Anesthesia Management for Electroconvulsive Therapy by Shigeru Saito

Author:Shigeru Saito
Language: eng
Format: epub
Publisher: Springer Japan, Tokyo

5.4 Respiratory Management

Although respiratory care during ECT is required for only approximately 10 min, inappropriate management interferes with the efficacy of the therapy and increases the risk of complications [10, 24, 83]. Following anesthesia induction with an anesthetic agent and a muscle relaxant, the airway should be secured and ventilation should be supported manually. Hypocarbia induced by hyperventilation may be required in some patients, to ensure appropriate seizure duration, because hypocarbia prolongs seizure duration [84, 85]. Our previous study [24] demonstrated that end-tidal carbon dioxide measurement at the nostrils is effective in maintaining the required carbon dioxide level before electrical stimulation. In some patients for whom mask ventilation is difficult because of oromandibular anatomic reasons, airway devices, including laryngeal masks, can be used for adequate ventilation [86]. Since incidents involving regurgitation are very rare, intubation is not necessary in most cases [87]. Some authors, however, recommend intubation during ECT when this therapy is applied for depression during late pregnancy [88, 89].

During electrical stimulation, even under the use of a muscle relaxant, the facial muscles are electrically stimulated. Dental and lingual protection should be used, either by the use of a specially designed mouthpiece or by fixing the mandibular joint at the maximally closed position [10].

After completion of the electrical stimulation, oxygen consumption and carbon dioxide production are elevated by the seizure activity [46] (Fig. 5.7). Fasciculation that is induced by succinylcholine also contributes to the elevated oxygen demand and carbon dioxide production [24]. To overcome the elevated oxygen demand and carbon dioxide production, anesthesiologists should increase ventilation volume adequately. Hypoxia and/or hypercarbia induced by inadequate ventilation after the electrical stimulation aggravate hypertension and tachycardia after the seizure [24]. The incidence and intensity of postictal excitement and headache may also be increased by prolonged hypercarbia [86].

Fig. 5.7Typical respiratory management during electroconvulsive therapy (ECT) in a patient. (a) Minute volume trend when the anesthetist tried to maintain the end-tidal carbon dioxide partial pressure at 35–40 mmHg. (b) Typical trend of carbon dioxide production during ECT. (c) End-tidal carbon dioxide partial pressure trend when expired air was sampled from the laryngeal mask airway and the anesthetist tried to maintain the end-tidal carbon dioxide partial pressure at 35–40 mmHg (From Saito et al. [15]. Used with permission)

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