Nursing standards first level nurse responsibility registered nurse at each stage CPR competency escort nurse familiar and aware of legal issues and consent status backup easily available National Audit of ECT in Scotland, 1997-2000.
Guidelines for Anaesthesia consultant responsibility trained anaesthetists trained assistant (ODP) standard equipment ECT workup access to critical care for ASA grades 3 or above (medical condition affecting lifestyle)
Possible mode of action Anticonvulsant (1) Receptor modulator (2) Neurotrophic (BDNF) (3) Changes in gene expression (4) 1. Sackeim, The Anticonvulsant Hypothesis of the Mechanisms of Action of ECT: Current Status 2. Sattin A, The Role of TRH and Related Peptides in the Mechanism of Action of ECT 3. Krystal A & Weiner R, EEG Correlates of the Response to ECT all in The Journal of ECT vol 15 1999 4. Fochtmann LJ, Genetic approaches to the neurobiology of ECT. J of ECT 1998;14:206- 19
Advice and Liason ECT suite and equipment Staffing Liason Management - clinical governance Audit
Treatment policy 1. Role and interface between –psychiatrists, clinical and ECT teams –nurses –anaesthetist(s) 2. Treatment protocols
Prescription of ECT high dose low dose Bilateral 80% efficacy 70% efficacy s/e +++s/e ++ Unilateral70% efficacy but 30% efficacy depends on dose s/e +s/e +/- ref: Sackeim et al. New England J of Medicicne, 1993, 328:839-846 Sackeim et al. Archives of Gen Psychiatry. 2000, 57:425-434
Prescription of ECT high dose low dose Bilateral 70% efficacy s/e ++ Unilateral70% efficacy but 30% efficacy depends on dose s/e +s/e +/- ref: Sackeim et al. New England J of Medicicne, 1993, 328:839-846 Sackeim et al. Archives of Gen Psychiatry. 2000, 57:425-434
Prescription of ECT high dose low dose Bilateral 70% efficacy s/e ++ Unilateral70% efficacy but depends on dose s/e + ref: Sackeim et al. New England J of Medicicne, 1993, 328:839-846 Sackeim et al. Archives of Gen Psychiatry. 2000, 57:425-434
Bilateral ECT Sackeim et al. (series of studies 1991 - 93, USA) low dose UECT - 28% response low dose BECT - 70% response same seizure length cognitive side-effects related to dose above seizure threshold rather than absolute dose conclusion: best outcome when the dose exceeds seizure threshold (BECT) by 50 - 100% for a given individual
Unilateral ECT Efficacy increases with dose above ST maybe up to 12 fold side effects increase with dose above ST but probably not to the extent of BECT so maybe no need to measure ST? but technically more difficult ref:McCall, Reboussin, Weiner,Sackeim, Titrated Moderately Suprathreshold vs fixedhigh- dose Right Unilateral ECT, 2000, Archives of Gen Psychiatry, 57,438-444.
Cognitive side-effects Time to re-orientation (minutes): study 1study 2 low dose uni- (ST x 1.5) 1118.7 high dose uni- (ST x 5) 1930.7 low dose bi- (ST x 1.5) 37 high dose bi- (ST x 3) 4045.5 1. Sobin 1995, American J of Psychiatry 2. Sackeim et al. Archives, 2000, 57,425-434 3. Journal of ECT vol 16 June /00
Seizure threshold measure.pros:specific theraputic, despite seizure length decreased risk of overdose cons: time under anaesthetic risks of repeated stimulation? estimate. pros:quick cons:predictive factors for only 25% risk of overdose in upto 25% so keep starting dose low
EEG monitoring ? for:direct measure detection of prolonged seizures (indicator of clinical efficacy?) against: anxiety provoking?? time taken training implications
Other protocols Consent to treatment pre-ECT work-up record of treatment monitoring of side-effects feedback to clinical team
Special populations outpatients young people pregnancy cognitively impaired see The ECT Handbook 1995.
Training and supervision % adequate: 1981 1991 1996 1997 1999 (scotland) training 60 93 93 supervision 10 10 16 45 50 anaesthetist 43 66 100 100 100 nurses 35 66 ‘varied’ 94 1. Royal College of Psychiatrists, three audit cycles, 1981, 1991, 1996 2. The National Audit of ECT in Scotland, 1997-00
Tasks for the ECT team Dr Grace Fergusson Argyll and Bute Hospital Lochgilphead Royal College of Psychiatrists ECT training day, Jan 2002