In 1935, the Hungarian neuropsychiatrist Von Meduna thought that schizophrenia and epilepsy were two mutually antagonistic disorders (which later proved to be incorrect), and thus created spasmotherapy with the drug cardiazole (Fink 1984). In 1938, Creletti and Bini invented electroconvulsive therapy, which is easy to operate, easy to grasp and has fewer side effects, so it quickly replaced drug spasm therapy and was widely used. China is also the first to use drug spasm therapy, and then the application of electroconvulsive therapy. Electric convulsive therapy (ECT) is also known as electric shock therapy (EST). ECT was the main treatment method for schizophrenia and other psychiatric disorders in the 40s and 50s. ECT has been widely used at home and abroad to improve the traditional electroconvulsive treatment, that is, to add intravenous anesthetics and muscle relaxants before ECT, so that the patient’s convulsions are significantly reduced or do not occur and there is no fear after being electrified, and it is also easily accepted by patients and families. Because of its broad indications, high safety, few complications, and low mortality rate of about 1/80,000 (American Psychiatric Association 2001); therefore, it has been used as the standard treatment, and is generally called MECT in China.
I. Indications Same as with convulsive electroconvulsive shock.
1, severe depressive state, people with strong self-injury, suicide attempts and behaviors, and people with obvious self-blame and self-criminalization.
2, severe excitable state, those who are extremely excited, agitated, impulsive, and wounded
3.Persons who refuse to eat, disobedience and catatonic lignocaine
4.Psychotropic drug treatment is ineffective or intolerant to drug treatment.
II. Contraindications
There are no absolute contraindications to twitch-free electroconvulsive therapy, but the following specific clinical conditions may increase the risk of MECT treatment.
1. Occupational lesions of the brain and other lesions that increase intracranial pressure.
2. Recent intracranial hemorrhage.
Unstable or severe cardiovascular disease such as myocardial infarction, unstable angina, inadequate blood supply heart failure, and valvular heart disease.
4, Bleeding or unstable aneurysmal malformation.
5, Retinal detachment.
6.Pheochromocytoma.
7, Respiratory diseases such as severe chronic pulmonary obstruction, asthma, pneumonia, etc.
8.Diseases leading to risk of anesthesia (such as severe respiratory and liver and kidney diseases, etc.).
III. Pre-treatment preparation Same as with convulsive electroshock.
1. Obtain informed consent. In order to fully express the risks and benefits, the consent form should include the following information: (1) Who recommended the use of ECT treatment and for what reasons. (2) A description of alternative treatments for available patients. (3) A description of the treatment procedure for ECT, including the number of treatments and when they will be given and the place where they will be given. (4) Discuss with the patient the advantages and disadvantages of different types of methods of placing stimulating electrodes and explain the rationale for giving the patient a particular type of treatment. (5) After the maximum number of treatments that can be performed in a session has been fully completed, if continued treatment is still required, indicate to the patient that informed consent for that treatment needs to be renewed. (6) To indicate that treatment with ECT is not guaranteed to be definitely effective. (7) To indicate that the patient is at risk of recurrence after ECT treatment, and to indicate some other treatment that the patient should undergo after ECT treatment. (8) Indicate the likelihood of the risk occurring (very rare, rare, uncommon, or common) and the severity of the major risks, including fatalities, cardiovascular adverse effects, central nervous system adverse effects (including transient and long-term perceptual aspects), and some other common minor negative effects. (9) Informed consent for ECT should also include informed consent that the hospital has the right to take appropriate emergency measures if the patient presents with an indication that requires clinical emergency care. (10) A description of what behavioral limitations the patient has during the pre-ECT evaluation, during ECT treatment, and during the recovery period of the disease. (11) If the patient has questions about the recommended treatment plan, provide a person who is available at any time to answer such questions, specifying the name of this person and how to contact them. (12) Indicate that informed consent for ECT is entirely voluntary and that the option to withdraw is available at any time. (American Psychiatric Association 2001).
2. A detailed physical examination, including a neurological examination. Laboratory tests and ancillary examinations such as routine blood work, blood biochemistry, electrocardiogram, electroencephalogram, chest and spine radiographs, if necessary.
3. No anti-epileptic and anti-anxiety drugs are used for 8 hours before treatment to avoid undesirable seizures; lower doses of antipsychotics or antidepressants or lithium salts applied during treatment should be used.
4, the preparation of the treatment room: quiet, avoid noise, spacious and bright (light should not be too strong), room temperature to maintain 18-26 ℃; prepare emergency drugs and resuscitation appliances; electroconvulsive therapy appliances: power supply, electrotherapy machine, conductive gel, small sand pillow, dry towel, treatment table, dental pads, hard board bed, wrapped in gauze tongue depressor.
5.Fast 8 hours before treatment, 4 hours of water fasting, evacuation of urine and feces.
6.Temperature, pulse, respiration and blood pressure before treatment and recorded in the treatment sheet; temperature, pulse and blood pressure were measured before treatment. If the body temperature is above 37.5℃, pulse rate is above 120 beats/min or below 50 beats/min, blood pressure is above 150/100mmHg or below 90/50mmHg, it should be disabled.
7.Empty the bowels and urine, remove the movable denture, hairpin, untie the collar buckle and belt before doing the treatment.
8.Pre-treatment medication: usually subcutaneous injection of atropine 0.5~1.0mg 15~30 minutes before treatment to prevent vagus nerve overexcitation and reduce secretion. If the respiratory recovery is not good in the first treatment, lopressor 3.0-6.0 mg can be injected subcutaneously 15-30 minutes before each subsequent treatment.
MECT treatment team Contains at least one psychiatrist who performs MECT, an anesthesiologist, and one or more nurses. Trained and appropriately qualified to perform MECT.
1. Duties of the psychiatrist operating MECT: This person should have primary responsibility for MECT treatment; this also includes assessing the patient before MECT begins, ensuring that the pre-MECT assessment is completed successfully, confirming that the patient has a clinical indication for MECT treatment before each MECT treatment, and ensuring that MECT treatment is in accordance with local policies and treatment procedures.
2. Functions of the anesthesiologist: maintaining an open airway, administering oxygen to patients, use of simple anesthetics, use of muscle relaxants, cardiopulmonary resuscitation techniques, management of acute adverse reactions, etc. Anesthesiologists must be able to deal with medical emergencies until the arrival of relevant resuscitators.
3. The nursing staff and assistant functions include providing good logistics for the treatment team, preparing the treatment area before MECT treatment, transporting patients, performing stimulation and electrode monitoring, monitoring patient vital signs, patient pre-MECT assessment, and patient recovery care after treatment, etc., providing clinical or financial assistance, assisting in patient and family education, participating in the When MECT is performed in an ambulance, the nursing staff is also responsible for the patient’s pre-MECT assessment and post-treatment recovery care. The nursing staff in the recovery area must be registered nurses to care for the patient in the recovery area. Their duties include checking the patient’s vital signs, monitoring the oximeter and ECG, monitoring the patient’s mental status, administering oxygen and administering intravenous infusions to the patient, suctioning, and caring for the patient’s disorientation and irritability symptoms after treatment, and these duties should be performed under the supervision of an anesthesiologist or psychiatrist These duties should be performed under the direction of an anesthesiologist or psychiatrist. If there are multiple patients in the recovery area, it is best to have multiple nurses to care for them accordingly.
Operation method
1. Generally performed in the morning. The patient is placed supine on the treatment table with the limbs naturally extended and a sand pillow between the shoulder blades, so that the head overstretches the anterior spine.
2.Insert atropine 1mg to reduce respiratory secretions and prevent cardiac arrest caused by vagal nerve excitation during energization.
3.Insert 2.5% thiopental sodium 9-14ml (about 1.0-2.5mg/kg) at a rate of 3ml/min (faster) for the first 6ml and 2ml/min (slower) for the next 6ml until the lash reflex is blunted or disappears and the patient does not push until he/she calls out. Etomidate or propofol can also be used to induce anesthesia.
4, thiopental sodium sedation 7.5 ~ lOml or so (about 2/3 of the full amount) when giving oxygen inhalation.
5, 0.9% sodium chloride 2ml sedation to prevent precipitation of sodium thiopental mixed with succinylcholine chloride. Then, 1 ml of succinylcholine chloride (50 mg) was diluted to 3 ml with water for injection for rapid sedation (done in 10 seconds). One minute after drug injection, muscle bundle twitching (end-plate depolarization) from the lid face and corner of the mouth to the thorax and abdomen and extremities was seen, followed by general muscle relaxation, disappearance of tendon reflexes, and cessation of spontaneous breathing. This is the best time to pass electricity.
6.In the late stage of anesthesia, electrodes coated with conductive gel are placed immediately on the two temporal sides of the patient’s head (bilateral electrode placement) or on the right parietal temporal part (unilateral electrode placement), local contact should be steady to reduce resistance.
7. Stop oxygen supply. Place a tongue depressor between the upper and lower molars on the patient’s side, and hold the jaw tightly by hand (if there is no convulsive electrospasm treatment, the tongue depressor can also be used, but the jaw must be held tightly). In principle, the power regulation is based on the moderate power level above the threshold for causing spasmodic seizures. According to different treatment machines to determine the appropriate energization parameters, such as AC electrotherapy machine is generally 90 ~ 110 ~ 130mA, energization time of 3 ~ 4 seconds. If there are no convulsions within 20-40 seconds after energization, or if non-generalized convulsions are produced for a short period of time, the treatment can be repeated once, at which time the current can be increased by lOmA or the time by 1 second, but both should not be increased at the same time, and the number of energizations should not exceed 3 times per treatment.
8.When the lid, face and extremity convulsions will end, oxygen is supplied by a valve balloon and artificial respiration is performed under pressure, and spontaneous respiration can be completely restored in about 5 minutes.
9, The convulsive seizures seen under EEG monitoring are staged as follows: (l) EEG inhibition period at the beginning of spasm (referring to the end of energization to the beginning of fulminant EEG activity): manifested as isoelectric line recording, the duration of this period varies in each brain region, generally ranging from 0.5 to 10 seconds. (2) Epileptiform discharge recruitment phase: the positive rate is about 25%, the duration is shorter, about 0.5 to 3 seconds, and it is a beta wave-like performance. (3) Multi-spike slow-wave phase: It shows a gradual shift from complex high-amplitude multi-spike waves to multi-spike-slow-wave activity. The duration varies depending on the placement of electrodes for electroconvulsive therapy, and is generally about 25 to 75 seconds. About 40% to 70% of patients can see the sudden disappearance of all waveforms at the end of the multi-spike – slow wave period, and the phenomenon of isotonicity of different lengths, called the switch phenomenon. The rest of the patients also see the disappearance of spikes and slow waves to other waveforms of lower amplitude. At this point, it should be regarded as the termination of the convulsive seizure seen in the EEG.
10. If the patient is unconscious and excited after the treatment, care should be taken to prevent accidents.
11. Patients who have already received treatment should check the last treatment record in detail and increase or decrease the power and time according to the length of the convulsive seizure and the recovery of breathing. Too small an amount of electricity is not enough to cause sufficient spasmodic seizures and affect the efficacy of treatment. Too much power and too long a convulsion duration (which may also be too short) can aggravate cognitive impairment and other side effects. The size of the twitch threshold varies depending on the patient’s gender, age, body type and the drugs applied to affect the twitch threshold. For example, young males who have not used sedative antispasmodic drugs and have a smaller amount of intraoperative anesthetics have a lower twitch threshold and vice versa.
V. Treatment course Same as with convulsive electroconvulsive.
Generally set at 6 to 12 times. In the first week and the second week, 1 time every other day, that is, 3 times a week, in the third week and the fourth week, 1 time every 3 days, that is, 2 times a week, and in the fifth and sixth week, 1 time. It can be increased or decreased according to the condition. Generally, about 6 times for manic state is enough; 8-12 times for hallucinatory delusional state; between the two for depressive state.
VI. Post-treatment care Same as with convulsive electroshock.
1.Wipe off the conductive agent with water or alcohol at the site where electrodes are installed.
2.After respiration is completely restored and agitation is calmed, and with the doctor’s consent before sending back to the ward.
3.Take blood pressure, pulse and respiration after treatment and record them in the treatment sheet.
4.Before full recovery of consciousness, a protective belt should be placed around the waist to prevent the patient from falling off the bed due to excitement and agitation, and to prevent the second convulsion from occurring in individual patients. However, it is better not to restrain the limbs firmly to prevent fractures caused by convulsions, and to keep someone to observe.
5.After recovering consciousness, the patient feels headache, dizziness or general weakness, etc., and needs to be assisted when getting up to prevent falling, so it is still necessary to have someone to patrol and observe.
6.After treatment, let the patient rest peacefully to reduce the headache and dizziness.
VII. Adverse effects of MECT
1.Cardiovascular complications
2.Prolonged seizures
3.Prolonged apnea
4.Headache, muscle pain, nausea
5.Acute mania caused by the treatment
6, Post-treatment delirium
7, Perceived side effects
The incidence of complications of non-convulsive electroconvulsive therapy is lower and less severe than that of conventional electroconvulsive therapy. No special treatment is necessary, and severe cases are treated symptomatically. Memory loss mostly recovers within a few weeks after cessation of treatment. However, anesthetic accidents, delayed asphyxia, and severe arrhythmias can occur and cardiopulmonary resuscitation should be given immediately.