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- Apr 30, 2006
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Hi all.
I'm currently assisting my attending with ECT on a 78 y/o male with lifelong intermittent depression, now substantially worse as he's gotten older. Some suspicion for bipolar depression though no clear recent mania or hypomania. Currently on venlafaxine and being switched from abilify to seroquel. Has tried a dozen or so other agents from every class other than MAOI. Only things he hasn't tried are ltihium (got it once in his 20's had a "bad reaction" that he can't remember and refuses to try it) and T3.
He had first gotten a course of ECT in his 20's. Then about 8 years ago a brief course here, and was maintained on meds until about 4 months ago. Got 6 or 8 treatments this fall on an inpatient basis and was transitioned to maintenance ECT. He never improved 100% but is kinda crotchety even at baseline so he never admits he's better. But still, had started grooming appropriately, wearing street clothes, joking with nurses, playing games with other patients, but wouldn't subjectively admit he was better. He continued on maintenance ECT for ~2 months but missed a session due to being in the hospital with pneumonia and had decompensated in that short time span (he was also being tapered from q3w to q4w at the time of the pneumonia, so maybe it was the combo that did him in).
We started a new index course of ECT approx 3 weeks ago. He's improved since then but only slightly. One of my concerns is that the seizure length is only 8-12 seconds per ECT (at best!) despite being at 100% of energy for the machine. Some of the seizures are only like 5-6 seconds. At the other site I've done ECT at the attending is always aiming for 30-60 seconds. There's been some increase in confusion to him. Now I worry that we're giving him cognitive s/e for potentially minimal gain. In the fall they got mostly 20-40s seizures (with one or two mini-seizures of 4 seconds) with much lower energy, but they were using etomidate. Now anesthesia is using propofol. My attending sympathizes but is reluctant to use caffeine (a. fib, though we haven't had cards weigh in) and gas is reluctant to go back to etomidate because they blame it for one episode of postictal confusion/agitation requiring haldol. I of course want to try out ketamine, but good luck trying to sell that.
So this is a long winded way of asking, what do you guys think about seizure length in ECT? I know a lot of books make vague hand-wavey gestures about "postictal suppression index" but is seizure length still a valid measure? Do you in your ECT practice aim for longer seizures than I'm getting here?
I'm currently assisting my attending with ECT on a 78 y/o male with lifelong intermittent depression, now substantially worse as he's gotten older. Some suspicion for bipolar depression though no clear recent mania or hypomania. Currently on venlafaxine and being switched from abilify to seroquel. Has tried a dozen or so other agents from every class other than MAOI. Only things he hasn't tried are ltihium (got it once in his 20's had a "bad reaction" that he can't remember and refuses to try it) and T3.
He had first gotten a course of ECT in his 20's. Then about 8 years ago a brief course here, and was maintained on meds until about 4 months ago. Got 6 or 8 treatments this fall on an inpatient basis and was transitioned to maintenance ECT. He never improved 100% but is kinda crotchety even at baseline so he never admits he's better. But still, had started grooming appropriately, wearing street clothes, joking with nurses, playing games with other patients, but wouldn't subjectively admit he was better. He continued on maintenance ECT for ~2 months but missed a session due to being in the hospital with pneumonia and had decompensated in that short time span (he was also being tapered from q3w to q4w at the time of the pneumonia, so maybe it was the combo that did him in).
We started a new index course of ECT approx 3 weeks ago. He's improved since then but only slightly. One of my concerns is that the seizure length is only 8-12 seconds per ECT (at best!) despite being at 100% of energy for the machine. Some of the seizures are only like 5-6 seconds. At the other site I've done ECT at the attending is always aiming for 30-60 seconds. There's been some increase in confusion to him. Now I worry that we're giving him cognitive s/e for potentially minimal gain. In the fall they got mostly 20-40s seizures (with one or two mini-seizures of 4 seconds) with much lower energy, but they were using etomidate. Now anesthesia is using propofol. My attending sympathizes but is reluctant to use caffeine (a. fib, though we haven't had cards weigh in) and gas is reluctant to go back to etomidate because they blame it for one episode of postictal confusion/agitation requiring haldol. I of course want to try out ketamine, but good luck trying to sell that.
So this is a long winded way of asking, what do you guys think about seizure length in ECT? I know a lot of books make vague hand-wavey gestures about "postictal suppression index" but is seizure length still a valid measure? Do you in your ECT practice aim for longer seizures than I'm getting here?
