Psychiatric Bulletin (2000) 24: 301. doi: 10.1192/pb.24.8.301
© 2000 The Royal College of Psychiatrists
Psychiatric Bulletin (2000) 24: 301
© 2000 The Royal College of Psychiatrists
Investigation of the ‘cuff’ method for assessing seizure duration in electroconvulsive therapy
M. E. Jan Wise, Registrar in Psychiatry,
Fiona Mackie, Senior House Officer in Psychiatry,
Antonios C. Zamar, Lecturer and Honorary Senior Registrar in General Adult
Psychiatry and
James P. Watson, Professor of Psychiatry, Guy's, King's & St Thomas
Department of Psychiatry, Thomas Guy House, Guy's Hospital, London SE1
9RT
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Abstract
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AIMS AND METHOD
Electroconvulsive therapy should be effectively monitored and seizure
duration accurately ascertained. We observed the seizure duration in both
lower and upper limbs using the Hamilton ‘cuff’ method.
RESULTS
Thrity-nine seizures in 19 patients were observed. There were no
statistically significant differences between cuffed and uncuffed limbs, nor
between upper and lower limbs.
CLINICAL IMPLICATIONS
Alternatives to the Hamilton cuff method to observe seizure duration need
to be considered.
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Introduction
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Despite a high stimulus dose a tonic—clonic seizure may not be
witnessed. This has been reported to be due to inattention by the attendants,
absence of seizure activity or too much muscle relaxation (Pippard &
Ellem, 1980; Fink, 1983). While
continuous electroencephalogram (EEG) monitoring has been proposed for quite
some time (Fink & Johnson, 1982;
Chesen, 1983) the Royal College
of Psychiatrists still recommends the Hamilton cuff technique in its absence
(Royal College of Psychiatrists,
1995). With this technique a sphygmomanometer cuff is applied to
the contralateral side to the anaesthetic administration site and inflated to
above systolic blood pressure, prior to administration of the muscle relaxant.
In theory, this should prevent paralysis of distal limb musculature and allows
the attendants to observe any seizure activity undiminished by muscle
relaxants. We attempted to investigate whether there was any observable
difference in observed seizure duration between a ‘cuffed’ and an
‘uncuffed’ limb.
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Method
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Nineteen patients receiving electroconvulsive therapy (ECT) within a
six-month period gave consent to be included in the trial. Patients with
peripheral vascular disease were excluded, as were patients who could not read
English. Standard ECT procedures were followed. After administration of the
anaesthetic agent, arm and leg cuffs, contralaterally placed, were inflated to
200 mm Hg and 220 mm Hg respectively. A specific leg cuff was used to prevent
erroneously elevated sphygmomanometer readings. The muscle relaxant followed
by the stimulus dose was then administered. Three observers noted the duration
of the convulsion: one observed the face, one the arms and one the legs.
Seizure duration was defined as the length of time between cessation of the
stimulus and absence of tonic—clonic seizures.
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Results
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Thirty-nine convulsive episodes were observed. The mean seizure duration
(MSD) for the head was 23.9 seconds (s.d.=8.8). In the upper limbs, the MSD
was 24.2 (s.d.=8.95) seconds cuffed and 23.6 seconds uncuffed (s.d.=9.5). In
the lower limbs, the MSD was 25.1 seconds cuffed (s.d.=8.6) and 25.9 seconds
(s.d.=8.2) uncuffed. Data were analysed using the Statistical Package for
Social Sciences v7.5 for Windows. A two-way analysis of variance (ANOVA), the
appropriate test for simultaneous continuous observations, found no
significant difference between upper and lower limbs, nor between cuffed and
uncuffed limbs in terms of the MSD. In no case did a seizure occur in a cuffed
limb and not in the uncuffed limb.
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Comments
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From these results it appears that there is little observable difference
between a cuffed and an uncuffed limb, even if lower limbs and specialist
tourniquets are used. Several authors have suggested that there is little
difference in seizure duration observed with EEG monitoring and the Hamilton
‘cuff’ method (Lambert &
Petty, 1994). Our data suggests that there is no difference
between a cuffed limb and an uncuffed limb. We suggest that the use of the
Hamilton cuff method to ‘observe’ absent seizures should cease;
this merely delays addressing the real cause of ‘absent’ seizures
and may involve anaesthesia without therapeutic effect. This recommendation
should be dropped from the Royal College of Psychiatrists
(1995) handbook on ECT. Given
that as long ago as 1966 the literature suggested the adoption of continuous
EEG monitoring, and that the Hamilton cuff method has been shown to be
ineffective, the adoption of EEG monitoring as standard needs to be seriously
considered.
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References
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CHESEN, E. S. (1983) EEG Monitoring of ECT preferred
to cuff method. American Journal of Psychiatry,
140,
1648-1649.
FINK, M. (1983) Missed seizures and the
bilateral-unilateral electroconvulsive therapy controversy.
American Journal of Psychiatry,
140,
1198-1199.
FINK, M. & JOHNSON, L. Monitoring the duration of
electroconvulsive therapy seizures:‘cuff’ and EEG methods
compared. Archives of General Psychiatry,
39,
1189-1191.
LAMBERT, M. & PETTY, F. (1994) EEG seizure
duration monitoring of ECT. Progress in Neuropsychopharmacology
& Biological Psychiatry, 18,
497-502.[Medline]
PIPPARD, J. & ELLAM, L. (1980)
Electroconvulsive Treatment in Great Britain, 1980.
London: Headley Brothers.
ROYAL COLLEGE OF PSYCHIATRISTS (1995) The
ECT Handbook. Second Report of the Royal College of Psychiatrists' Special
Committee on ECT. London: Gaskell.
This article has been cited by other articles:
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P. Mahapatra
Monitoring of seizures during electroconvulsive therapy by the 'cuff' method is still relevant today
Psychiatr. Bull.,
November 1, 2000;
24(11):
434 - 434.
[Full Text]
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Abstract
Introduction
