ECT (Electroconvulsive Therapy)
Patient phenotype
Severe depression / catatonia / treatment-resistant schizophrenia. Multiple sessions (typically 6-12 across 3-4 weeks). Often elderly + medical comorbidities. Same patient back q2-3 days.
Procedure
Brief electrical stimulus to brain → therapeutic generalized seizure (target 20-30 sec). Anesthesia + NMB to prevent musculoskeletal injury during seizure. Brief case (~10 min total). Recovery 30-60 min.
Anesthetic plan
Methohexital 1 mg/kg OR propofol 0.5 mg/kg (low dose to allow seizure) + sux 0.5-1 mg/kg. Bite block essential. Hyperventilate pre-stim (lowers seizure threshold). Document seizure duration + EEG.
Setup
- ·Standard ASA monitors + EEG (ECT machine)
- ·PIV
- ·Bite block (CRITICAL — tongue + tooth injuries common)
- ·Mask + bag for ventilation (no ETT typically)
- ·Drugs: methohexital or propofol, sux, atropine, esmolol/labetalol
- ·Quick recovery space (high turnover)
Biggest concerns by phase
Cardiovascular response — seizure causes catechol surge
Initial parasympathetic surge → bradycardia (sometimes asystole). Then sympathetic surge → HTN, tachycardia. Risk: MI, arrhythmia, stroke in elderly. Pre-treat with esmolol 0.5 mg/kg or labetalol 5-10 mg if cardiac history.
Anesthetic dose — too much suppresses seizure
Goal: brief, light anesthesia for stimulus, then asleep through seizure + recovery. Methohexital 1 mg/kg classic (lowest seizure threshold elevation among induction agents). Propofol 0.5-1 mg/kg used but raises threshold (may need higher stim dose).
Sux dose + bite block placement
Sux 0.5-1 mg/kg IV after induction agent. Wait 60 sec (visualize fasciculation end). Place bite block. Stimulate. Sux dose: enough to attenuate seizure motor activity but allow EEG seizure activity to confirm therapeutic effect.
Bite block placement + tongue protection
Without bite block, the patient can bite tongue, fracture teeth, lacerate cheek during seizure (even with sux). Place bite block firmly between molars before stim. Document any oral injury.
Hyperventilate pre-stim to enhance seizure
Hyperventilation (PaCO₂ 28-32) lowers seizure threshold. Bag mask ventilate vigorously for 30-60 sec before stim. After seizure, ventilate to normocarbia.
Quick recovery — confusion + headache common
Patient awakens in 10-15 min. Confusion common (transient). Headache + myalgia from sux (treat with NSAID/acetaminophen — opioid usually not needed). Watch cognitive baseline trajectory across the series.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
75-year-old female on her 4th ECT session, recent CAD with stable angina. Right after the stimulus + seizure, BP rises to 220/110 + HR 130. She's still recovering from sux. What do you do?
What an examiner probes for
- ▹Recognizes catecholamine surge (sympathetic hyperactivity post-seizure)
- ▹Esmolol 10-20 mg IV bolus or labetalol 5-10 mg
- ▹Maintain ventilation (sux still active 5-10 min)
- ▹ECG check for ischemia
- ▹Pre-treat next session with esmolol prophylactically
Sources
- APA ECT Practice Guidelines
- Miller's Ch 75 (non-OR anesthesia)
- Stoelting Pharmacology
Anatomy reference
Sourced reference images. 4 matches for "brain cortex consciousness".
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