ECT while intubated?

[DebDynamite]

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Ladies and Gentleman,

I am wondering if any of you have ever seen or known of a patient receiving ECT while on the Vent. I posted this Q in psych a few hours ago about a patient I have been called to consult, and my senior doc who is managing the transfer out of our hospital says no one will ever do it. I am inclined to agree but would like to hear your opinions if you have ever known an anesthesiologist to do this. THANKS in advance.

 

[WholeLottaGame7]

Ladies and Gentleman,

I am wondering if any of you have ever seen or known of a patient receiving ECT while on the Vent. I posted this Q in psych a few hours ago about a patient I have been called to consult, and my senior doc who is managing the transfer out of our hospital says no one will ever do it. I am inclined to agree but would like to hear your opinions if you have ever known an anesthesiologist to do this. THANKS in advance.

I've never seen it done but I don't know why you couldn't. We basically do a very short GA for ECT anyway, and in this case the airway is already taken care of.

The question is, why would psych want to ECT someone who is intubated?

 

[DebDynamite]

This is the type of reply I was hoping to hear. I agree- never sen it done but in theory have no clue why it could not be done- if the patient is otherwise healthy enough to stand the seizures.

We don't want pt shocked while intubated but medicine wants us to transfer MICU to MICU to a facility where they have ECT so pt can bet ECT regardless of intubation. This pt has such a longstanding catatonia they can't swallow or walk but can stumble and w/hx of COPD keeps getting intubated for HAP.

I wanted to know if anyone over on your team has ever done this or seen or heard of it.

 

[BobBarker]

I think extubating to room air after 10mg of morphine will help this patient more than ECT.

 

[WholeLottaGame7]

This is the type of reply I was hoping to hear. I agree- never sen it done but in theory have no clue why it could not be done- if the patient is otherwise healthy enough to stand the seizures.

We don't want pt shocked while intubated but medicine wants us to transfer MICU to MICU to a facility where they have ECT so pt can bet ECT regardless of intubation. This pt has such a longstanding catatonia they can't swallow or walk but can stumble and w/hx of COPD keeps getting intubated for HAP.

I wanted to know if anyone over on your team has ever done this or seen or heard of it.

So I guess what I'm asking is why specifically don't you want the patient shocked while intubated?

Like I said, we do worse procedures on sicker patients than this all the time.

If you're like Barker and it's because he already has a poor prognosis and you don't think it's medically justified, someone's going to have to cowboy up and fight that fight.

Just for giggles, I had an ECT day where there was talk of some future patient floating around that needed ECT but had documented MH. For us it's typically methohexital or etomidate then succ plus whatever adjuncts, so that was obviously out. We floated around all kinds of crazy ideas. Roc + ETT and a PACU/ICU stay, chicken-dose of NMB just to loosen things up + reversal, roc + acquire some black market sugammadex, etc.

So this attending was considering putting a tube IN to do the ECT. Just to say that there's nothing about being intubated specifically that's a contraindication to ECT.

 

[Spinach Dip]

Just for giggles, I had an ECT day where there was talk of some future patient floating around that needed ECT but had documented MH. For us it's typically methohexital or etomidate then succ plus whatever adjuncts, so that was obviously out. We floated around all kinds of crazy ideas. Roc + ETT and a PACU/ICU stay, chicken-dose of NMB just to loosen things up + reversal, roc + acquire some black market sugammadex, etc.

But did you consider a retrograde wire?

 

[DebDynamite]

So I guess what I'm asking is why specifically don't you want the patient shocked while intubated?

Like I said, we do worse procedures on sicker patients than this all the time.

If you're like Barker and it's because he already has a poor prognosis and you don't think it's medically justified, someone's going to have to cowboy up and fight that fight.

Just for giggles, I had an ECT day where there was talk of some future patient floating around that needed ECT but had documented MH. For us it's typically methohexital or etomidate then succ plus whatever adjuncts, so that was obviously out. We floated around all kinds of crazy ideas. Roc + ETT and a PACU/ICU stay, chicken-dose of NMB just to loosen things up + reversal, roc + acquire some black market sugammadex, etc.

So this attending was considering putting a tube IN to do the ECT. Just to say that there's nothing about being intubated specifically that's a contraindication to ECT.

I have no problem with this patient being shocked while intubated. No one will accept this patient and do it. I would love for this patient to be transferred out of my hospital and get shocked. I posted here to see if anyone who does the anesthesia has ever also maintained the airway while pt is on the vent for ECT. You know all we do is push the button and shock. We can't get anyone to accept this patient and shock. So I wanted to know if you have ever heard of it happening, anywhere. I would love it!

 

[Orin]

I have done this in a MICU pt with Catalonia of unknown etiology and sepsis. Just went to the ICU with an extra pair of hands, touch of prop and sux, shock, and go. Don't think it helped as the seizure was rather short likely due to long infusions of sedative medications but never followed up.

Is feasible but not sure if this is the best for the patient. Trach perhaps?

 

[IlDestriero]

Just do it. I don't understand what the problem is, other than it not being effective because of sedation.
Get fancy, transition to precedex and a touch of fentanyl and shock shock shock. With sux of course.

 

[psychbender]

Am I alone in wondering why an anesthesiologist would need to get involved with performing an ECT on an intubated and sedated individual in the ICU? We don't generally get involved with EGDs or other procedures in the unit on their pt's who are already tubed and sedated.

 

[DebDynamite]

The pt can't be shocked in the unit unless you know how to magically get the equipment there and the hospital to agree to that.
And we don't have ECT in our hospital so that's not going to happen. So the idea would be to transport on the vent to a place that would have ECT and be willing to shock on the vent.

I think movement to trach is going to be the next step, but it's going to have nasty outcomes because this pt is catatonic and pulls on every line they can, tugs on everything. I guess if pt could get trach, be restrained physically or chemically then transported to a diff hospital with ECT we would have a plan and that's what we are hoping for. But this pt keeps getting put back on the vent due to COPD plus HAP. This is the consult from hell. Pt is supposedly over HAP but they are still running abx, afebrile now no high white count anymore so medicine is saying just send her out. Baseline tachcardia but that's from the catatonia. Pt showed up in the ED already too ataxic to stand on their own, on pureed diet at home. Family brought in when they could no longer swallow. No ECT here and now we are supposed to transfer them for ECT. No one will take them. People over in psych are saying they have seen it done but always within their own facility and rarely. Very frustrating.

 

[DebDynamite]

I have done this in a MICU pt with Catalonia of unknown etiology and sepsis. Just went to the ICU with an extra pair of hands, touch of prop and sux, shock, and go. Don't think it helped as the seizure was rather short likely due to long infusions of sedative medications but never followed up.

Is feasible but not sure if this is the best for the patient. Trach perhaps?

I wish we had the equipment here to send to the unit. This pt would need multiple treatments, six to eight. And your point is also well noted which is that we have been recommending high dose benzos as that's the step right before ECT. So pt will have to clear those before getting shocked anyways.

 

[psychbender]

The pt can't be shocked in the unit unless you know how to magically get the equipment there and the hospital to agree to that.
And we don't have ECT in our hospital so that's not going to happen. So the idea would be to transport on the vent to a place that would have ECT and be willing to shock on the vent.

At my last hospital where we did ECTs, Psych would bring their equipment to the procedure bay in the back of the PACU, where we did minor cases (EGD/colos, Peds sedation, woundvac changes, etc), so I figured portability was not an issue. I recognize that ECT capability is not in your hospital, but given the general portability of some of those devices, the question still stands of why an anesthesiologist would even get involved, unless you had to take an intubated/sedated patient out of the unit to wherever the psychiatrists normally do these procedures, if the equipment cannot be moved.

 

[DebDynamite]

At my last hospital where we did ECTs, Psych would bring their equipment to the procedure bay in the back of the PACU, where we did minor cases (EGD/colos, Peds sedation, woundvac changes, etc), so I figured portability was not an issue. I recognize that ECT capability is not in your hospital, but given the general portability of some of those devices, the question still stands of why an anesthesiologist would even get involved, unless you had to take an intubated/sedated patient out of the unit to wherever the psychiatrists normally do these procedures, if the equipment cannot be moved.

Actually that's good to hear because where I am there is no one doing that. I should think about it. Considered getting ECT cert many times, making it portable I could stay in business down here all year. Nice.

 

[deleted59964]

have intubated for ect before -- morbid obesity, heavy smoker, rapid desaturation despite preoxygenation with prior ECT.

get psych to move the equipment - if you can do a thoracotomy in the unit you can sure do ect.

... or just go with morphine and room air