The Identification and Management of Patients with a High Risk for Cardiac Arrhythmias During Modified ECT

A recent report of the task force on ECT protocol emphasized the careful tailoring of both the anesthetic agent and muscle relaxant to the individual patient based on body weight and other medications. It also stressed the use of 100% oxygen via the anesthetic mask for 2-3 minutes before injecting the anesthetic agent in patients with higher risk. On the basis of our data showing that arrhythmias and ischemic events occur more frequently in patients in the high risk category, we suggest that other precautions be taken for ECT in this group to minimize the morbidity and mortality of ECT. The additional precautions should include: 1) medical clearance from an internist or cardiologist familiar with the complications of ECT. 2) cardiac monitoring immediately preceding during and for at least a ten to 15 minute period following ECT. 3) the presence at ECT of personnel trained in cardiopulmonary resuscitation and the emergency management of arrhythmias. 4) an EKG reading before each successive treatment to establish no significant interval change and 5) frequent electrolytes particularly in patients on a diuretic or digitalis therapy throughout the ECT course.

Both suicidal and non-suicidal deaths are higher in the depressed population and ECT is effective in reducing the incidence of both types of deaths. Studies indicate that ECT is superior to tricyclics in rapidity of response and in the percentage of positive responses. ECT exposes the patient to a very short period of risk during which time he is under the direct supervision of trained personnel. In addition tricyclic use has been associated with a variety of cardiotoxicities.

Although the rate of complications for ECT is very low, those that occur most often are cardiovascular in nature. It is hoped that through early identification and management of the group of patients at high risk for these complications that the morbidity and mortality of this extremely effective treatment for severe depression will be lowered even further.

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