefit considerations has been made. 6. A decrease in stimulus intensity at subsequent treatments should be considered following a prolonged seizure, unless such a dosage has previously elicited an inadequate response. |
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