ECT IN SPECIAL

POPULATIONS
Perinatal
Children and adolescents
Elderly
Medically ill patients
Cardiovascular Ds
Stroke
Epilepsy
SOL
Brain Tumors
Implant
• Although ECT may carry a higher degree of risk in some patients, it
may prove to be life-saving treatment and should not be unduly
delayed
Perinatal
• The American Psychiatric Association Task Force on ECT
recommended that ECT can be administered safely in all three
trimesters of pregnancy for severe illness (American Psychiatric
Association, 2001)
• Risk of severe mental illness vs psychotropic drugs vs ect
• During the later stages of pregnancy, concerns about premature labor
and placental abruption become more prominent.
• noninvasive fetal monitoring should be undertaken
• should be conducted in a facility having specialist obstetric services
• Pregnant woman about to undergo ECT should have obstetric
consultation beforehand.
• Postpartum
• Breast feeding - not need to be interrupted during a course of ECT
• Anesthetic agents administered with ECT pose little risk to the nursing infant
• The exposure to medication administered during ECT is lessened if breast
feeding is delayed by a few hours post treatment or by collection and storage
of breast milk the day prior to ECT.
Children and adolescents
• “ECT in children and adolescents is a safe, effective and lifesaving
treatment!” (Roberson et al. 2013)
• Clinical indications for ECT in children and adolescents are broadly
similar to those noted for adults
• Preferably anesthesiologist is experienced in the treatment of
adolescents
• Second opinion from an independent psychiatrist (AAPA)
• AACP (American Academy of Child and Adolescent Psychiatry) recommended that
before an adolescent is considered for ECT, he/she must meet three criteria:
1. Diagnosis: Severe, persistent major depression or mania with or without
psychotic features, schizoaffective disorder, or, less often, schizophrenia. ECT
may also be used to treat catatonia and neuroleptic malignant syndrome
2. Severity of symptoms: The patient’s symptoms must be severe, persistent, and
significantly disabling. They may include life-threatening symptoms such as the
refusal to eat or drink, severe suicidality, uncontrollable mania, and florid
psychosis
3. Lack of treatment response: Failure to respond to at least two adequate trials
with adequate dosage of appropriate psychopharmacological agents
accompanied by other appropriate treatment modalities
• Adverse effect may be similar to adult but lack of data
• Reports of more prolonged seizures but all evidences are weak
Immediately Post-
During ECT Long-term
ECT

Physical / /
Cognitive / /
Prolonged seizure /
Cardiovascular /
Death /
Elderly
• Effective in 50% patients who have failed drug therapy
• Short-term outcome of ECT treatment in the elderly with depression
appears to be more favourable compared with younger adults
• ECT should be considered a first-line treatment for those elderly
patients whose hepatic, renal, or cardiac functions prevent the use of
pharmacotherapy for depression
• ECT is a very reasonable choice, particularly for the elderly patient
who is medically compromised and is either not tolerating or not
responding to medications
• Medical consultation
• Issues
• Higher seizure threshold – need higher stimulus
• Medical comorbidities
• Higher risk of adverse events
• Confusion – unilateral ECT favoured
• Cardiac events
Medical Conditions
• SOL
• Intracranial AVM
• Epilepsy
• Cardiovascular Ds
• Implant

• No robust evidence
Medical Conditions - SOL
• Minimal risk, unless a/w increased ICP or other mass effects
• Asymptomatic meningioma most successful
• Risk-reduction strategies:
• Corticosteroids
• Diuretics
• Antihypertensive medications
• Hyperventilation
• Neurosurgical consultation pre-ECT is suggested to assess
• the status of the mass
• to consider whether a surgical procedure is indicated before ECT
• to suggest risk-reduction strategies that may be used during ECT
Medical Conditions - Intracranial AVM
• Risk of rupture
• Risk–benefit analysis on a case-by-case basis
• Primary anesthetic goal is to try to control the systemic BP
• Sudden increase/drop in Bp can caus rupture
• Risk-reduction strategies:
• Avoid hyperventilation
• Atenolol + Infusion of sodium nitroprusside
Medical Conditions - Epilepsy
• ECT has excellent anticonvulsant property
• For intractable medication-resistant epilepsy or status epilepticus
• May need regular epilepsy medication, despite increase in seizure threshold
• ECT safe
• Neurologist often recommend mimimal changes of AED
• ECT need higher stimulus
• Withold AED 24 hours or night before ECT
• Adjust AED dose - Watchout for breakthrough seizure
Medical Conditions - Cardiovascular Ds
• Do u remember this morning slide?
 ECT stimulation
Atropine
Glycopyrrolate
anticholinergi
c

Parasympathetic vagal outflow

Severe life-
threatening
Intense sympathetic surge bradyarrythmia
& hypotension
3-5 minutes
Tachycardia, Hypertension, Increased myocardial O2 Consumption

Myocardial
infatrct &
intracerebral Seizure terminated
hemorrhage
Rapid drop in BP & HR
• CCF
• Sympathetic nervous system stimulation ➜ aggravation of compromised left
ventricular function
• Stable or compensated CHF less likely to experience complications
• Decompensated CHF - should not undergo ECT
• Post MI
• Risk of re-MI
• Sympathetic nervous system stimulation ➜ ↑ myocardial O2 demand ➜
cardiac ischemia
• ≥60 days should elapse after a MI before noncardiac surgery in the absence of
a coronary intervention2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery
• Atrial Fibrillation
• 3 possible outcomes post ECT
• No complications
• Develop AF after ECT - should undergo a thorough cardiac evaluation before ECT is
resumed
• Convert from AF to sinus rhythm with ECT
• Patient’s heart rate should be well controlled
• ECG rhythm should be inspected prior to each treatment
Implant
• Cardiac pacemaker
• No issue with modern pacemaker
• But may interfere with older generation of pacemaker
• Consult with cardiologist
• Cochlear implant
• Consult otologist
• Do unilateral ECT at the opposite site of implant
• DBS
• Consult neurologist
• Recommendation is to off the DBS during course of ECT
References
• The Electroconvulsive Therapy Workbook: Clinical Applications, Alan
Weiss, 2018.
• Prinsloo S, Pretorius PJ. Electroconvulsive therapy and its use in
modern-day psychiatry. SAJP. 2004;10(2):38-44
• Hospital Kuala Lumpur Handbook on Elctroconvulsive Therapy. Yoon
CK, Yee OK, Aziz SA. 2014
• Rabheru K. The use of electro convulsive therapy in special patient
population. Can J Psychiatry. 2001;46:710–719
• Power point presentation by Mohammad Nabhan Khalil