ECT Workshop. Rahul Bajekal Consultant Anaesthetist Newcastle upon Tyne 23 November 2017

Transcription

1 ECT Workshop Rahul Bajekal Consultant Anaesthetist Newcastle upon Tyne 23 November 2017

2 My role To attenuate seizure appropriately Manage comorbidity Best place to treat?

3 What we don t like Complex comorbidity Difficult airways Unclear history Polypharmacy Remote locations

4 What we do like. Complex comorbidity Difficult airways Unclear history Polypharmacy Remote location

5 Polypharmacy Cardiac Liver Electrolytes

6 But it is only a short GA.. Complex patients Iatrogenic seizure

7 Lee s synopsis of Anaesthesia 9 th Ed 1982 Suxamethonium is still the standard relaxant Atropine and glycopyrrolate continue Methohexital is out Propofol is common Remifentanil is cool Rocuronium (and sugammadex) is available

8 What s new? Induction agents Muscle relaxants Management of airway Monitoring Advances in co-existing diseases

9 Physiological effects Of anaesthesia Of seizure CVS Resp Neuro Muscle

10 Seizure Initial vagal stimulation Hypothalamic May be persistent Titration Sympathetic stimulation Via spinal cord Increased Na and Adr

11 CNS Increased CBF Monroe Kellie Increased IOP Hyperventilation if achievable but mechanism? Neuroendocrine effects ACTH, TSH, Prolactin

12 What s trending on ECTAS forum Etomidate Intracranial aneurysm Safety cannulae Anaesthetic machine

13 Patient X 50 year old, bipolar, manic or catatonic Alcohol excess, liver disease Haematemesis reflux oesophagitis COPD Diabetes Recurrent urosepsis BMI 17

14 Treatment 2 sessions of ECT with physical restraint At 3 rd, communicating well with team, noticeable improvement 6 hours later retrosternal chest pain A&E -?NSTEMI Cardiology admit Troponin rise and fall <20% Likely NSTEMI started on dual antiplatelet

15 Transfer back ECT withheld Fall -?intracranial bleed CT 3 days later haematemesis, drowsy,? Bowel obstruction

16 Troponin and ECT Duma et al Anesthesiology 2014 Prospective 100 patients, 245 sessions Etomidate and Sux Hs Troponin I Incidence 8%, cumulative 3.7% Some had rise with one but not subsequent treatment Martinez et al Am J of Med 2011 Incidence 11.5%

17 Mechanism of action anaesthetics Meyer Overton hypothesis Lipid bilayer model Specific receptor(s) & multisite action GABA A NMDA Ketamine (thalamus & limbic cortex), Nitrous oxide K channels inhaled

18 Evidence for agents Singh et al JECT 2015 Review of studies EEG seizure Etomidate Methohexital Propofol 17.6s Thio 11.8s 2.2s longer Motor seizure 1.4s 11.6s 3.6s

19 Which agent is best? Peng et al Cochrane review 2014 Papers from 1966 to 2012, updated Feb 2017 Significant bias in papers Low quality of evidence Studies not designed to detect effect on depression scores If inadequate seizure with Propofol, try methohexitone If patient slow to wake, Propofol may be better than thio Anaesthetic agents should be chosen on the basis of adverse event profile, emergence and how they affect seizure duration

20 103 reviews 10% high level evidence for first listed primary outcome In 47% authors made conclusive statements about effect of intervention

21 Etomidate Cardiostable Favourable seizure Adrenocortical suppression Definite in infusions in critically ill Possibly with repeated doses Single doses? Evidence? Wang et al JECT 2011 repeated doses for ECT did not significantly affect cortisol levels (Etomidate vs Propofol)

22 Other agents used Ketamine Inhalational anaesthetics Opioids

23 Suxamethonium Commonest muscle relaxant for ECT Fasciculations Myalgia Incidence upto 50% Small dose non-depolarising agent may help but adverse effects! More with lower doses of Sux No correlation with fasciculation NSAID or lignocaine pretreatment can help

24 Other relaxants Atracurium Mivacurium Rocuronium Specific reversal -sugammadex Anaphylaxis similar to Sux

25 Opioids Alfentanil, Fentanyl, Remifentanil In combination with induction agent Longer seizure, slower recovery Likely action - decreased induction agent needed

26 Inadequate seizure Check meds Hyperventilation Etomidate or ketamine Add opioid Sole opioid induction not recommended because of unreliable loss of recall

27 Contraindications/Caution Recent MI Unstable angina, decompensated heart failure Recent intracranial bleed Intracranial mass lesion

28 Attenuate sympathetic response Esmolol Better than labetalol Shortens seizure although still >30s Labetalol Prolonged effect

29 Airway New kit including supraglottic airways and laryngoscopes New DAS guidelines for difficult airway Clear guidance on surgical airway Human factors

30 AAGBI monitoring standards 2015 NM monitor every time a blocker is used Capnography Continuous monitoring through to recovery Apply to the ECT suite (specifically named) Pulse oximeter, ECG, NIBP Inspired and Expired gases Airway pressure Nerve stimulator when blocker used Until recovered fully alert, responding to commands, speaking

31 In summary Complex patients with comorbidities Propofol and suxamethonium commonly used No clear and high level evidence supporting a particular technique A team approach is essential