Psychiatric Bulletin (2002) 26: 237-238. doi: 10.1192/pb.26.6.237
© 2002 The Royal College of Psychiatrists
Psychiatric Bulletin (2002) 26: 237-238
© 2002 The Royal College of Psychiatrists
Guidelines for ECT anaesthesia
Statement from the Royal College of Psychiatrists' Special Committee on ECT
These guidelines have been endorsed by the Royal College of Anaesthetists.
The Royal College of Anaesthetists produces guidance on the safety of
anaesthetic services in its publication Guidelines for the Provision of
Anaesthetic Services, to which reference should be made. This document is
available on the internet at
http://www.rcoa.ac.uk/dload/GLINES
. PDF. In the near future the Royal College of Psychiatrists and Royal College
of Anaesthetists, in collaboration with the National Institute for Clinical
Excellence, will produce fuller guidelines.
Staffing
- There must be a named consultant anaesthetist responsible for the
electroconvulsive therapy (ECT) clinic. The consultant should have regular
input, and not just be nominally in charge.
- A suitably experienced trainee or non-consultant career grade anaesthetist
can administer the anaesthetics as long as he or she is supported by a named
consultant who takes responsibility for the delegation. This would preferably
be the consultant anaesthetist responsible for the clinic's management.
Guidelines for the supervision of trainees can be found in the Royal College
of Anaesthetists document, The CCST in Anaesthesia I: General Principles,
a Manual for Trainees and Trainers
(http://www.rcoa.ac.uk/dload.rcoa.ccst1.pdf
).
- Continuity of care needs to be established, with a minimum number of people
rotating through the service.
- A core group of suitably experienced anaesthetists is required.
- ECT sessions should be incorporated into job plans, and not be done
routinely by the on-call anaesthetists, or occasional unsupervised senior
house officer.
- All anaesthetists must have a suitably trained assistant present.
- The training and qualifications of anaesthesia assistants are detailed in
The Anaesthesia Team (Association
of Anaesthetists of Great Britain and Ireland, 1998).
- Continuity and experience are also important for assistants.
Remote siting of the ECT clinic
A remote site is defined as not having immediate access to critical care,
namely cardiac arrest and intensive care teams. In the majority of cases,
where there is no added risk, ECT should not prove any higher risk than minor
day-case surgery, which is regularly practised at remote sites. However, the
following guidelines should be adhered to:
- For any patient assessed as being ASA3 (see
Box 1 for American Society of
Anesthesiologists (ASA) definitions) or above, serious consideration should be
given to transferring them to the district general hospital (DGH).
- If ECT is given on a remote site, then a protocol needs to be in place for
transferring patients who are ASA3 or above to a DGH or training hospital with
access to critical care.
- If a patient ASA3 or above, who has been transferred to a DGH, proves
manageable after a few sessions, then consideration can be given to
transferring him/her back to the remote site.
Anaesthetic agents
Methohexitone
Methohexitone was the drug of choice for ECT, but is no longer available.
The three agents below seem to be appropriate alternatives.
Propofol
It is a widely used anaesthetic agent and is popular among
anaesthetists.
- Pros:
- well-tolerated
- short-acting anaesthetic with rapid recovery
- can be useful where attenuation of hypertensive response to ECT is
needed.
- Cons:
- shortens seizure length
- possible effect on seizure threshold
- The Committee on Safety of Medicines have advised special caution in day
case surgery because of concerns over convulsions (some delayed); anaphylaxis;
and delayed recovery
- may be associated with bradycardia and hypotension.
- Comments:
- some clinics have switched to propofol with little significant effect
- several small studies indicate effect on seizure duration does not affect
overall efficacy
- some studies suggest ECT courses may be prolonged.
Etomidate
- Pros:
- short-acting, with rapid recovery
- little hangover effect
- less associated with hypotension compared with propofol
- may lengthen seizure duration compared with methohexitone and propofol.
- Cons:
- high incidence of extraneous muscle movements
- pain at the injection site
- rarely associated with adrenocortical dysfunction in repeated doses.
- Comments:
- may be particularly suitable for patients who have brief/abortive seizures
with other agents.
Thiopental sodium
- Pros:
- little documented effect on seizure threshold or duration.
- Cons:
- longer duration of action can delay recovery times
- longer recovery times may cause added problems in the elderly
- not widely used in anaesthetic practice
- availability may also be limited in future.
- Comments:
- some units report regular use of thiopentone with minimal problems.
Recommendations
Based on the present evidence the Committee feels that it is not possible
to make a clear first-choice recommendation as a replacement for
methohexitone. The three agents above would seem acceptable alternatives,
although there are disadvantages with each. It is likely that each unit needs
to gain experience with more than one agent. It is probably inadvisable for
the induction agent to be changed during a course of ECT without consultation
between the anaesthetist and psychiatrist. With all the above agents, some
disadvantages can be minimised by using the lowest effective dose required for
safe and adequate anaesthesia.
References
ASSOCIATION OF ANAESTHETISTS OF GREAT BRITAIN AND IRELAND
(1998) The Anaesthesia Team. London:
Association of Anaesthetists of Great Britain and Ireland.
