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Salinas FV. Contemporary Anesthetic Evaluation and Management for Electroconvulsive Therapy. Adv Anesth 2022; 40:201-221. [PMID: 36333048 DOI: 10.1016/j.aan.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Electroconvulsive therapy (ECT) is a medical treatment most often used in patients with severe major depression that has not responded to other treatments. ECT is also indicated for patients with other severe psychiatric conditions, including bipolar disorder, schizophrenia, schizoaffective disorders, catatonia, and neuroleptic malignant syndrome. Contemporary "modified ECT" involves inducing general anesthesia with neuromuscular blockade before inducing the therapeutic seizure. The goal of this review is to combine an evidence-based update with the experience of the author's institution to provide a practical approach to anesthetic care for the patient undergoing ECT.
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Affiliation(s)
- Francis V Salinas
- Swedish Medical Center, Seattle and Issaquah, Washington, USA; Medical Director of Anesthesia Services and Interventional Platform-Swedish Issaquah Hospital, Issaquah, Washington, USA.
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Pérez-Balaguer A, Sánchez-Rivero I. Electroconvulsive therapy, catatonia, deep vein thrombosis and anticoagulant treatment: a case report. Gen Psychiatr 2022; 34:e100666. [PMID: 35028525 PMCID: PMC8705197 DOI: 10.1136/gpsych-2021-100666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/06/2021] [Indexed: 11/03/2022] Open
Abstract
Electroconvulsive therapy (ECT) is considered an effective treatment for pharmacotherapy-resistant severe mental disorders. Catatonia is a complex syndrome characterised by important psychomotor disturbances. Deep vein thrombosis (DVT) and pulmonary embolism (PE) are frequent side effects of prolonged immobility in catatonic patients. Therefore, it is important to resolve the catatonia as soon as possible. ECT is the most effective therapy available and is generally considered a safe procedure. Nevertheless, its use in patients with DVT or PE and anticoagulant treatment remains controversial. We describe a case of a woman in her 40s with a previous diagnosis of bipolar disorder and dysfunctional personality traits. She was hospitalised with persecutory and reference delusions, high emotional lability, anxiety, somatisation and regressive conduct. She later developed catatonic symptoms. No progress was achieved after a month of hospitalisation, despite several pharmacological treatments. She suffered multiple complications of prolonged bedding, such as an extensive DVT of the left common femoral, the external iliac and the common iliac veins. ECT was conducted under treatment with bemiparin. After the third administration, she showed improvement. No major bleeding or PE was developed. The safety of ECT while receiving anticoagulant therapy has been documented, though dosage and type of anticoagulant must be considered. Location of DVT (proximal or distal) may be an important topic to take into account. This report provides further evidence about the efficacy and safety of undergoing ECT in the context of concomitant serious medical conditions, such as DVT and anticoagulant therapy administration.
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Affiliation(s)
- Ana Pérez-Balaguer
- Department of Psychiatry, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain
| | - Irene Sánchez-Rivero
- Department of Psychiatry, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain
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Nordenskjöld A, Güney P, Nordenskjöld AM. Major adverse cardiovascular events following electroconvulsive therapy in depression: A register-based nationwide Swedish cohort study with 1-year follow-up. J Affect Disord 2022; 296:298-304. [PMID: 34606801 DOI: 10.1016/j.jad.2021.09.108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/06/2021] [Accepted: 09/26/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The cardiovascular response during electroconvulsive therapy (ECT) could induce major adverse cardiovascular events (MACE) in the short-term, while reduced depression could decrease the risk of MACE in the long-term. The balance between these potential effects has not been thoroughly investigated. METHODS This nationwide, registry-based cohort study included all patients admitted to Swedish hospitals due to moderate or severe unipolar depression between 2011 and 2018. Patients were divided into an ECT group and a non-ECT group, and followed for 1 year. Patients were matched by risk factors for cardiovascular disease by propensity score matching. Cox regression was used to examine the association between ECT and MACE. RESULTS Out of a total of 28 584 inpatients, 5476 patients who had received ECT were matched to 5476 non-ECT patients. ECT was associated with reduced risk of MACE within 90 days and 1 year. Within 1 year after admission, a total of 127 patients (2.3%) in the non-ECT group and 82 patients (1.4%) in the ECT group had at least one MACE (hazard ratio [HR], 0.65; 95% confidence interval, 0.49-0.85). LIMITATIONS Real-life observational studies carry risk for residual confounding. CONCLUSIONS ECT in patients hospitalized for depression was not associated with any significant short-term risks of cardiovascular events. Instead, ECT was associated with a reduced risk of MACE within 1 year after admission compared with patients not treated with ECT. This association may be explained by reduced depressive symptoms after ECT, improved risk factor management in the ECT-group or by residual confounding by indication.
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Affiliation(s)
- Axel Nordenskjöld
- The University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Pelin Güney
- The University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anna M Nordenskjöld
- Department of Cardiology, Faculty of Medicine and Health, Örebro University, Södra Grev Rosengatan, Örebro 701 85, Sweden.
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Centanni NR, Craig WY, Whitesell DL, Zemrak WR, Nichols SD. Safety of ECT in patients receiving an oral anticoagulant. Ment Health Clin 2021; 11:254-258. [PMID: 34316422 PMCID: PMC8287866 DOI: 10.9740/mhc.2021.07.254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/21/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction This study assessed the use, tolerability, and safety of anticoagulation via direct oral anticoagulants or warfarin in medical and psychiatric inpatients receiving ECT. Methods This retrospective cohort study included 32 patients who received ECT while on either a direct oral anticoagulant (9) or warfarin (23) and spanned 247 encounters at Maine Medical Center between December 2012 and December 2018. Data are presented descriptively and analyzed using SPSS version 25 and Microsoft Excel version 2016. Results Among the 247 ECT patient encounters, there were few major adverse effects of ECT in this medically complex population. These adverse effects included headache during 4 encounters (1.6%), respiratory distress during 2 encounters (0.8%) and a cardiovascular event during 1 encounter (0.4%). One patient (3.1%) who was receiving concurrent rivaroxaban and venlafaxine experienced gastrointestinal bleeding that was determined to be unrelated to ECT. One patient on fluoxetine and warfarin experienced hemoptysis thought to be secondary to epistaxis. No other major bleeding or clotting event occurred during an ECT session nor for the duration of the hospitalization. Discussion Direct oral anticoagulants and warfarin appear safe in the treatment of patients with atrial fibrillation or acute venous thromboembolism who are receiving concomitant ECT. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Nicolette R Centanni
- Research Navigator, Maine Medical Center Research Institute/Center for Outcomes Research & Evaluation, Scarborough, Maine.,Director, Consultation and Liaison Services, Associate Residency Training Director, Psychiatry Clerkship Director, Maine Medical Center, Portland, Maine.,Pharmacy Supervisor of Hemostasis and Thrombosis, Maine Medical Center, Portland, Maine.,Associate Professor of Pharmacy, Westbrook College of Health Professions, Portland, Maine; Adjunct Clinical Assistant Professor of Psychiatry, University of New England School of Medicine, Tufts University, Boston, Massachusetts
| | - Wendy Y Craig
- Research Navigator, Maine Medical Center Research Institute/Center for Outcomes Research & Evaluation, Scarborough, Maine
| | - Dena L Whitesell
- Director, Consultation and Liaison Services, Associate Residency Training Director, Psychiatry Clerkship Director, Maine Medical Center, Portland, Maine
| | - Wesley R Zemrak
- Pharmacy Supervisor of Hemostasis and Thrombosis, Maine Medical Center, Portland, Maine
| | - Stephanie D Nichols
- Associate Professor of Pharmacy, Westbrook College of Health Professions, Portland, Maine; Adjunct Clinical Assistant Professor of Psychiatry, University of New England School of Medicine, Tufts University, Boston, Massachusetts
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Yoshizawa K, Takeshima M, Ishino S, Ogasawara M, Fujiwara D, Itoh Y, Imanishi A, Ohta H, Mishima K. Severity of Depressive Symptoms is Associated with Venous Thromboembolism in Hospitalized Patients with a Major Depressive Episode. Neuropsychiatr Dis Treat 2021; 17:2955-2963. [PMID: 34584413 PMCID: PMC8464371 DOI: 10.2147/ndt.s331409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/10/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE A major depressive episode is a risk factor for venous thromboembolism (VTE) in psychiatric inpatients. However, it is unclear whether the severity of depressive symptoms or duration of the current depressive episode is associated with VTE. Further, the VTE prevalence among hospitalized patients with a major depressive episode receiving electroconvulsive therapy is unknown. This retrospective study examined factors associated with VTE among hospitalized patients with a major depressive episode and estimated the prevalence of VTE in such patients who underwent electroconvulsive therapy. PATIENTS AND METHODS Patients with a major depressive episode hospitalized in the Department of Neuropsychiatry at Akita University Hospital between January 2018 and December 2020 were included. Data from the first week of hospitalization were extracted from medical records. VTE was diagnosed based on the findings of computed tomography. To evaluate whether the severity of depressive symptoms or duration of the current depressive episode was associated with VTE, logistic regression analysis was conducted after adjusting for covariates with known VTE risk factors (antidepressants, antipsychotics, and physical comorbidities). RESULTS We analyzed 133 patients; of these, 14 were diagnosed with asymptomatic VTE. The severity of depressive symptoms (odds ratio: 1.220, 95% confidence interval: 1.081-1.377, p = 0.001) was significantly associated with VTE. The prevalence of VTE among those receiving electroconvulsive therapy was 35% (7/20). CONCLUSION The prevalence of VTE was 35% among patients receiving in-hospital electroconvulsive therapy for a major depressive episode. VTE should be considered for hospitalized patients with severe depressive symptoms and patients receiving in-hospital electroconvulsive therapy for a major depressive episode.
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Affiliation(s)
- Kazuhisa Yoshizawa
- Department of Psychiatry, Akita Prefectural Center for Rehabilitation and Psychiatric Medicine, Daisen City, Akita, 019-2492, Japan
| | - Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita City, Akita, 010-8543, Japan
| | - Sayaka Ishino
- Department of Neuropsychiatry, Sugawara Hospital, Yurihonjo City, Akita, 015-0012, Japan
| | - Masaya Ogasawara
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita City, Akita, 010-8543, Japan
| | - Dai Fujiwara
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita City, Akita, 010-8543, Japan
| | - Yu Itoh
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita City, Akita, 010-8543, Japan
| | - Aya Imanishi
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita City, Akita, 010-8543, Japan
| | - Hidenobu Ohta
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita City, Akita, 010-8543, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita City, Akita, 010-8543, Japan
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Flumazenil for Successful Seizure Induction With Electroconvulsive Therapy: Case Report and Literature Review. Clin Neuropharmacol 2020; 44:29-32. [PMID: 33351502 DOI: 10.1097/wnf.0000000000000429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) is indicated for various psychiatric situations that are difficult to manage otherwise and may be regarded as a last resort but seizure induction is sometimes difficult, resulting in inadequate trials and futile outcomes. METHOD We report on a 72-year-old female patient with bipolar depression whose seizure induction with ECT was challenging but the use of flumazenil was deemed effective to obtain remission in the end. We also provide a literature review on this topic. RESULTS Seizure induction was managed with the use of flumazenil, a selective GABA-A receptor antagonist to neutralize the effects of benzodiazepine hypnotics, together with decreasing the amount of anesthesia, increasing the pulse width, and adding chlorpromazine. A PubMed search with keywords of flumazenil and ECT yielded only 14 hits (December 2020) and found some indication that flumazenil might be of use for this purpose even in the absence of benzodiazepines, although evidence base has remained very limited. CONCLUSIONS Flumazenil, an antidote of benzodiazepines, may be effective regardless of whether benzodiazepines are in use. Because inefficient ECT is clinically problematic, more studies are necessary to investigate the effectiveness of flumazenil for successful seizure induction with ECT.
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Electroconvulsive therapy in patients with cerebral aneurysms taking an anticoagulant or antiplatelet-report on three cases and review of the literature. Psychiatry Res 2020; 288:113022. [PMID: 32335467 DOI: 10.1016/j.psychres.2020.113022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/14/2020] [Accepted: 04/14/2020] [Indexed: 11/20/2022]
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Warriach ZI, Shamim SA, Saeed A, Kashif S, Malik BH. Association of the Thrombo-embolic Phenomenon with Electroconvulsive Therapy Treatment in Schizophrenia with Catatonia Patient. Cureus 2019; 11:e5656. [PMID: 31700757 PMCID: PMC6822908 DOI: 10.7759/cureus.5656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Catatonia is a condition in which patients manifest with a complex of symptoms of behavioral and motor abnormalities. This condition can present with schizophrenia, bipolar, depression, and certain neurological illnesses. In this article, we analyze the coincidence of deep venous thrombosis (DVT) in schizophrenia with catatonia patients managed with electroconvulsive therapy (ECT) and the possible outcome of complications as an adverse event. The conclusion drawn from this traditional review reveals the importance of early diagnosis and treatment intervention of catatonia patients with ECT. No bleeding-related complications occurred with the use of anticoagulants by catatonic patients managed with ECT and having underlying thrombosis. Literature also indicates that ECT can be safely administered for patients with distal deep venous thrombosis (DVT) treated with anticoagulants, while those with proximal DVT, ECT should be halted and anticoagulation treatment should be continued until the resolution of DVT to safely resume the ECT sessions. A possible alternative to ECT therapy for the patients with refractory schizophrenia with catatonia (who have safety concerns) is recombinant transcranial magnetic stimulation (rTMS). Nonetheless, more studies are needed to support our assertion.
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Affiliation(s)
- Zain I Warriach
- Psychiatry, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Sohaib A Shamim
- Neurology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Aisha Saeed
- Family Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Saima Kashif
- Department of Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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