Dr Karen Butler and Dr Jim Watts, both consultants at East Lancashire NHS Trust, Blackburn, Lancashire, discuss electro convulsive therapy services during the COVID-19 pandemic
Electro convulsive therapy (ECT) is considered an essential treatment for patients with severe depression [1-5].
ECT involves the passage of an electric current through the brain (using either bilateral or unilateral approaches) to induce a seizure. The amount of electricity used is titrated against the duration of the seizure and the clinical improvement.
The safe administration of anaesthesia in these cases requires ensuring pre oxygenation, maintenance of the airway, and safe return to spontaneous breathing. A muscle relaxant-usually suxamethonium-is administered in small doses to attenuate the severity of the seizure. Sometimes, anaesthetists are asked to hyperventilate the patient prior to the shock being delivered in order to lower the seizure threshold.
Providing ECT services throughout the COVID-19 epidemic has been a clinical and logistical challenge. Due to the necessity to ensure a clean environment between patients, and the avoidance of cross contamination by maintaining social distancing, the throughput has been greatly reduced, resulting in a limit being placed on the number of procedures that can be safely performed in a session. Patients must also be screened prior to entering the ECT suite for fever and symptoms. In addition, staff have to adhere to the PPE requirements for possible aerosol generating procedures (AGP) – including bag and mask ventilation- to decrease the risk of spread of COVID-19. However, whilst some airway manipulations are AGPs, it is unclear whether seizure activity in itself can be regarded as potentially spreading COVID-19 (6).
It is clear that the approach to such services must be both pragmatic and safe, but that general guidelines cannot be specific to every possible situation, requiring the creation of local guidelines tailored to local environments and circumstances. Below, we have outlined the precautions taken at East Lancashire NHS Trust in order to maintain a safe environment for patients and staff.
Modified Practice for ECT in during the COVID-19 Pandemic: General Principles
- Check each patient does not have a cough/fever or other symptoms of COVID-19. If they are symptomatic, they must undergo isolation and a COVID-19 test. Patients who are Covid-19 positive or suspected will not have ECT until asymptomatic
- Full PPE to be worn by anaesthetic staff including: FFP3 face mask for whole session, with a surgical mask over top changed for each patient; long sleeved fluid repellent gown, visor and gloves (7)
- Standard PPE ( surgical face mask, water repellent apron, gloves and visor) to be worn by staff in treatment room, recovery and discharge areas. Staff should attempt to maintain an appropriate 2 m distance from the patient if possible (7)
- PPE requirement to be changed in accordance with NHSE/PHE guidance
Conduct of Anaesthesia
- Antiviral filter HME in circuit
- Ask patient to pre-oxygenate self
- Administer anaesthesia and suxamethonium as per usual practise
- After suxamethonium, avoid bag and mask ventilation unless there are serious about the extent of desaturation
- Do not manually hyperventilate the patient to lower the seizure threshold
- ECT to be administered in the usual manner
- Following the seizure, a Guedel airway may be inserted. Hold the oxygen mask over the patient with oxygen at 15litres/minute. A surgical facemask may be placed over the patient’s nose and mouth during the seizure. Do not manually ventilate unless necessary
- When spontaneous ventilation returns, place Hudson facemask over face
- Treatment nurse & psychiatrist to stand 2 metres away after delivering ECT
- Recover in treatment room until maintaining their own airway, not coughing and no longer requiring oxygen then transfer to recovery
- Clean room
- 20 minute period to elapse before room can be cleaned to allow appropriate ventilation/ air exchange (n.b. this is based on theatre air exchange figures and may vary depending on the air flow and exchange in the ECT area, and should be subject to local policy)
- Medicine Michigan Electroconvulsive Therapy Program A Brief History of ECT (http://www.psych.med.umich.edu/ect/history.asp last accessed 20th June 2017)
- ECT Accreditation service ECT Accreditation Service (ECTAS) Standards for the administration of ECT Thirteenth Edition: April 2016 http://www.rcpsych.ac.uk/pdf/ECTAS%2013th%20Edition%20Standards.pdf last accessed 20 June 2017
- Guidance on the use of electroconvulsive therapy 2003 (updated 2009; reviewed 2014 https://www.nice.org.uk/guidance/ta59 last accessed 20th June 2017
- Paw H GW Gopalswarmy HK 6.4 Anaesthesia for electroconvulsive therapy (ECT) in ECT clinics in Royal College of Anaesthetists | Raising the Standard: a compendium of audit recipes 3rd Edition 2012
- Uppal V, Dourish J, Macfarlane A Anaesthesia for electroconvulsive therapyContin Educ Anaesth Crit Care Pain (2010) 10 (6): 192-196
- WFSA List of Aerosol Generating Procedures https://www.wfsahq.org/components/com_virtual_library/media/232beeb71573bafbf6a2528bf327457e-18—List-of-Aerosol-Generating-Procedures–from-CDC-website-.pdf
- Public Health England COVID-19 personal Protective Equipment https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe