Transcript The ECT consultant

Tasks for the ECT team
Dr Grace Fergusson
Argyll and Bute Hospital
Lochgilphead
Royal College of Psychiatrists ECT training day, January 2002
The ECT consultant
Advice and liason
 Treatment policy
 Training
 Supervision

Advice and Liason
ECT suite and equipment
 Staffing
 Liason
 Management - clinical governance
 Audit

ECT machines - UK
Machine
output
(mC)
control +display
EEG
ECTONUS 5A 50-700
ECTONUS 5B 50-700
single
single
yes
yes
optional
optional
NTS-R
NTS-C
multiple
single
no
no
no
no
75-4455
60-720
ECT machines - Mecta
Machine
output
(mC)
control +display
EEG
JR1
SR1
JR2
SR2
Spectrum
4000 Q or M
5000 Q or M
22-1152
22-1152
25-1200
25-1200
multiple
multiple
single
single
yes
yes
yes
yes
no
yes
no
yes
5-1152
5-1152
either
either
yes
yes
no
yes
ECT machines - Somatics
Machine
output
(mC)
control +display
EEG
Thymatron
DGx
25-1008
either
yes
optional
Thymatron
system IV
25-1008
either
yes
yes
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
 Receptor modulator
 Neurotrophic (BDNF)
 Changes in gene expression
(1)
(2)
(3)
(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;14:20619
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
s/e +++
70% efficacy
s/e ++
Unilateral
70% efficacy but 30% efficacy
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
s/e +/-
Prescription of ECT
high dose
Bilateral
Unilateral
low dose
70% efficacy
s/e ++
70% efficacy but 30% efficacy
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
s/e +/-
Prescription of ECT
high dose
Bilateral
Unilateral
low dose
70% efficacy
s/e ++
70% 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 fixedhighdose Right Unilateral ECT, 2000, Archives of Gen Psychiatry, 57,438-444.
Cognitive side-effects
Time to re-orientation (minutes):
study 1
study 2
low dose uni- (ST x 1.5) 11
18.7
high dose uni- (ST x 5) 19
30.7
low dose bi- (ST x 1.5) 37
high dose bi- (ST x 3) 40
45.5
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
Stimulus dosing protocols
missed seizures
 partial seizures
 progressive shortening of seizure
length


prolonged seizures
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:




training
supervision
anaesthetist
nurses
1981 1991 1996 1997 1999
(scotland)
10
43
35
10
66
66
60
93
16
45
100
100
‘varied’
1. Royal College of Psychiatrists, three audit cycles, 1981, 1991, 1996
2. The National Audit of ECT in Scotland , 1997-00
93
50
100
94
Tasks for the ECT team
Dr Grace Fergusson
Argyll and Bute Hospital
Lochgilphead
Royal College of Psychiatrists ECT training day, Jan 2002