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IV. CONTRAINDICATIONS AND SITUATIONS OF HIGH RISK There are no "absolute" contraindications to ECT. There are situations in which ECT is associated with an appreciable likelihood of serious morbidity or mortality. In such cases, the decision for ECT should be based upon the premise that the patient's condition is too grave, i.e. "life-threatening", to leave untreated, and that ECT is the safest treatment available. In these instances, careful medical evaluation of risk factors should be carried out prior to ECT, with specific attention to treatment modifications which may diminish the level of risk. Those situations associated with substantial risk are not treated at PPC and would require transfer to a general medical facilily for treatment, Specific conditions associated with substantially increased risk include the following: I.Space-occupying cerebral lesion, or other conditions with increased intracranial pressure 2. Recent myocardial infarction with unstable cardiac function 3. Recent intracerebral hemorrhage 4. Bleeding, or otherwise unstable vascular aneurysm or malformation 5. Retinal detachment 6. Pheochromocytoma 7.Anesthetic risk rated at ASA level 3 or higher with some exceptions such as, healed myocardial infarction (APPENDIX V) V. ADVERSE EFFECTS Physicians should be aware of the principal adverse effects which may accompany the use of ECT. The nature, likelihood, and persistence of adverse effects should be considered on a case-by-case basis in the decision to recommend ECT and in obtaining informed consent. Efforts will be made to minimize adverse effects either by appropriate modifications in ECT technique, and/or the use or adjunctive medications. A. Cognitive Dysfunction PILGRIM PSYCHIATRIC CENTER Facility Policy Issuing Office: Clinical Services Issue Date: 10/11/97 Revision Date: 2/20/2001 Reviewed Date:2/20/2001 Page 9 of 58 Subject: ELECTROCONVULSIVE THERAPY (ECT)-] 2. Orientation and memory function should be assessed prior to ECT and at least weekly throughout the ECT course to detect and monitor any ECTrelated cognitive dysfunction. This assessment should attend to patient selfreports of memory difficulty and/or formal testing. If a patient develops severe cognitive side effects, the physician administering ECT should review the case and take appropriate action. The contributions of medications, ECT technique, and spacing of treatments should be reviewed. Potential treatment modifications include a change from bilateral to unilateral right or bitemporal to bifrontal electrode placement; decreasing the intensity of electrical stimulation; increasing the time interval between treatments; and/or altering the dosage of medications, or, if necessary, terminating the treatment course. B. Cardiovascular Dysfunction The electrocardiogram (ECG) and vital signs (blood pressure, pulse, and respiration) should be monitored during each ECT treatment in order to detect cardiac arrhythmias and hypertension. C. Prolonged Apnea Resources for maintaining an airway for an extended period, including intubation, should be available in the treatment room. D. Prolonged Selzures Seizures persisting for more than 180 seconds by motor and/or EEG criteria are considered to be "prolonged", and should be terminated pharmacologically as outlined in Section XV,D. E. Treatment Emergent Mania In rare occurrences patients may switch from depressive or affectively mixed states into hypomania or mania during a course of ECT. Treatment strategies to address this include: continuation of ECT, delay ECT and observe the patient, and termination of the ECT course followed by pharmacotherapy. F. Adverse Subjective Reactions PILGRIM PSYCHIATRIC CENTER Issue Date: 10/1/97 Revision Date: 2/20/2001 Facility Policy Reviewed Date:2/20/2001 Page 10 of 58 Issuing Office: Clinical Services Subject: ELECTROCONVULSIVE THERAPY (ECT) Apprehension and/or fear of ECT by patients or their families should be addressed both during the informed consent procedure, and throughout the ECT course. The patient should be encouraged to discuss these concerns with the treating psychiatrist and/or members of the ECT treatment team. When possible, treatment procedures should be modified to ameliorate these concerns. G. Other Adverse Effects Headache, nausea, and muscle ache or soreness during the first few hours following seizure induction are common. Such occurrences warrant symptomatic treatment. When such effects are recurrent or particularly bothersome, prophylaxis should be considered. |
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