Discussion of some cases from ECTAS list. Rupert McShane

Transcription

1 Discussion of some cases from ECTAS list Rupert McShane

2 Ventricular Tachycardia Maintenance ECT 100 session 610mC No ECT Stupor unresponsive to drugs Usu has rhythm disturbance Bigeminy lasting 5 mins BP, O2 always OK VT 240/min on ECG and pulse Started immediately until just after end of fit (~60s) Cause? Prevention?

3 Escalating may become symptomatic?svt with aberrant conduction MSc project: Ventricular dsyfunction post ECT can persist for up to 6 hours? Attributable to catecholamine surge Cardiology referral: 24 h tape and ECHO Bisoprolol / labetolol as premed Prepare for long VT. Put defib pads before ECT starts Consider shocking (100J with sedation) Make sure amiodarone available Do in theatre

4 How much frontal impairment in depression before investigating for FTD? 70y woman, 3y Hx depression Near catatonic state, mood congurent psychosis Reduced verbal fluency, poor clock, motor dyspraxia No FHx dementia, Psych Hx: depression Remains flat after 19 treatments, but lipstick positive scan normal Persistent fatigue, lying in bed all day, self neglect similar frontal tests SPECT - FTD

5 70y successful writer unable to think, associative thinking, painful, pointless PHx manic illness Flat, rather monotonous, apathetic Enjoys company sometimes Wife has to check and now write speeches Recently becoming disorganised, CT-PET: widened interhemispheric fissure only

6 Reduce ECT to weekly, document change formally (depression, cognitive) Pramipexole rtms prefrontal activation Language and socialisation returns by week 2-3 Working memory, complex tasks, planning and more positive by week 3-4 Ketamine Psychostimulant single dose trial?sodium amytal TCA / MAOI (?stop ECT when on MAOI)

7 S62 Is ECT hazardous 62. (1) Sections 57 and 58 above shall not apply to any treatment (a) which is immediately necessary to save the patient s life; or (b) which (not being irreversible) is immediately necessary to prevent a serious deterioration of his condition; or (c) which (not being irreversible or hazardous) is immediately necessary to alleviate serious suffering by the patient; or (d) which (not being irreversible or hazardous) is immediately necessary and represents the minimum interference necessary to prevent the patient from behaving violently or being a danger to himself or to others

8 ECT one of safest treatments in psychiatry Hazardous treatments are treatments where the risk of adverse reaction or the severity of such reaction would be disproportionate to the degree of benefit the treatment is likely to confer or the prospect of success White Paper Cmnd 7320 paragraph S62 subsection (3) states: "For the purposes of this section treatment is irreversible if it has unfavourable irreversible physical or psychological consequences and hazardous if it entails significant physical hazard. Test for thresholds on (a) and (b) not tested yet

9 Driving Not within 24h, but what about between? Acute biweekly = too unwell What line would insurance take? OK after 48h Maintenance OK when 2 weeks apart If surrendered, OK to drive as soon as fit Outpatient documentation signed form

10 Eyes Corneal abrasions Tape eyes shut? No Main risk might be in recovery Face masks may ride up nose Patch if neurological condition prevented shutting

11 Retinal detachment 71y woman, TRD, 6x RUL 2-3/52 of floaters in L eye bilateral posterior vitreous detachment and vitreous syneresis (= pre-retinal detachment) Retinal detachment related to intra ocular pressure Ophthalmologist says carry on, but not v clear Definitely needs ECT

12 Believe the ophthalmologist Get specialist vitreo-retinal surgeon opinion Suxamethonium can IOP, so reduce dose by adding atrocurium before sux

13 Anaesthesia during transfer Do you have a syringe driver? Syringe drivers with TCI software (alaris, braun and Fresenius Pay a lease on one 6K + maintenance Driver can be used for ketamine? Need a second, one for propofol and one for other drug Portable oxygen, simple anaesthetic circuit, ambubag backup

14 Agitation post cannula removal IM Lorazepam Buccal midazolam Intranasal midazolam and reestablish IV access

15 Under 18s 16y, Depression and ASD with rigid thinking Preoccupied with ASD Self harming if given opportunity Plan: Aripip IM followed by depot, but if this doesn t work, can I use ECT