Electro-convulsive Therapy (ECT)

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ELECTRO-CONVULSIVE THERAPY

INTRODUCTION
Most of people ( educated and non educated ) think that life inside mental illness hospitals is horror and scary. It is the effect of media that shows psychotic patients in disgusting appearance and doing unbelievable acts.lt is also shows the role of electroconvulsive therapy in a scary scenario , -when two or more huge male nurses pull the patient - then connect him to an electrical device , while he is fully awake - -which make him scream with a loud voice - - cry and then lose his consciousness because of the severe pain he got.
Electroconvulsive therapy (ECT), also known as electroshock, is a well established, albeit controversial psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect.
HISTORY
ECT first appearance was by the scientist, Meduna in 1935 when he notice that most of schizophrenic symptoms are temporary disappear after a normal convulsion.He induced a seizure with an injection of campor-in-oil in a patient with catatonic schizophrenia,Cerletti and Bini introduced the use of electric shock to induce seizures in 1938 and soon this method became the standard.
DEFINITION
Artificial induction of a grandmal seizure (tonic phase 10-15sec, clonic phase:30-6() sec.)through the application of electrical current to the brain, the stimulus is applied through electrodes which are placed either bilaterally in the fronto-temporal region or unilaterally on the non dominant side.
PARAMETERS
·         VOLTAGE- 70-120 Volts
·         Duration - .7-1.5 sec
BENEFITS OF ECT:
·         ECT relieve very severe depressive illnesses when other treatments have failed.
·         ECT has saved patients lives because 15% of people with severe depression will kill themselves.
·         ECT works faster than all antidepressants drugs.
MECHANISM OF ACTION
1.Neurotransmitter theory.
ECT works like anti-depressant medication, changing the way brain receptors receive important mood-related chemicals.Anti-convulsant theory. ECT-induced seizures teach the brain to resist seizures. This effort to inhibit seizures dampens abnormally active brain circuits, estabilishing mood.
2.Neuroendocrine theory.
The seizure causes the hypothalamus to release chemicals that cause changes throughout the body. The seizure may release a neuropeptide that regulates mood.
3.Brain damage theory.
Shock damages the brain, causing memory loss and disorientation that creates an illusion that problems are gone, and euphoria, which is a frequently observed result of brain injury. Both are temporary.
4.Psychological theory.
Depressed people often feel guilty, and ECT satisfies their need for punishment. Alternatively, the dramatic nature of ECT and the nursing care afterwards makes patients feel they are being taken seriously - the placebo effect
TYPES OF ECT
·         Direct ECT  
·         Modified ECT
·         Unilateral ECT
·         Bilateral ECT
Method Used
1.Direct ECT:
In this, ECT is given in the absence of anesthesia & muscular relaxation. This is not  commonly used method now.
2.Modified ECT.
In this, ECT is modified by drug-induced muscular relaxation, general anesthesia oxygenation. Administer the anesthetic agent(thiopental sodium 3-5mg/kg bodyweight & muscle relaxant (1 mg/kg body weight of succynyl choline)
Placement Of Electrodes
1. Bilateral ECT:
Each electrode is placed 2.5-4 (l – 1½  inch) above the midpoint, on a line joining the  tragus of the ear & the lateral canthus of the eye.
 2. Unilateral ECT:
Electrodes are placed only on one side of head, usually non-dominant side (right side of head in a right-handed individual). Unilateral ECT is safer, with much fewer side-effects  particularly those of memory im pairment.
ELECTRODE PLACEMENT
Each electrode is placed 2.5 -4 cm(l- 1.5 inches) on the midpoint on a line joining the tragus of the ear and the lateral canthus of the eye
INDICATIONS
1.Severe depression
·         Severe episodes.
·         Need for rapid antidepressant response (e.g. due to failure to eat or drink in depressive stupor; high suicide risk).
·         Failure of drug treatments.
·         Patients who are unable to tolerate side- effects of drug treatment (e.g. puerperal depressive disorder).
·         Previous history of good response to ECT.
·         Patient preference.
·         Suicidal ideas
2.Mania That hasn't improved with medications
3.Severe Catatonia
4.Schizophrenia
5.Psychosis
6.When medications are insufficient or symptoms are severe
7.All of the above disorders during pregnancy.

CONTRAINDICATIONS
Absolute
·         Increased ICP
Relative
·         Cardiovascular (Coronary artery disease, HTN, aneurysms, arrhythmias)
·         Cerebrovascular effects (Recent strokes, space occupying lesions, aneurysms)  
·         Severe pulmonary diseases (T.B, Pneumonia, Asthma)
COMPLICATION OF ECT
 l. Fractures & dislocations:
·         Most frequently the fracture & dislocation are caused by muscular contraction due to ECT Compression fracture of vertebrae of dorsal area between thc 2nd & 8th usually 3rd , 4th & 5th vertebrae is common.
·         Fracture of femur & humerus occurs in young muscular individuals.
·         Dislocation of jaw is the most frequent complication of the tonic phase.
2. Complication in the respiratory system: Apnea , Respiratory arrest
 3. Other coinplication:
·         Headache, backache,
·         Painful mastication,
·         Injuryof mouth & tongue.
·         Fear due to an unpleasant experience on waking up after the treatment.
·         Stuns & subshocks occur due to an insufficient current applied to the patient which does not result in a full convulsive stage. These subshocks or stuns will sometimes produce ca rdiac irregularities, respiratory distress &collapse
COURSE OF ECT
·         ECI is usually given 3 times a week, reduced to twice a week or once a week once symptoms begin to respond.
·         This limits cognitive problems.
·         'l'hcre is no evidence that a greater frequency enhance treatment response.
·         Treatment of depression usually consists of 6-12 treatments.
·         Treatment-resistant psychosis and mania up to (or sometimes more than)20 treatments. 
·         Catatonia usually resolves in 3-5 treatments.
ECT TEAM
·         Psychiatrist
·         Anesthetist
·         Trained Nurses   Nursing aids
·         ECT assistant
MEDICATIONS USED IN ECT
·         Inj.Atropine 0.6mg Inj.
·         Succinyl choline 25-40 mg
·         Sodium Pentothal 150-250 mg
Ø  A pre-treatment medication such as atropine sulfate , glycopyrolate is administered IM 30 minutes before treatment, ( to decrease secretion and counteract the effect of vagal stimulation induced by ECT. e a short acting anesthesia ( the patient should be unconscious when the ECT is given)
Ø  Muscle relaxant ( to prevent muscle contraction during the seizure reduction of possibility of fracture or dislocated bone 9Pure oxygen before and after treatment .
TREATMENT FACILITIES
3 rooms
·         Waiting room  
·         ECT room
·         Recovery room
ARTICLES NEEDED FOR ECT
·         Articles for anesthesia
·         Suction Apparatus
·         Face mask
·         O2 cylinder  
·         Tongue depressor
·         Mouth gag
·         Resuscitation apparatus
·         Full set of emergency drugs
·         ECT drugs
·         Defibrillator
PROCEDURE
Time: 10-15 minute plus time for prep & recovery
1.Intravenous (IV) catheter is inserted in the arm or hand
2.Oxygen mask may be given 3 electrodes are placed on the head
·         Unilateral: one side receives electricity
·         Bilateral: both sides
3.Anesthetic is injected IV.
 Unconscious and unaware of procedure 
4. Muscle relaxant is injected into IV.
·         Prevent violent convulsions
5.Blood pressure cuff placed around forearm or ankle
·         Prevents muscle relaxant from paralyzing, so doctor can confirm seizure with movement of hand/foot
6.Electric current is sent through electrodes to brain.
·         Seizure lasts 30-60 sec. Few minutes later, anesthetic and muscle relaxant wear off.
RISKS & SIDE EFFECTS
Impairment of Cognition
·         Period of confusion immediately after ECT.
·         May not know where you are or why you are there Generally lasts few min. to several hrs.
·         Memory Loss , May forget weeks/months before treatment, during treatment, or after treatment has stopped
·         Usually improves within couple of months
·         Permanent in relatively rare cases
MEDICAL COMPLICATIONS
·         Heart problems
·         Small risk of death same as other procedures using anesthesia 
·         Physical Symptoms
·         Nausea
·         Vomiting
·         Headache
·         Muscle ache  
·         Jaw pain
ROLE OF NURSE IN ECT PRE -ECT CARE
·         Informed consent
·         Fully explain the risks and benefits of procedure and answer questions from patients or  their relatives.  
·         Information sheets
·         Reduce patients anxiety and help establish good patient-doctor relationship
·         Administration of drugs
·         Check patient record
·         Explain procedure Keep patient on NPO 6-8 hrs before ECT
·         Discourage smoking just before ECT  
·         Remove artificial dentures and articles
·         Vital signs
·         Ensure emergency articles are accessible
·         Emotional support
·         Transfer patient to ECT room with necessary records
CLIENT EDUCATION BEFORE ECT (PRE -ECT)
·         An instruction sheet describing the procedure is given to client & their significant others.
·         The nurse emphasizes that the client will be asleep during the procedure.
·         Although low voltage current is passed to the brain, the client will not be harmed or fccl any pain.
·         Instruction for preparation: 1- Nothing by mouth (NPO).2- Outline the need to void before the procedure.
ECT ROOM (PRE -ECT)
·         Check patients identity.
·         Check patient is fasted (for 8hrs) and has emptied their bowels and bladder prior to coming to treatment room.
·         Check patient is not wearing restrictive clothing and jewellery/ dentures have been removed.
·         Consult ECT record of previous treatments (including anaesthetic problems).
·         Ensure consent form is signed appropriately.
·         Check no medication that might increase or reduce seizure threshold has been recently given.
·         Check ECT machine is functioning correctly.
DURING ECT
·         Reassurance & support Place patient in supine position
·         Necessary Drug administration
·         Mouth gag
·         Apply upward pressure to mandible   
·         Oxygen administration
·         Clean the Scalp with normal saline
·         Prevent fall, fracture, dislocation
·         Remove the mouth gag after seizure occurred
·         Suck the oral secretion & apply O2 mask
POST ECT CARE
·         Shift client to post-procedure room
·         Check vital signs every 15 mts
·         Administer drugs if patient is aggressive/violated/ confused
·         If respiratory difficulty continue oxygen
·         Provide side rails
·         Be with the client
·         Documentation

·         Reorient the client after recovery

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notes.nursium.com: Electro-convulsive Therapy (ECT)
Electro-convulsive Therapy (ECT)
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