Why side lying position is given after electroconvulsive therapy

The ECT treatment and recovery areas should contain equipment to monitor vital signs and provide initial management of medical emergencies. An optimal treatment site includes separate functional areas for waiting, treatment, and recovery. [1]

A stethoscope, a blood pressure measurement device, electrocardiographic and pulse oximetry measurement devices, and an oxygen delivery system should be present. Supplies for inducing anesthesia, providing ventilation, monitoring physiologic functions (including seizure activity), and performing resuscitation should be present.

Examples of ECT machines available in the United States include the Thymatron System IV (Somatics, LLC, Lake Bluff, Ill) and the MECTA Spectrum 5000Q (MECTA Corporation, Lake Oswego, Ore). Extensive details on equipment, physiologic monitoring, and treatment site can be found in the American Psychiatric Association's Task Force Report. [1]

Common electrode positions in ECT include the bitemporal, right unilateral (also known as the d'Elia placement), and bifrontal positions. [42]  Bitemporal electrode placement is often referred to as bilateral electrode placement. However, since both bitemporal and bifrontal electrode placements are bilateral, particular care should be given to nomenclature. Further research is needed for the asymmetric bilateral placement and other novel electrode placements. [1, 43]

With bitemporal position, electrodes are placed bifrontotemporally, with the center of each electrode approximately 1 inch above the midpoint of an imaginary line drawn from the tragus to the external canthus. [42]

With unilateral electrode placement, one electrode is typically placed over the nondominant frontotemporal area, and the other electrode is placed just lateral to the midline vertex on the nondominant side. [42]  As the left hemisphere is dominant in most people, unilateral electrode placement is almost always over the right hemisphere and is commonly referred to as right unilateral ECT.

In the bifrontal position, the placement of an electrode on each side of the head is more frontal than in bitemporal placement.

In the first several years of use, ECT was performed without anesthesia. Since the late 1950s, however, ECT has been performed under general anesthesia. [18] The goal is to produce a brief period of general anesthesia accompanied by muscle relaxation. The level of desired sedation exceeds so-called conscious sedation. Inadequate anesthesia may lead to problems such as incomplete unconsciousness and autonomic arousal.

Induction anesthetic agents used in ECT include the following: [1, 44]

• Methohexital (barbiturate)

• Etomidate (nonbarbiturate)

• Ketamine (nonbarbiturate)

• Fentanyl and analogues (opioid)

• Propofol (nonbarbiturate)

Methohexital is most commonly used and is the preferred anesthetic for ECT because of its established safety record, effectiveness, and low cost. Propofol, while an effective induction anesthetic, has the greatest anticonvulsant properties of commonly used agents for ECT. Ketamine and etomidate have the least negative impact on seizure duration [1, 44] Inhalational anesthesia with medications such as sevoflurane may also be an option, but such approaches are uncommon. [45]

The cognitive outcome after ECT may be affected by the choice of the anesthetic medication. [46] No matter which anesthetic medication is used, the appropriate dose should be established at each treatment session, and adjustments should be made at subsequent treatment sessions. [1]  As seizure quality is directly affected by the choice of induction anesthetic agent, the ECT treatment team and the anesthesia team should discuss choice of induction agent and should consider seizure efficacy when considering changes to the anesthesia care plan. [47]

Neuromuscular blockers are administered to prevent musculoskeletal complications (fractures or dislocations) related to motor activity during the seizure that occurs with ECT. [18]  This is especially important if the patient has osteoporosis or a history of spinal injury. [48, 18]

Muscle relaxation is traditionally performed with succinylcholine. This agent is the most commonly administered neuromuscular blockade during the ECT procedure. However, rocuronium and other nondepolarizing neuromuscular blockade agents can also be considered particularly when followed by reversal using sugammadex. [49]

A nondepolarizing muscle relaxant may be indicated in patients with pseudocholinesterase deficiency, hypercalcemia, severe neuromuscular disease, severe osteoporosis, or a personal or family history of malignant hyperthermia. [1]

Prior to electrical stimulation, the sufficiency of muscle relaxation is determined by the reduction or loss of deep tendon reflexes; loss of plantar reflexes; loss of muscle tone; the reduction or failure to respond to a nerve stimulator; or any combination of these factors. [1]

ECT is associated with significant, but brief, shifts in autonomic nervous system response. After the electrical stimulus is administered during ECT, the patient experiences a parasympathetic response with a short period of bradycardia. This parasympathetic response typically lasts for a few seconds and is followed by a longer sympathetic nervous system response with tachycardia and a transient rise in blood pressure.

Prior to anesthesia, administration of anticholinergics (eg, atropine, glycopyrrolate) can reduce the risk of vagally mediated bradyarrhythmias or asystole and minimize oral and respiratory secretions. [1]

Anticholinergics can increase preexisting tachycardia and can cause constipation, fecal impaction, and urinary retention. Anticholinergic medication use is also associated with delirium. [1]

Due to tachycardia and associated rise in blood pressure (and presumably intracranial pressure) during ECT, clinicians may choose to proactively address the sympathetic nervous system response in patients prone to hypertension. Ideally, the patient's oral antihypertensive regimen would be optimized prior to their initiation of ECT. Once in the treatment room, clinicians can consider delivery of intravenous beta blockers prior to anesthesia induction. While esmolol is an effective intravenous beta blocker, it's anticonvulsant properties negatively impact seizure duration for the purposes of ECT. Other beta blockers, such as labetolol, are known to have less effect on seizure duration. [50]

A collaborative approach between the ECT psychiatrist, medical consultants, and anesthesia provider is a more meaningful and inclusive method than simply asking for clearance. [51]

A pre-ECT evaluation should include the following components: [1, 18, 42, 51]

• A thorough psychiatric history and examination, including history of response to ECT and other treatments

• Documentation of results of medication trials with speical attention to dose and duration

• An indication of hand dominance (i.e., right v. left)

• A medical history and examination, with special attention to cardiovascular, pulmonary, neurological, and musculoskeletal systems

• A history of dental problems and examination for loose or missing teeth

• A history of personal and family experiences with anesthesia

• A cognitive assessment (at minimum, evaluation of orientation and memory)

Though no routine set of laboratory tests for patients before undergoing ECT has been established, commonly ordered tests prior to initiation of ECT may include the following:

• Chest radiograph (especially with cardiovascular or pulmonary disease or history of smoking)

• Brain imaging (CT or MRI)

• Electroencephalogram (guided by history and examination)

• Neuroradiological/neuropsychological tests (guided by history and examination)

• Spinal radiograph (especially with known or suspected spinal disease)

• Consultation with medical specialties such as cardiology, neurology, neurosurgery, or endocrinology as required by special medical conditions

Informed consent is an important part of the process for ECT. In a descriptive systematic review of papers and reports that included 134 testimonies, approximately half the patients reported that they had received sufficient information about ECT and adverse effects. In that review, approximately one third of patients did not feel they had freely consented to ECT, even when they had signed a consent form. [52]

No patient with a capacity to give voluntary consent should be treated with ECT without his or her written, informed consent. The capacity to consent has generally been interpreted as evidence that the patient can understand information about the procedure and can act responsibly on the basis of this information. [1, 53]

The use of involuntary ECT is uncommon but may be critical in life-threatening situations such as catatonia, severe mania, or psychosis. Clinicians must be familiar with local state laws about the use of ECT in patients lacking the ability to provide informed consent. [54]

The informed-consent process should be documented in the patient's medical record and should include a discussion of the disorder, its natural course, and the option of receiving no treatment. [53]  Printed literature and videotapes about ECT may be useful. The family of the patient should be included in the discussion. [55]

The consent form for ECT should include the following information: [1, 53]

• A description of the ECT procedure with proposed benefits and potential risks

• A description of treatment alternatives including a discussion of no treatment

• A discussion of options regarding electrode placement and stimulus type

• The typical range for the number of treatments

• A statement concerning the need for continuation or maintenance treatment including pharmacotherapy and/or maintenance ECT

• Discussion of the possible risks, including death, cardiac dysfunction, confusion, and memory impairment

• A listing of patient requirements during the ECT course, such as taking nothing by mouth after midnight and stopping driving

• A statement that consent is voluntary and can be withdrawn at any time

Concurrent medical conditions and their treatments may affect the response to and risks associated with electroconvulsive therapy. [1]

Neurological comorbidities

Caution is advised for patients with space-occupying intracranial lesions, as these individuals are at increased risk for edema and brain herniation after ECT. Patients with intracerebral lesions that lack a mass effect can safely undergo ECT. [56]

ECT increases intracranial pressure and blood flow to the brain. Patients who have increased intracerebral pressure or are at theoretical risk for cerebral bleeding, such as those with cerebrovascular disease and aneurysms, may be at increased risk during ECT. Patients with very recent strokes may be an area of special concern. However, patients with remote history of cerebrovascular accident have not shown adverse effects from ECT when studied. [56]

ECT has been safely used after coil embolization of a cerebral aneurysm. [57] ECT has been used in the presence of Charcot-Marie-Tooth disease, [58] arachnoid cysts, [59, 60] epilepsy, [1, 61] myasthenia gravis, [1] and multiple sclerosis. [1]

Cardiac comorbidities

Patients with cardiac disease can be evaluated by a cardiologist who can provide recommendations for the patient’s management during the course of ECT. [1, 18, 62] In patients with unstable angina, uncompensated congestive heart failure, uncontrolled hypertension, high-grade atrioventricular block, and symptomatic ventricular arrhythmias, ECT raises the risk of symptoms from these cardiac conditions. [1] Patients with hypertension should be stabilized with antihypertensive medications before undergoing ECT. [63] Patients with a recent myocardial infarction (MI) may be at higher risk of cardiac complications such as MI, although the risk decreases as the time interval between the MI and ECT increases.

With a proper pre-ECT cardiac and pacemaker/defibrillator assessment, patients with cardiac pacemakers and implantable cardioverter defibrillators can safely undergo ECT. [64] ECT has been used in the presence of severe aortic stenosis [65] , and it has been used after heart transplantation, though further studies are needed. [66]

Other comorbidities

Patients who have medical disorders associated with autonomic sensitivity (eg, clinically evident hyperthyroidism, pheochromocytoma), with sensitivity to anesthesia (eg, amyotrophic lateral sclerosis, porphyria, pseudocholinesterase deficiency), or with cognitive sensitivity (eg, traumatic brain injury) may require more extensive workup and closer monitoring during ECT. [48]

Patients with gastroesophageal reflux disease may experience worsening symptoms during ECT, due to stimulation of the vagus nerve. [18]

Patients with diabetes, metabolic disorders (eg, hyperkalemia, hypokalemia, hyponatremia), chronic obstructive pulmonary disease, hypercoagulable states, glaucoma, and renal disease require close monitoring during ECT. [1, 67]

Some medications may be continued during ECT, some medications are decreased or withdrawn, and some augment ECT. [1]

In general, medications that decrease acute risks from general anesthesia or the ECT procedure should be given prior to treatment. Medications such as antihypertensives, antianginals, antiarrhythmics (except lidocaine), bronchodilators (except theophylline), glaucoma medications (except long-acting cholinesterase inhibitors), and corticosteroids [1] may be safely given prior to ECT. Antacid medications and proton pump inhibitors may be safely used. [18]

Diuretics and hypoglycemics may be withheld until after an ECT treatment. [1, 48] Theophylline should be discontinued if possible given the proconvulsant effect of that medication. [1, 48]

Anticonvulsants should be lowered in dose as much as clinically possible during ECT, because antiepileptics may raise seizure threshold, adversely affect seizure expression, or possibly affect clinical efficacy. [1] One review found that the combination of various anticonvulsants and ECT was safe and effective, though no evidence indicated that this combination increased efficacy. [68]

Monoamine oxidase inhibitors (MAOIs) can be continued during the course of ECT. Nevertheless, some clinicians withdraw MAOIs 7–14 days before ECT. [1]

The combination of ECT and antipsychotics may be more effective in schizophrenia than either treatment alone. [1, 33] Although definitive conclusions cannot be made, the combination of ECT and antipsychotics is safe and effective in schizophrenia, especially in patients whose symptoms are refractory to conventional treatments. [69, 70]  Although clozapine is known to induce spontaneous seizures, this adverse effect was not increased in populations receiving ECT and clozapine simultaneously. [33]

Debate about the safety of lithium during ECT is ongoing, as some patients have no problems but others may have a higher risk for delirium or prolonged seizures. [1, 42, 71]  A study of maintenance ECT included lithium as a long-term medication without increased cognitive adverse effects in the patients receiving lithium and ECT. [23]  Benzodiazepines should be discontinued if possible. If benzodiazepines cannot be discontinued, then the dose should be reduced to the lowest effective dose. [1]

Many child and adolscent psychiatrists have little training or knowledge of ECT. The American Academy of Child and Adolescent Psychiatry published an overview of ethical issues in January 2012. The guidelines suggest that written, informed consent be obtained from the parents and that a second opinion on the necessity of ECT be obtained from an independent psychiatrist not involved in the treatment of the minor. [72]

Diagnostic considerations for ECT in an adolescent patient [73] include severe or persistent major depression or mania [74] with or without psychotic features, schizoaffective disorder, schizophrenia, catatonia, [75] or neuroleptic malignant syndrome. The symptoms must be severe, persistent, and disabling.

Before considering ECT in children and adolescents, lack of treatment response should be documented. Lack of treatment response is defined as failure to respond to at least 2 adequate trials of appropriate psychopharmacological agents accompanied by other appropriate treatment modalities. [73]  

The response rate for mood disorders to ECT in the pediatric population is 63% and 80% for catatonia according to the largest review of ECT use in the pediatric population. [76]  A more recent systematic review from 2013 found similar results. [77]

Geriatric patients can be particularly sensitive to adverse effects from daily medications, including psychotropic medications. The use of ECT in the elderly population may reduce risks associated with polypharmacy if the number of psychotropic medications can be reduced. A high proportion of patients who receive ECT are in the geriatric age group. [1] In elderly patients, ECT has been used to treat catatonia, [78] bipolar mania, [79] and psychotic disorders. [78]

Generally, geriatric patients with depression have better outcomes with ECT than do younger patients. [1] ECT is especially indicated for patients with depression who are at risk for harm because of psychosis, suicidal ideation, or severe malnutrition, [80, 81, 82] but it is also helpful for treatment-resistant nonpsychotic major depression. [83, 84]

Seizure threshold may rise with increasing age, and effective seizures may be hard to induce. [1] Geriatric patients may be at a higher risk for persistent confusion and greater memory deficits during and after ECT. [1]

ECT is considered safe and effective for the mother and fetus in the treatment of major depressive disorder during pregnancy. [22, 63] ECT is a potential treatment for patients with bipolar disorder who are experiencing mixed episodes [27] , severe mania, or severe depression during pregnancy. [28]

ECT can be considered as an option to decrease extended exposure to psychotropic medication during pregnancy [85] or for those pregnant women whose symptoms fail to respond to standard therapy. [86] Obstetric consultation should be obtained and fetal monitoring should be used, when appropriate.

Patients in late pregnancy should lie on their left side during ECT to ensure adequate blood flow to the fetus. Hyperventilation is to be avoided. [87]

Transmission of anesthesia medications across the maternal-fetal barrier is considered to be minimal. [18] ECT is considered relatively safe in terms of teratogenicity and neonatal toxicity. [1] Because of an increased risk of gastric reflux and possible aspiration, pregnant women may be premedicated with a nonparticulate antacid, such as sodium citrate. [1]

Generally, breastfeeding does not need to be interrupted during ECT. Anesthetic agents pose little risk to the nursing infant. Exposure of nursing infants to medications may be decreased if the mother delays feeding for several hours after an ECT treatment. Alternatively, breast milk may be collected and stored before an ECT treatment and given via bottle after an ECT treatment. [1]