Do Psychiatrists Usually Determine Anesthesia Medications and Dose for ECT?

[AD04]

How common is it for psychiatrists to determine which medications and at what dose to use for anesthesia for ECT? Do other proceduralist tell anesthesia how to practice?

The psychiatrist I'm learning from is choosing the preanesthetic medication and dose (in this case it was glycopyrrolate), the induction agent and dose, and the dose of the skeletal muscle relaxant. This guy is a genius and not just in psychiatry and I'm not sure if he is going above and beyond what psychiatrists usually do.

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[Taddy Mason]

How common is it for psychiatrists to determine which medications and at what dose to use for anesthesia for ECT? Do other proceduralist tell anesthesia how to practice?

The psychiatrist I'm learning from is choosing the preanesthetic medication and dose (in this case it was glycopyrrolate), the induction agent and dose, and the dose of the skeletal muscle relaxant. This guy is a genius and not just in psychiatry and I'm not sure if he is going above and beyond what psychiatrists usually do.

It varies in my experience. It was mutually discussed and decided upon between my attending and gas when I did my ECT months in residency. When I observed in med school (several different psychiatrists and at different hospitals) the psychiatrists barely talked with gas and just seemed to go along with whatever was done/recommended.

 

[Sushirolls]

I would typically say we're doing the default of med X and Y. Anesthesia would then set the weight based dosing or adjustment for what ever reason. Before the case we would consider other variables that would require adjustments. Typically from the angle of seizure threshold and anticipated needs of this unique patient.

Part of my documentation would include a recommendations for the next procedure, which might be an increase or decrease say in methohexital, or perhaps addition or subtraction of glycopyrolate, or whatever. Typically as patient is recovering would discuss these possible changes with anesthesia.

It really is a fluid discussion between the two specialties - mostly driven by seizure threshold concerns and quality of patient recovery.

My consult notes, would have in the A/P a section of recommended sedation meds. Anesthesia knew to review my consult / H&P note to guide which meds they would prep and have drawn up for the day. Rarely would they change it, and if they did we'd have a good discussion as to why before actually pushing meds.

 

[Liquid8]

Seems unusual to get too involved with that side of things as it's not typically something we'd be trained in doing.

Here our protocol is that the psychiatrist prescribing ECT will handover to both the psychiatrist and anaesthetist involved in the initial ECT session. Usually any red flags to be handed over will be obvious (eg. patient had a previous adverse reaction to an anaesthetic agent before) but they will do their own pre-op anaesthetic consultations and make decisions accordingly.

 

[Sushirolls]

Like many things in Psychiatry, things are different in our field. When it comes to ECT our job is to elicit a seizure, and a quality one. Seizure threshold. Stimulus dosing above threshold. RUL, BF, BT, BFT, etc for lead placements and their corresponding settings. Age based titration. Stimulus based seizure threshold dose titration. Anesthesiology came out with some good review articles several years back on methohexital dosing weight based, and also for succinylcholine. Some services have dropped using glyco unless determined a need for it. Others use by default. I've preemptively in my notes stated we need to use propofol, or blend of propofol with methohexital. I've done combos with ketamine or even etomidate.

Because the sedation meds impact what the procedure is about - a quality seizure - you bet we guiding which meds are used. Typically anesthesiology doesn't care because they are in the field of sedation people, and have used most of these meds on a regular basis and quite well versed in short sedation like that of the GI suite. They won't really speak up unless needed, and for good reasons, and when they do 99.9% of the time I say that sounds look a good reason to change and is in the best interest of the patient, make it happen.

Some ECT services in larger centers simply have the outpatient docs refer/order the treatment. Sometimes these patients get a consult with the ECT service some times they don't. Depends on the center. If they get a consult, the meds will likely be recommended in the consult note, or actually placed in the pre-procedure orders. If the former flow, the ECT service will see the ECT order, and that triggers the ECT nurse to likely tidy things up and prep the rest of the orders for the procedure doc on the first day of treatment, who will e-sign them ahead of time. Lots of different ways to get things done.

I had a simple solo set up where I did the consult, did the generic procedure orders, placed the med recommendations in my note. Anesthesiology came along did their consult, or did their outpatient anesthesiology clinic visit, and at that point, entered the fine details of the med orders for their anesthetics. Truly teamwork.

None of the above has even touched upon the issue of flumazenil... dosing, when to push, etc.
Then there are the recovery post procedure meds...

 

[AD04]

Interesting thing happened the other day. Patient wasn't fully flaccid after succinylcholine (same dose as the previous visit when she was completely flaccid) as she still had myoclonic jerks. The CRNA wasn't comfortable giving more succinylcholine due to fear of inducing severe bradycardia. I didn't know if I should have shocked or not.

I'm getting conflicting answers:

- yes as worst case is myalgia
- no as it could break bones and should have pushed for more succinylcholine

Have you ever encountered this situation and how did you respond?

 

[Sushirolls]

Interesting thing happened the other day. Patient wasn't fully flaccid after succinylcholine (same dose as the previous visit when she was completely flaccid) as she still had myoclonic jerks. The CRNA wasn't comfortable giving more succinylcholine due to fear of inducing severe bradycardia. I didn't know if I should have shocked or not.

I'm getting conflicting answers:

- yes as worst case is myalgia
- no as it could break bones and should have pushed for more succinylcholine

Have you ever encountered this situation and how did you respond?

Lots of variables. Join the ISEN-ECT.org society, and you'll get good answers there about application of the stimulus.

Succ doses seldom have drastic changes between cases especially after first few treatments; review of IV line, perhaps a flush, more time to circulate, etc.

 

[Stagg737]

How common is it for psychiatrists to determine which medications and at what dose to use for anesthesia for ECT? Do other proceduralist tell anesthesia how to practice?

The psychiatrist I'm learning from is choosing the preanesthetic medication and dose (in this case it was glycopyrrolate), the induction agent and dose, and the dose of the skeletal muscle relaxant. This guy is a genius and not just in psychiatry and I'm not sure if he is going above and beyond what psychiatrists usually do.

It varies in my program. At our academic institution, anesthesia handles all the meds. After the procedure we (the attendings) let them know if we felt the seizure was adequate or if adjustments need to be made then gas makes the adjustments themselves. At the VA we rotate through, it's basically how Sushi previously described. It's mostly CRNAs who work on the ECT cases, so the attending psychiatrists decide what initial doses are used and if adjustments need to be made during the procedure the CRNAs ask the attending before administering the adjusted dose. Afterwards the attendings record what the dose for the next procedure should be.