Anaesth. Intens. Care (1\)75), 3, 250
ANAESTHESIA FOR ELECTROCONVULSIVE THERAPY D. ].
ilIcCLEAVE* AKD
W.
B. BLAKE:lIOREt
Royal Adelaide Hospital, Adelaide SU;\nIARY
The resltlts oj a prospecti,'e study oj 3,600 Anaesthetics jor electrocom'ulsi've therapy is presented. A1inimal differences were observed between thiopentone and methohexitone. Propanidid and Diazepam were jound to be unsuitable induction agents. Other jindings inclllded minimal scrum potassium cle,)ation and a lmc incidence oj post treatment muscle paills. The place oj the sillf!,le-handed operator and the place oj ltJl1ll0dijied electroconvulsive therapy is questioned as being unacceptable practice. INTIWDl:CTIOX
The introduction of "Shock" treatment in the] 930's was a significant therapeutic advance in psychiatric practice, and in a way represented an important eyent in the history of anaesthesia. The modification of convulsions produced by " shock" treatment, led to muscle relaxants being introduced into general anaesthesia. Sakee (I!I:)J) produced a series of epiIepti-form convulsions by insulin overclosage, and :\lcduna (I !l3J) used" relative oyerdosages of metrazol " to produce a similar effect (l\lajor 1954). ;\lthough reasonable therapeutic results were obtained, the yiolence and nature of the con tractions not onl v resulted in increased oxygen utilization anel at times hypoxia, but abo in severe fractures and dislocations of the spine and other long bones, Other analeptic:; such as triazol, picrotoxin and coriam vcin were also unsuccessfull\' used in an effort 'to reduce the incidence of cOl"nplications. Yarious ingenious physical restraints and the use of spinal analgesia were employed as an adjunct; however, these also were not effective. In 1938 Cerletti and Bini introduced the principle of passing an electric current (of brief duration) through the brain. Although a similar therapeutic effect was obtained with less physiological alteration, the incidence of
* l\LB" Ch.B.(Otago). F,F,A.R.A.C.S., Staff Spccialist. t l\LB., n.S. (Syd.), l\LA'x,Z,C.P., Yisiting Specialist. Address for reprints: Dr. D. J. l\lcCleayc, Intcnsi\'~ Care Unit, H.oyal Adclaide Hospital, Adc1aic.le, S.A. 5000.
vertebral compression fractures was still high. Dewalt (195J) states that the incidence was in the range of 40 to 50 per cent-not all of these being apparent clinically. In 19JO Bennett described the use of curare for modifying drug (pentylenetetrazol (:\Ietrazol)) convulsions- not electroconvulsions as stated in many standard text books. Curare was subsequently used for electroconvulsive therapy but its use did not he come widespread for several years. Altschute (I!H7), Bellett (HlJl) and Kolb (19J6) reported on the cardio,'ascular complications following convulsions, however, it would seem that hypoxia clue to inadequate ventilation in partially curarized patients was probably the cause. Further advances in convulsion modification were made with the introduction of gallamine (Hughenanl and Bone 19·1!)) and finally with suxamethonium by Holmberg and Thesleff (1951). Reports on the use of these drugs in electroconvulsive therapy preceded papers on their use in general anaesthesia. Several years elapsed before the technique of using short acting intrayenous induction agents and depolarizing muscle relaxants became acceptecl as a simple, safe regime (Yalentine 1968). ~o doubt the major problems of apnoea, hypoxia and the risks of regurgitation were responsible for this delay. In ]957 in the case of Bolan v. Friern Hospital (B.I11.J. Report 1957) it was stated that the death rate in the period] 9J8-1953 in U.s.A. was one in 370 if relaxants were used. In the same case a senior psychiatrist stated that he would only use
Anaesthesia and Intensive Care, Vol. III, Xo, 3, August, 1975
251
ANAESTHESIA FOR ELECTROCONVULSIVE THERAPY
relaxants if electronconvulsive therapy given " straight" was dangerous to the patients' life! Apparently in the Friern Hospital in 1950-1957 only six fractures occurred in 70,000 cases of unmodified electroconvulsive therapy. Hence the plaintiff got no compensation for his bilateral fractured acetabula. Of the numerous articles on anaesthesia for electroconvulsive therapy, few have been written by practising trained anaesthetists. Many of the reported complications occurred as a result of inadequate knowledge of the physiological and pharmacological principles associated with anaesthesia, and inadequate training in resuscitative procedures. MATERIALS AND METHODS
A prospective study of anaesthesia for electroconvulsive therapy was carried out. During the pre-operative visit and assessment, enquiry was made concerning the patient's current and previous medication. Sedation was only given to those who were excitable or extremely apprehensive. Either pentobarbitone or amylobarbitone was given orally three to four hours prior to induction. Using a 23G butterfly needle, induction was carried out using either sodium thiopentone, sodium methohexitone or propanidid. Suxamethonium chloride was used to produce muscle paralysis. Atropine 0·6 mg was administered either prior to induction, with the induction agent, or with the muscle relaxant. Patients were then ventilated with 100 per cent oxygen, a mouth gag was inserted, and the electroconvulsive treatment given. After the modified convulsion patients were assisted until normal spontaneous ventilation returned. The response to therapy was classified as follows (Davies 1949, Ferguson 1952) : (a) Shock: GOOD-Facial muscle contraction only. MODERATE-Facial muscles, shoulders and other parts. POOR-Severe contraction of all muscles including back. (b) Convulsion: GOOD-Movement of facial muscles and platysma, with slight movement also of the longer joints. MODERATE-Above plus slight muscle movement. POOR-Severe movement of all muscles. In a small group of patients, serum potassium levels were measured prior to induction, following the convulsion, and 15 minutes later.
Observation of blood pressure and pulse rate changes were also made. Electro-cardiographic monitoring was carried out in those who had recently had infarcts, and the results compared with a control group. Other observations included an assessment of three commercially available electrode pastes, the incidence of muscle pain associated with the procedure, and the reliability of ancillary signs to indicate a successful convulsive shock had been administered. RESULTS
A total of 3,500 anaesthetics for electroconvulsive therapy (E.C.T.) were carried out on 425 patients. Ninety-eight per cent required E.C.T. because of failed drug therapy. At the time of E.C.T., all patients were on some form of medication (Table 1), the tricyclics and benzodiazepines were the most frequently used and drugs were usually prescribed in combination. Nitrazepam was the drug most frequently used for night sedation. TABLE
Tricyclics Benzodiazepines Chlordiazepoxide Diazepam Phenothiazines Chlorpromazine Thioridazine .. Others .. Lithium carbonate Monoamide oxidase inhibitors Evening sedatives Nitrazepam Barbiturates .. Chloral hydrate
70% 6% 52% 24%
8% 4% 6% 6%
60% 24% 10%
The average age for males was 40·3 (±SD1, 10) years, and for females 42·6 (±SD1, 19) years. The incidence male : female was 1 : 2. Each patient usually received six treatments -an average of 2-3 per week. There was a small chronic group who required 3-4 treatments every 3-4 months. Eleven patients had sustained myocardial infarcts less than three months previously. They required E.C.T. because of severe depression and drug therapy had either not been successful, or in therapeutic doses, had resulted in cardiac problems. Electrocardiographic monitoring of these patients failed to reveal any significant rhythm alteration. The same result was observed in a control group.
Anaesthesia and Intensive Care, Vol. Ill, No. 3, August, 1975 D
1
An Analysis of the Most Commonly Prescribed Drugs in 200 Psychiatric Patients
D. J.
:!52
MCCLEAVE AND
IXDI"CTIO:-l AGEXTS
The average doses of thiopentone, methohexitone and propanidid are shown below: );0. of
Anaesthetics Thiopentone .. :\lethohcxi tone ]'ropanidid
:!600 350 ;iO
1-- .-~~~--l\lale
Female
225L 25 mg 200 ± 25 mg 50:lc 25 mg 40± 10 mg 300 _I::. 50 mg 250 -I. 50 mg
------------
The amount of suxamethonium chloride used was the same with both thiopentone and methohexitone (40 15 mg and 30 cl, 5 mg for males and females respectively). Smaller doses of suxamethonium were used with propanidid (30 +5 mg and 20 le.') mg for males and females respectively). Despite this however, the time of apnoea and the" induction-leaving time" were significantly greater after propanidid. (The " induction -lea ving time" is used to refer to the interval between induction and the time at which the patient has established normal spontaneous ventilation, and protective airway reflexes, and hence safe to leave under the care of a trained sister.) Apnoea Time Thiopentone :\lethohexitone l'ropanidid ..
I i
InductionLeaving Time
120±.60~('~--1~' HOI :2 min 120±60 sec 4· 70 ±2 min 180::!::90scc
5·50±:lmin __ i _ _ _ ..___ _
In a group of fifty severely depressed patients, reduced dosages of thiopentone were required (:!OO ::!::25 mg and 17.')l::25 mg respectively for males and females). This apparent increased sensitivity to induction agents is in agreement with the lowered" sedation threshold" reported in those with psychotic depressive illness (Shagass Hlfi2). Based on Davies' classification, the following effects were observed: Poor Shock Convulsion
g OI /0 :ll%
Hence it is concluded that the dosages used were acceptable for adequate treatment modification.
W. D.
BLAKEMORE
Serum Potassium Alteration Serum potassium levels were measured in 50 patients during their first treatment. Blood samples were obtained prior to induction, after the stage of clonic convulsion and 15 minutes later. A combination of Thiopentone and Suxamethonium was used for all patients. The mean serum potassium levels were: Pre-induction
I~~~~t-convu\Sion
I
15 min. Later
- 4-'-3'-~\lO;~t-im-I_-_-_4_.-4_~I~_:1_7L_~6_-_~_'-_---,-1_4'3H!.To?ji!5 m This rise in serum potassium is not statistically significant. Cardiovascular effects In 200 patients, the mean elevation in systolic pressure and pulse rate alteration were: Post Convulsion
15 mins Post-induction
- - - - - - - - - - - - - -I
1
~:£:~::u:: . bIO~~ I ~~ ~: gj~~~~
10±5 torr 8±7jmin
Atropine sulphate (0' ti mg) given intravenously either prior to induction, mixed with thiopentone, or with suxamethonium did not produce any significant difference in pulse rate changes following E.C.T.-even when used in the same patient at different times. Five h~'pertensive patients had increases in systolic blood pressure of greater than tiO mm Hg. In these patients, there was a moderate response to the shock, and the subsequent convulsion was adequately modified. In subsequent anaesthetics, the blood pressure increases in these patients was not as high when larger drug dosages were employed. .11 uscle Pains Ninety-eight per cent of patients who received E.C.T. were ambulant. Eighteen complained of muscle pains on more than one occasion, whilst by indirect questioning, a further thirty indicated they had experienced muscle discomfort. The overall incidence was 2 per cent. All of these patients had adequately modified convulsions, and there was no relationship between the incidence of pains and the medication the patients were receiving.
Anaesthesia and Intensive Care, l"ol. liT,
1\'0.
3, August, l!J75
ANAESTHESIA FOR ELECTRo,CONVULSIVE THERAPY
Assessment of Electrode Conductive Material Undoubtedly there are many factors responsible for electrode burns. Of particular significance is the surface of the electrode (e.g. pitted), poor skin contact, and movement during current administration. We assessed the incidence of burns in 3,000 E.C.T.s and compared some of the currently available electrode conducting material.
Hypertonic saline soaked pads " D.H.A." conductive paste " Telectronics gel" " EKG Sol" Cream
Number of E.C.T.s
Percentage Burns
300 1000
2·0
1200
0·03
500
1·6
1·3
The conductive Gel (Telectronics) had a significantly lower incidence of burns. The burns that occurred were mainly superficial blisters. No deep burns were encountered.
The Value of A ncilliary Signs Elridge (1952) described goose flesh appearing after electrical stimulus as a sign that a convulsion would follow. In this series, the sign was observed in only 55 per cent of those who had a modified convulsion. It is also said (Thomas 1953) that if the pupils remain constricted after a stimulus, then a convulsion rarely follows. This was true in 85 per cent of cases. Hence it is concluded that these signs are not necessarily useful indicators of a successfully administered shock. DISCUSSION
As well as modifying the effects of electroconvulsive therapy, anaesthesia is also aimed at producing a rapid, smooth loss of consciousness, and an equally rapid awakening period devoid of the hazards of delayed recovery. In essence, one should aim at making the experience as pleasant as possible for the patient (Practising Psychiatrist 1953).
The basic principles governing the administration should be: 1. Full clinical assessment, and a full evaluation of current and previous drug therapy-this should be coupled with an awareness of their effects on the anaesthetic agent employed. 2. The anaesthetic should be administered by an experienced practitioner who is aware of the possible complications associated
253
with this form of anaesthesia. He must also be familiar with the management of cardiovascular and respiratory emergencies (MacLay 1953, Cronholm 1963). 3. There must be ready access to emergency drugs and equipment should resuscitation be necessary. 4. It is mandatory that the nursing staff be familiar with the management of semiconscious or unconscious patients. Because of the wide scope of the trainee psychiatrist's curriculum, it is difficult to see how the recently qualified can guarantee to fulfil the above criteria. I t is also questionable whether the single handed operator can devote his full time and attention to patient care.
Patient Medication Most psychiatric patients receiving electroconvulsive therapy are taking a variety of sedative, anti-depressant and other drugs. There are numerous reports in the literature of interactions between these drugs and those used for anaesthesia. Induction Agents Although electroconvulsive therapy renders the patient amnesic, the technique described by Impastato (1957) of giving 10 mg of suxamethonium to modify an induced petit-mal seizure, and then using the resultant amnesia to enable a larger dose of relaxant to be given, followed by a normal treatment is just as bad as using an induction agent without a relaxant (Delilkan 1969). Avoidance of using an induction agent is not only unpleasant for the patient, but also cannot be guaranteed to produce complete amnesia. Indeed some patients who have had unmodified treatment (no anaesthesia at all) can still recall after several years the frightening flash before they lost consciousness. Using an induction agent without relaxants does not guard against fractures or dislocations occurring. Of significance in this series was the finding, that contrary to published reports (Pitts 1968, Triesse 1968, McInnes 1972) the inductionawakening time was similar for thiopentone and methohexitone. Despite the reduced dosages of suxamethonium with propanidid, the effects were significantly prolonged; this is well recognized (Clarke 1964, 1967, Ellis 1968). It was of concern to us that some patients regained consciousness after propanidid, and had the unpleasant experience of being unable to breathe, and move because of the effects of suxamethonium.
Anaesthesia and Intensive Care, Vol. Ill, No. 3, August, 1975
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D.
J.
McCLEAVE AND
Minimal excitatory effects were observed with propanidid and methohexitone, and if they did occur, it was difficult to differentiate between these and the emotional release that is commonly observed in narco-analysis. Diazepam was used on 10 occasions, however, its longer induction and delayed recovery indicated its limited use in this situation (Martin 1971, McInnes 1972). It would appear from recent work (Foley 1972) that Althesin may be a useful drug to use in electro-convulsive anaesthesia.
Suxamethonium Chloride Haw (1972) reported elevation of plasma potassium levels after electro-convulsive therapy using a methohexitone-suxamethonium combination. 1\0 elevation occurred when thiopentone-suxamethonium was used. Pilditch and Baker (1974) on the other hand observed significant elevations with both combinations. In this series, smaller doses of depolarizing relaxant were used, and our results failed to reveal significant elevations. Churchill-Davidson (1954) reported that in ambulant patients, the incidence of muscle pain after suxamethonium was 70 per cent. These findings are confirmed in other papers (Bourne 1952, Currie 1953, Waters 1971). In this series 90 per cent of those who received electro convulsive therapy were ambulant, however, the incidence of muscle pain was only 2 per cent. There was no relationship between patient medication, the induction agents used, the response to treatment, and the occurrence of pains. Although other authors (Sonnenklar 1972, Hey 1972, (~ibb 1973) have recognized this lower incidence we have been unable to find how our results compare with others. These findings, coupled with the fact that to date no case of malignant hyperpyrexia associated with electroconvulsive therapy has been reported suggest that the patients medication, the hyperventilation following induction, the avoidance of acidosis and hypoxia, or the treatment itself are in some way related to the variations in the normal response of suxamethonium.
Cardiovascular System Kline (1942) showed that atropine decreased the incidence of bradycardia and arrythmias in unmodified electroconvulsive therapy. Vagal hyperactivity occurs whether or not anaesthesia is used (Evans 1947, Altshute 1947, Moore 1947). In this study, as well as using atropine all patients were pre-oxygenated, and then
W. D.
BLAKEMORE
controlled or assisted ventilation was used until respiration had returned to normal. Provided this technique is followed the incidence of myocardial complications is minimized (Hussar 1968). Kolb (1942) reviewed 62 deaths associated with electroconvulsive therapy, and reported that four patients died of cerebral haemorrhage. The marked blood pressure elevations we observed in hypertensive patients, stress that these patients are at risk, and require full modification. The other important role of atropine in E.C.T. may be that of increasing the tone, and hence competence of the cardiac sphincter (Clark 1962, Snow 1963). Although atropinization may not produce any reduction of intra-gastric pressure after suxamethonium (Miller] 971) the fact that the competence of the sphincter is increased may be significant in preventing regurgitation. La Cour (1969) reported that during suxamethonium fasciculations, the increased intraabdominal tension produced intra-gastric pressures up to 85 cm H 2 0, and although we did not perform any measurements during the tonic and clonic convulsive phases, it is reasonable to assume that this pressure would be significantly increased. However, no cases of regurgitation were observed in the series.
Patient Responsibility Both the psychiatrist and the anaesthetist must remember that there are certain legal issues relating to electroconvulsive therapy. Despite the fact that the patient might be disorientated or confused, consent for the procedure should always be obtained-if necessary by the patients next of kin. The anaesthetist should be familiar with the man.agement of any cardiovascular and respIratory emergencies, and it is his responsibility to ensure that the necessary drugs and equipment are readily available. Of equal importance is the avoidance, diagnosis, and treatment of injury associated with the procedure. Despite modification, injury to the teeth still occurs, especially in the hands of the inexperienced. We have found that the Guedel airway is unsuitable, as with contraction and retraction of the jaw during the tonic phase, pressure is exerted on the incisor teeth. It has been our experience that a mouth gag applied between the premolar and molar teeth on each side is safer. Care must also be taken to avoid injury to the lips and tongue.
Anaesthesia and Intensive Care, Vol. Ill, No. 3, AugflSt, 1975
ANAESTHESIA FOR ELECTROCONVULSIVE THERAPY
Reegen (1954) states that legally, injuries received because of confusion and disorientation following treatment are the responsibility of the psychiatrist, and that it is up to the latter to see that the risks are minimized. Davies (1971) assessed two commonly used E.C.T. machines. One of them did not meet with the required manufacturers specifications regarding electrical safety, whilst the minimal currents delivered by both were far greater than that required to produce a seizure. "Just as electrical equipment in operating theatres is periodically checked, so also should the onus be on the psychiatrist to ensure that his machine is electrically safe". (Davies 1971). ACKNOWLEDGEMENTS
Our thanks are expressed to the Psychiatrists at Fullarton Hospital for their help and advice in performing this study. The Matron and nursing staff were of great assistance. We are also grateful to Dr. ]. Havill for his encouragement and helpful suggestions. REFERENCES
Altschute, M. D., Sulzbuch, W. M., Tolloston, K. J. (1947) : "Significance of Changes in E.C.G. after Electric Induced Convulsions in Man ", Arch. Neurol. and Psycho., 58, 316. Bellett, S., Kerschbaum, A., Furst, W. (1941) : " Electrocardiography During Electric Shock Treatment of Mental Disorders ", Amer. j. M. 5ci., 201, 167. Bennett, A. E. (1940): "Prevention Traumatic Complications in Convulsive Shock Therapy by Curare ", j. Amer. Med. Ass., 114, 322. Medico-Legal Report (1957): .. E.C.G., Fractures ", Brit. Med. j., 1, 591. Bovet, W., Bovet-Witti, F., Guarino, S., Longo, V. C., Marotta, M. (1949) : " Pharmacodynamic Properties of Some Derivatives of Benzoyl Choline Having a Curarizing Action ", Biolog. Abstracts, 24,32762. Bourne, J. G., Collier, H. O. S., Somers, G. F. (1952) : .. Succinyl Choline" (SuccinoyJcholine) Muscle Relaxant of Short Action ", Lancet, 1, 1225. Cannicott, S. M. (1962) : " Unilateral Electroconvulsive Therapy", Postgrad. Med. j., 38, 451. Cannicott, S. M. (1963): .. Technique of Unilateral Electroconvulsive Therapy", Amer. ]. Psychiat., 120,477. Cerietti, V., Bini, L. (1938): "L'ettroshock ", Arch. Gen. Psychiat., 19, 266. Churchill-Davidson, H. C. (1954): "Suxamethonium (Succinyl Choline) and Muscle Pains ", Brit. Med. ].,1,74. Clark, C. G., Ruddock, M. E. (1962) : " Observation of Human Cardia at Operation ", Brit. j. Anaesth., 34, 875. Clarke, R S. J., Dundee, J. W., Daw, R H. (1964) : " Clinical Studies on Induction Agents XI ", Brit. ]. Anaesth., 36, 307. Cronholm, B., Ottoson, J. O. (1963): .. Experiences Memory Function After Electroconvulsive Therapy", Brit. ]. Psychiat., 109, 251.
255
Currie, T. T. (1953): "Subcostal Pain Following Controlled Respiration ", Brit. Med. j., I, 1032. Davies, D. L., Lewis, A. (1949): "Effects of Decamethonium Iodide on Respiration and ori Induced Convulsions in Man ", Lancet, 1,775. Davies, R. K., Detre, T. P., Egger, M. D. (1971): " Electroconvulsive Therapy Instruments-ShoUld They be Reevaluated ", Arch. Gen. P,ychiat., 25, 97. Delilkan, A. E. (1969): "Electroconvulsive Therapy With No-Relaxant Anaesthesia ", Brit. j. Anaesth., 41, 884. Dewald, P. A., Margolis, W. M., Weiner, H, (1954): " Vertebral Fractures as a Complication of Electroshock Therapy", ]. A mer. Med. Ass., 154,981. Dowdy, E. G., Fabian, L. W. (1963): "Ventricular Arrythmias Induced from Succinyl Choline in Digitalized Patients ", Anesth. Analg., 42, 501. Dundee, J. W., McDowell, S. A. (1971): .. Influence Drug Therapy on Anaesthesia", General Anaesthesia, 3rd Edition. Gray and Nunn (Eds.), Butterworths, London. Eldridge, A. (1952): "Discussion on New Muscle Relaxant in Electroconvulsive Therapy", Proc. Ray. Soc. Med., 45, 869. EIlis, F. R (1968) : "The Neuromuscular Interaction of Propanidid with Suxamethonium and Tubocurare ", Brit. j. Anaesth., 40, 818. . Evans, V. L. (1947): "Electrocardiographic Changes after Electric Shock Treatment ", ]. Lab. Cli n . Med., 22, 1518. Ferguson, A. L. (1952): "New Muscle Relaxants in E.C.T.", Proc. Roy. Soc. Med., 45, 875. Foley, E. I., WaIton, B., Savege, T. M., Strunin, L., Simpson, B. R (1972): "A Comparison of Re'covery Times Between Althesin and Methohexitone Following Anaesthesia for Electroconvulsive Therapy", Postgrad. Med. j., 48 Suppl., 2, 112. Ford, H. F., McDonald, E. C., Towler, M. L. (1965) : " Clinical Evaluation of Unilateral E.s.T.," Amer. j. Psychiat., 121, 1087. Frost, I. (1957) : " Unilateral Electric Shock ", Lancet 3, 1, 157. Gibb, D. B. (1973): .. Suxamethonium-A Review", Anaesth. Intens. Care, 1, 2. Gibb, D. B. (1974): .. Suxamethonium-A Review", Anaesth. Intens. Care, 2, 1. Haw, M. E. (1972) : .. Variations in Serum Potassium During Electroconvulsive Therapy", Brit. ]. Anaesth., 44, 707. Hey, V. M. (1972) : .. Hyperpyrexia after Anaesthesia ", Lancet, 2, 230. Holmberg, A. G., Thesleff, S. (1951) : "Succinylkolin Jodid Som Muskelavslappande Medel via Elektroshock Behandling ", 5. Nord. Med., 46, 42, 1567. Huguenard, P., Boue', A. (1948) : " Un Nouvel OrthoCurare Francais de Synthese le 3697 RP., .. Raport a' la Sac d' Anesthesie di Paris, 5cande du '7. Hussar, A. E., Patcher, M. (1968): .. Myocardial Infarction and Fatal Coronary Insufficiency During Electroconvulsive Therapy", j. Amet'. Med. Ass., 104, 1004. Impastato, D. J. (1957): .. Safer Administration of Succinyl Choline Without Barbiturates", A mer, ]. Psychiat., 113, I, 257.
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J.
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Impastato, D. J., Karlinger, \V. (I !l66) : "Control of Memory Impairment in E.S.T. by Unilateral Stimulus ", Dis. Ncrv. Syst., 27, 182. Kline, E. M., Fcltcrman, J. L. (1942): "Electrocardiographic Changes Following Electrically Induced Convulsions ", AlIley. Heart j., 24. 66;";. Kolb, L., Vogel, V. (1942): "Electroconvulsive Treatment ", A mer. j. Psyehiat., 99. La Cour, D. (Hi6H): " Rise in lntragastric Pressure Caused hv Suxametiloniull1 Fasciculations ", Acta. Anaesthi;l Seand., 13, 255. Lancaster, N. P., Steinart, K C, Frost, T. (1958): " Unilateral Electroconvulsive Therapy", j. lvlent. Sei., 104, 221. Mclnnes, E. J., James, N. M. (l!l72) : "Comparison of Ketamine and l\Iethohexitol in Electroconvulsive Therapy", Med. j. Aust., 1, 1031. MacLay, \V. S. (IH53): "Death Due to Electroconvulsive Treatment ", Proc. Roy. Soc. Med., 46, 13. Major, K H. (1954): History of M.edicine, Vol. 11, Thomas, Illinois. Martin, W. E., Ford, H. F., McDonald, E. C., Tower, M. L. (1\)65): "Clinical Evaluation Unilateral E.s.T. ", Amer. j. Psychiat., 121, 1087. Miller, R. D., Way, W. L. (IH71): "Inhibition of Succinyl Choline~Induced Intragastric Pressure by Non-Depolarizing Muscle Relaxants and Lidocaine", A nesthesiology, 34, 185. Patterson, .\. S., King, D. \V. (1!)74) "Electrocon"ulsive Fractures ", Brit. ,1Ied. J., 1, 11l8. l'ilditch, F. D., Baker, A. B. (1974) : " Effects Modified Electroconvulsive Therapy on Four Induction Agcnt~J{elaxant Regimes on Plasma Potassium ", Anaeslh. Intens. Care, 2, 142. Pitts, F. W., Woodruft, R. A., Craig, A. G., Hich, C. L. (1962) : " Drug Modification of Electroconvulsive Therapy", Arch. Gen. Psychiat., 19, 51)5.
W. D.
BLAKEMORE
Practising Psychiatrict (l!l53) : "The Experiences of Electroconvulsive Therapy", Brit. J. Psychiat., 3, :165. Prett, R c., Warrington, E. K, Halliday, A. M. (1971) : " tOnilateral E.C.T. as Test Cerebral Dominance ", Brit. j. Psychiat., 119, 4H. l{eebcn, R L. (IH54): "Liability for Injury Caused by Shock Treatment ", Kansas Law Review, 2, 393. Shagass, C., and Schwartz, M. (1962): "Cerebral Cortical Reactivity in Psychotic Depressions", Arch. Gen. Psyehiat., 6, 235. Sonnenklar, N., Rendell-Bakcr, L. (lH72): "Hyperpyrexia During Pregnancy", Lancet, 2, 43. Snow, K G. (1963) : " :\Iuscle l{elaxants in the Cardia Including Clinical Management of Patients Likely to Vomit or Regurgitate ", Brit. j. A naesth., 35, 541. Thes1cff, S. (1952): "Pharmacological Principles Succinyl Choline Iodide ", Acta. Physiol. Seand., 26, 103. Thomas, E., Honan, B. F. (lH53) : "Electroconvulsive Therapy", Brit. lVled. j., 2, 97. Triesse, 1'. S., Stenhouse, N. S. (1968): "Electroconvulsive Treatment Phases with/without Anaesthesia ", Brit. j. Psyehiat., 114, 1383. Yalentine, M., Keddie, K. M. G., Dunne, D. (1968): "Comparison, Techniques in Electroconvulsive Therapy", Brit. J. Psychiat., 114, 98!l. Waiter, C. J., l\litchell-Heggs, N., Sargant, N. (1972) : "Modified Narcosis, E.C.T. and Antidepressant Drugs. A Review of Technique and Immediate Outcome ", Brit. j. Psyehiat., 120, 651. Waters, D. J., Mapleson, W. M. (1971) : "Suxamethonium Pains~Hypothesis and Observation ", Anaesthesia, 26, 127. Zamora, E. W., Kalbing, R. (1966): "Memory and Electroconvulsive Therapy", A mer. J. Psychiat., 122,546.
Anaesthesia and lntensive Care, Vol. Ill, No. 3, August, 1975
ANAESTHESIA FOR ELECTROCONVULSIVE THERAPY D. ].
ilIcCLEAVE* AKD
W.
B. BLAKE:lIOREt
Royal Adelaide Hospital, Adelaide SU;\nIARY
The resltlts oj a prospecti,'e study oj 3,600 Anaesthetics jor electrocom'ulsi've therapy is presented. A1inimal differences were observed between thiopentone and methohexitone. Propanidid and Diazepam were jound to be unsuitable induction agents. Other jindings inclllded minimal scrum potassium cle,)ation and a lmc incidence oj post treatment muscle paills. The place oj the sillf!,le-handed operator and the place oj ltJl1ll0dijied electroconvulsive therapy is questioned as being unacceptable practice. INTIWDl:CTIOX
The introduction of "Shock" treatment in the] 930's was a significant therapeutic advance in psychiatric practice, and in a way represented an important eyent in the history of anaesthesia. The modification of convulsions produced by " shock" treatment, led to muscle relaxants being introduced into general anaesthesia. Sakee (I!I:)J) produced a series of epiIepti-form convulsions by insulin overclosage, and :\lcduna (I !l3J) used" relative oyerdosages of metrazol " to produce a similar effect (l\lajor 1954). ;\lthough reasonable therapeutic results were obtained, the yiolence and nature of the con tractions not onl v resulted in increased oxygen utilization anel at times hypoxia, but abo in severe fractures and dislocations of the spine and other long bones, Other analeptic:; such as triazol, picrotoxin and coriam vcin were also unsuccessfull\' used in an effort 'to reduce the incidence of cOl"nplications. Yarious ingenious physical restraints and the use of spinal analgesia were employed as an adjunct; however, these also were not effective. In 1938 Cerletti and Bini introduced the principle of passing an electric current (of brief duration) through the brain. Although a similar therapeutic effect was obtained with less physiological alteration, the incidence of
* l\LB" Ch.B.(Otago). F,F,A.R.A.C.S., Staff Spccialist. t l\LB., n.S. (Syd.), l\LA'x,Z,C.P., Yisiting Specialist. Address for reprints: Dr. D. J. l\lcCleayc, Intcnsi\'~ Care Unit, H.oyal Adclaide Hospital, Adc1aic.le, S.A. 5000.
vertebral compression fractures was still high. Dewalt (195J) states that the incidence was in the range of 40 to 50 per cent-not all of these being apparent clinically. In 19JO Bennett described the use of curare for modifying drug (pentylenetetrazol (:\Ietrazol)) convulsions- not electroconvulsions as stated in many standard text books. Curare was subsequently used for electroconvulsive therapy but its use did not he come widespread for several years. Altschute (I!H7), Bellett (HlJl) and Kolb (19J6) reported on the cardio,'ascular complications following convulsions, however, it would seem that hypoxia clue to inadequate ventilation in partially curarized patients was probably the cause. Further advances in convulsion modification were made with the introduction of gallamine (Hughenanl and Bone 19·1!)) and finally with suxamethonium by Holmberg and Thesleff (1951). Reports on the use of these drugs in electroconvulsive therapy preceded papers on their use in general anaesthesia. Several years elapsed before the technique of using short acting intrayenous induction agents and depolarizing muscle relaxants became acceptecl as a simple, safe regime (Yalentine 1968). ~o doubt the major problems of apnoea, hypoxia and the risks of regurgitation were responsible for this delay. In ]957 in the case of Bolan v. Friern Hospital (B.I11.J. Report 1957) it was stated that the death rate in the period] 9J8-1953 in U.s.A. was one in 370 if relaxants were used. In the same case a senior psychiatrist stated that he would only use
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relaxants if electronconvulsive therapy given " straight" was dangerous to the patients' life! Apparently in the Friern Hospital in 1950-1957 only six fractures occurred in 70,000 cases of unmodified electroconvulsive therapy. Hence the plaintiff got no compensation for his bilateral fractured acetabula. Of the numerous articles on anaesthesia for electroconvulsive therapy, few have been written by practising trained anaesthetists. Many of the reported complications occurred as a result of inadequate knowledge of the physiological and pharmacological principles associated with anaesthesia, and inadequate training in resuscitative procedures. MATERIALS AND METHODS
A prospective study of anaesthesia for electroconvulsive therapy was carried out. During the pre-operative visit and assessment, enquiry was made concerning the patient's current and previous medication. Sedation was only given to those who were excitable or extremely apprehensive. Either pentobarbitone or amylobarbitone was given orally three to four hours prior to induction. Using a 23G butterfly needle, induction was carried out using either sodium thiopentone, sodium methohexitone or propanidid. Suxamethonium chloride was used to produce muscle paralysis. Atropine 0·6 mg was administered either prior to induction, with the induction agent, or with the muscle relaxant. Patients were then ventilated with 100 per cent oxygen, a mouth gag was inserted, and the electroconvulsive treatment given. After the modified convulsion patients were assisted until normal spontaneous ventilation returned. The response to therapy was classified as follows (Davies 1949, Ferguson 1952) : (a) Shock: GOOD-Facial muscle contraction only. MODERATE-Facial muscles, shoulders and other parts. POOR-Severe contraction of all muscles including back. (b) Convulsion: GOOD-Movement of facial muscles and platysma, with slight movement also of the longer joints. MODERATE-Above plus slight muscle movement. POOR-Severe movement of all muscles. In a small group of patients, serum potassium levels were measured prior to induction, following the convulsion, and 15 minutes later.
Observation of blood pressure and pulse rate changes were also made. Electro-cardiographic monitoring was carried out in those who had recently had infarcts, and the results compared with a control group. Other observations included an assessment of three commercially available electrode pastes, the incidence of muscle pain associated with the procedure, and the reliability of ancillary signs to indicate a successful convulsive shock had been administered. RESULTS
A total of 3,500 anaesthetics for electroconvulsive therapy (E.C.T.) were carried out on 425 patients. Ninety-eight per cent required E.C.T. because of failed drug therapy. At the time of E.C.T., all patients were on some form of medication (Table 1), the tricyclics and benzodiazepines were the most frequently used and drugs were usually prescribed in combination. Nitrazepam was the drug most frequently used for night sedation. TABLE
Tricyclics Benzodiazepines Chlordiazepoxide Diazepam Phenothiazines Chlorpromazine Thioridazine .. Others .. Lithium carbonate Monoamide oxidase inhibitors Evening sedatives Nitrazepam Barbiturates .. Chloral hydrate
70% 6% 52% 24%
8% 4% 6% 6%
60% 24% 10%
The average age for males was 40·3 (±SD1, 10) years, and for females 42·6 (±SD1, 19) years. The incidence male : female was 1 : 2. Each patient usually received six treatments -an average of 2-3 per week. There was a small chronic group who required 3-4 treatments every 3-4 months. Eleven patients had sustained myocardial infarcts less than three months previously. They required E.C.T. because of severe depression and drug therapy had either not been successful, or in therapeutic doses, had resulted in cardiac problems. Electrocardiographic monitoring of these patients failed to reveal any significant rhythm alteration. The same result was observed in a control group.
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1
An Analysis of the Most Commonly Prescribed Drugs in 200 Psychiatric Patients
D. J.
:!52
MCCLEAVE AND
IXDI"CTIO:-l AGEXTS
The average doses of thiopentone, methohexitone and propanidid are shown below: );0. of
Anaesthetics Thiopentone .. :\lethohcxi tone ]'ropanidid
:!600 350 ;iO
1-- .-~~~--l\lale
Female
225L 25 mg 200 ± 25 mg 50:lc 25 mg 40± 10 mg 300 _I::. 50 mg 250 -I. 50 mg
------------
The amount of suxamethonium chloride used was the same with both thiopentone and methohexitone (40 15 mg and 30 cl, 5 mg for males and females respectively). Smaller doses of suxamethonium were used with propanidid (30 +5 mg and 20 le.') mg for males and females respectively). Despite this however, the time of apnoea and the" induction-leaving time" were significantly greater after propanidid. (The " induction -lea ving time" is used to refer to the interval between induction and the time at which the patient has established normal spontaneous ventilation, and protective airway reflexes, and hence safe to leave under the care of a trained sister.) Apnoea Time Thiopentone :\lethohexitone l'ropanidid ..
I i
InductionLeaving Time
120±.60~('~--1~' HOI :2 min 120±60 sec 4· 70 ±2 min 180::!::90scc
5·50±:lmin __ i _ _ _ ..___ _
In a group of fifty severely depressed patients, reduced dosages of thiopentone were required (:!OO ::!::25 mg and 17.')l::25 mg respectively for males and females). This apparent increased sensitivity to induction agents is in agreement with the lowered" sedation threshold" reported in those with psychotic depressive illness (Shagass Hlfi2). Based on Davies' classification, the following effects were observed: Poor Shock Convulsion
g OI /0 :ll%
Hence it is concluded that the dosages used were acceptable for adequate treatment modification.
W. D.
BLAKEMORE
Serum Potassium Alteration Serum potassium levels were measured in 50 patients during their first treatment. Blood samples were obtained prior to induction, after the stage of clonic convulsion and 15 minutes later. A combination of Thiopentone and Suxamethonium was used for all patients. The mean serum potassium levels were: Pre-induction
I~~~~t-convu\Sion
I
15 min. Later
- 4-'-3'-~\lO;~t-im-I_-_-_4_.-4_~I~_:1_7L_~6_-_~_'-_---,-1_4'3H!.To?ji!5 m This rise in serum potassium is not statistically significant. Cardiovascular effects In 200 patients, the mean elevation in systolic pressure and pulse rate alteration were: Post Convulsion
15 mins Post-induction
- - - - - - - - - - - - - -I
1
~:£:~::u:: . bIO~~ I ~~ ~: gj~~~~
10±5 torr 8±7jmin
Atropine sulphate (0' ti mg) given intravenously either prior to induction, mixed with thiopentone, or with suxamethonium did not produce any significant difference in pulse rate changes following E.C.T.-even when used in the same patient at different times. Five h~'pertensive patients had increases in systolic blood pressure of greater than tiO mm Hg. In these patients, there was a moderate response to the shock, and the subsequent convulsion was adequately modified. In subsequent anaesthetics, the blood pressure increases in these patients was not as high when larger drug dosages were employed. .11 uscle Pains Ninety-eight per cent of patients who received E.C.T. were ambulant. Eighteen complained of muscle pains on more than one occasion, whilst by indirect questioning, a further thirty indicated they had experienced muscle discomfort. The overall incidence was 2 per cent. All of these patients had adequately modified convulsions, and there was no relationship between the incidence of pains and the medication the patients were receiving.
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ANAESTHESIA FOR ELECTRo,CONVULSIVE THERAPY
Assessment of Electrode Conductive Material Undoubtedly there are many factors responsible for electrode burns. Of particular significance is the surface of the electrode (e.g. pitted), poor skin contact, and movement during current administration. We assessed the incidence of burns in 3,000 E.C.T.s and compared some of the currently available electrode conducting material.
Hypertonic saline soaked pads " D.H.A." conductive paste " Telectronics gel" " EKG Sol" Cream
Number of E.C.T.s
Percentage Burns
300 1000
2·0
1200
0·03
500
1·6
1·3
The conductive Gel (Telectronics) had a significantly lower incidence of burns. The burns that occurred were mainly superficial blisters. No deep burns were encountered.
The Value of A ncilliary Signs Elridge (1952) described goose flesh appearing after electrical stimulus as a sign that a convulsion would follow. In this series, the sign was observed in only 55 per cent of those who had a modified convulsion. It is also said (Thomas 1953) that if the pupils remain constricted after a stimulus, then a convulsion rarely follows. This was true in 85 per cent of cases. Hence it is concluded that these signs are not necessarily useful indicators of a successfully administered shock. DISCUSSION
As well as modifying the effects of electroconvulsive therapy, anaesthesia is also aimed at producing a rapid, smooth loss of consciousness, and an equally rapid awakening period devoid of the hazards of delayed recovery. In essence, one should aim at making the experience as pleasant as possible for the patient (Practising Psychiatrist 1953).
The basic principles governing the administration should be: 1. Full clinical assessment, and a full evaluation of current and previous drug therapy-this should be coupled with an awareness of their effects on the anaesthetic agent employed. 2. The anaesthetic should be administered by an experienced practitioner who is aware of the possible complications associated
253
with this form of anaesthesia. He must also be familiar with the management of cardiovascular and respiratory emergencies (MacLay 1953, Cronholm 1963). 3. There must be ready access to emergency drugs and equipment should resuscitation be necessary. 4. It is mandatory that the nursing staff be familiar with the management of semiconscious or unconscious patients. Because of the wide scope of the trainee psychiatrist's curriculum, it is difficult to see how the recently qualified can guarantee to fulfil the above criteria. I t is also questionable whether the single handed operator can devote his full time and attention to patient care.
Patient Medication Most psychiatric patients receiving electroconvulsive therapy are taking a variety of sedative, anti-depressant and other drugs. There are numerous reports in the literature of interactions between these drugs and those used for anaesthesia. Induction Agents Although electroconvulsive therapy renders the patient amnesic, the technique described by Impastato (1957) of giving 10 mg of suxamethonium to modify an induced petit-mal seizure, and then using the resultant amnesia to enable a larger dose of relaxant to be given, followed by a normal treatment is just as bad as using an induction agent without a relaxant (Delilkan 1969). Avoidance of using an induction agent is not only unpleasant for the patient, but also cannot be guaranteed to produce complete amnesia. Indeed some patients who have had unmodified treatment (no anaesthesia at all) can still recall after several years the frightening flash before they lost consciousness. Using an induction agent without relaxants does not guard against fractures or dislocations occurring. Of significance in this series was the finding, that contrary to published reports (Pitts 1968, Triesse 1968, McInnes 1972) the inductionawakening time was similar for thiopentone and methohexitone. Despite the reduced dosages of suxamethonium with propanidid, the effects were significantly prolonged; this is well recognized (Clarke 1964, 1967, Ellis 1968). It was of concern to us that some patients regained consciousness after propanidid, and had the unpleasant experience of being unable to breathe, and move because of the effects of suxamethonium.
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D.
J.
McCLEAVE AND
Minimal excitatory effects were observed with propanidid and methohexitone, and if they did occur, it was difficult to differentiate between these and the emotional release that is commonly observed in narco-analysis. Diazepam was used on 10 occasions, however, its longer induction and delayed recovery indicated its limited use in this situation (Martin 1971, McInnes 1972). It would appear from recent work (Foley 1972) that Althesin may be a useful drug to use in electro-convulsive anaesthesia.
Suxamethonium Chloride Haw (1972) reported elevation of plasma potassium levels after electro-convulsive therapy using a methohexitone-suxamethonium combination. 1\0 elevation occurred when thiopentone-suxamethonium was used. Pilditch and Baker (1974) on the other hand observed significant elevations with both combinations. In this series, smaller doses of depolarizing relaxant were used, and our results failed to reveal significant elevations. Churchill-Davidson (1954) reported that in ambulant patients, the incidence of muscle pain after suxamethonium was 70 per cent. These findings are confirmed in other papers (Bourne 1952, Currie 1953, Waters 1971). In this series 90 per cent of those who received electro convulsive therapy were ambulant, however, the incidence of muscle pain was only 2 per cent. There was no relationship between patient medication, the induction agents used, the response to treatment, and the occurrence of pains. Although other authors (Sonnenklar 1972, Hey 1972, (~ibb 1973) have recognized this lower incidence we have been unable to find how our results compare with others. These findings, coupled with the fact that to date no case of malignant hyperpyrexia associated with electroconvulsive therapy has been reported suggest that the patients medication, the hyperventilation following induction, the avoidance of acidosis and hypoxia, or the treatment itself are in some way related to the variations in the normal response of suxamethonium.
Cardiovascular System Kline (1942) showed that atropine decreased the incidence of bradycardia and arrythmias in unmodified electroconvulsive therapy. Vagal hyperactivity occurs whether or not anaesthesia is used (Evans 1947, Altshute 1947, Moore 1947). In this study, as well as using atropine all patients were pre-oxygenated, and then
W. D.
BLAKEMORE
controlled or assisted ventilation was used until respiration had returned to normal. Provided this technique is followed the incidence of myocardial complications is minimized (Hussar 1968). Kolb (1942) reviewed 62 deaths associated with electroconvulsive therapy, and reported that four patients died of cerebral haemorrhage. The marked blood pressure elevations we observed in hypertensive patients, stress that these patients are at risk, and require full modification. The other important role of atropine in E.C.T. may be that of increasing the tone, and hence competence of the cardiac sphincter (Clark 1962, Snow 1963). Although atropinization may not produce any reduction of intra-gastric pressure after suxamethonium (Miller] 971) the fact that the competence of the sphincter is increased may be significant in preventing regurgitation. La Cour (1969) reported that during suxamethonium fasciculations, the increased intraabdominal tension produced intra-gastric pressures up to 85 cm H 2 0, and although we did not perform any measurements during the tonic and clonic convulsive phases, it is reasonable to assume that this pressure would be significantly increased. However, no cases of regurgitation were observed in the series.
Patient Responsibility Both the psychiatrist and the anaesthetist must remember that there are certain legal issues relating to electroconvulsive therapy. Despite the fact that the patient might be disorientated or confused, consent for the procedure should always be obtained-if necessary by the patients next of kin. The anaesthetist should be familiar with the man.agement of any cardiovascular and respIratory emergencies, and it is his responsibility to ensure that the necessary drugs and equipment are readily available. Of equal importance is the avoidance, diagnosis, and treatment of injury associated with the procedure. Despite modification, injury to the teeth still occurs, especially in the hands of the inexperienced. We have found that the Guedel airway is unsuitable, as with contraction and retraction of the jaw during the tonic phase, pressure is exerted on the incisor teeth. It has been our experience that a mouth gag applied between the premolar and molar teeth on each side is safer. Care must also be taken to avoid injury to the lips and tongue.
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ANAESTHESIA FOR ELECTROCONVULSIVE THERAPY
Reegen (1954) states that legally, injuries received because of confusion and disorientation following treatment are the responsibility of the psychiatrist, and that it is up to the latter to see that the risks are minimized. Davies (1971) assessed two commonly used E.C.T. machines. One of them did not meet with the required manufacturers specifications regarding electrical safety, whilst the minimal currents delivered by both were far greater than that required to produce a seizure. "Just as electrical equipment in operating theatres is periodically checked, so also should the onus be on the psychiatrist to ensure that his machine is electrically safe". (Davies 1971). ACKNOWLEDGEMENTS
Our thanks are expressed to the Psychiatrists at Fullarton Hospital for their help and advice in performing this study. The Matron and nursing staff were of great assistance. We are also grateful to Dr. ]. Havill for his encouragement and helpful suggestions. REFERENCES
Altschute, M. D., Sulzbuch, W. M., Tolloston, K. J. (1947) : "Significance of Changes in E.C.G. after Electric Induced Convulsions in Man ", Arch. Neurol. and Psycho., 58, 316. Bellett, S., Kerschbaum, A., Furst, W. (1941) : " Electrocardiography During Electric Shock Treatment of Mental Disorders ", Amer. j. M. 5ci., 201, 167. Bennett, A. E. (1940): "Prevention Traumatic Complications in Convulsive Shock Therapy by Curare ", j. Amer. Med. Ass., 114, 322. Medico-Legal Report (1957): .. E.C.G., Fractures ", Brit. Med. j., 1, 591. Bovet, W., Bovet-Witti, F., Guarino, S., Longo, V. C., Marotta, M. (1949) : " Pharmacodynamic Properties of Some Derivatives of Benzoyl Choline Having a Curarizing Action ", Biolog. Abstracts, 24,32762. Bourne, J. G., Collier, H. O. S., Somers, G. F. (1952) : .. Succinyl Choline" (SuccinoyJcholine) Muscle Relaxant of Short Action ", Lancet, 1, 1225. Cannicott, S. M. (1962) : " Unilateral Electroconvulsive Therapy", Postgrad. Med. j., 38, 451. Cannicott, S. M. (1963): .. Technique of Unilateral Electroconvulsive Therapy", Amer. ]. Psychiat., 120,477. Cerietti, V., Bini, L. (1938): "L'ettroshock ", Arch. Gen. Psychiat., 19, 266. Churchill-Davidson, H. C. (1954): "Suxamethonium (Succinyl Choline) and Muscle Pains ", Brit. Med. ].,1,74. Clark, C. G., Ruddock, M. E. (1962) : " Observation of Human Cardia at Operation ", Brit. j. Anaesth., 34, 875. Clarke, R S. J., Dundee, J. W., Daw, R H. (1964) : " Clinical Studies on Induction Agents XI ", Brit. ]. Anaesth., 36, 307. Cronholm, B., Ottoson, J. O. (1963): .. Experiences Memory Function After Electroconvulsive Therapy", Brit. ]. Psychiat., 109, 251.
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Currie, T. T. (1953): "Subcostal Pain Following Controlled Respiration ", Brit. Med. j., I, 1032. Davies, D. L., Lewis, A. (1949): "Effects of Decamethonium Iodide on Respiration and ori Induced Convulsions in Man ", Lancet, 1,775. Davies, R. K., Detre, T. P., Egger, M. D. (1971): " Electroconvulsive Therapy Instruments-ShoUld They be Reevaluated ", Arch. Gen. P,ychiat., 25, 97. Delilkan, A. E. (1969): "Electroconvulsive Therapy With No-Relaxant Anaesthesia ", Brit. j. Anaesth., 41, 884. Dewald, P. A., Margolis, W. M., Weiner, H, (1954): " Vertebral Fractures as a Complication of Electroshock Therapy", ]. A mer. Med. Ass., 154,981. Dowdy, E. G., Fabian, L. W. (1963): "Ventricular Arrythmias Induced from Succinyl Choline in Digitalized Patients ", Anesth. Analg., 42, 501. Dundee, J. W., McDowell, S. A. (1971): .. Influence Drug Therapy on Anaesthesia", General Anaesthesia, 3rd Edition. Gray and Nunn (Eds.), Butterworths, London. Eldridge, A. (1952): "Discussion on New Muscle Relaxant in Electroconvulsive Therapy", Proc. Ray. Soc. Med., 45, 869. EIlis, F. R (1968) : "The Neuromuscular Interaction of Propanidid with Suxamethonium and Tubocurare ", Brit. j. Anaesth., 40, 818. . Evans, V. L. (1947): "Electrocardiographic Changes after Electric Shock Treatment ", ]. Lab. Cli n . Med., 22, 1518. Ferguson, A. L. (1952): "New Muscle Relaxants in E.C.T.", Proc. Roy. Soc. Med., 45, 875. Foley, E. I., WaIton, B., Savege, T. M., Strunin, L., Simpson, B. R (1972): "A Comparison of Re'covery Times Between Althesin and Methohexitone Following Anaesthesia for Electroconvulsive Therapy", Postgrad. Med. j., 48 Suppl., 2, 112. Ford, H. F., McDonald, E. C., Towler, M. L. (1965) : " Clinical Evaluation of Unilateral E.s.T.," Amer. j. Psychiat., 121, 1087. Frost, I. (1957) : " Unilateral Electric Shock ", Lancet 3, 1, 157. Gibb, D. B. (1973): .. Suxamethonium-A Review", Anaesth. Intens. Care, 1, 2. Gibb, D. B. (1974): .. Suxamethonium-A Review", Anaesth. Intens. Care, 2, 1. Haw, M. E. (1972) : .. Variations in Serum Potassium During Electroconvulsive Therapy", Brit. ]. Anaesth., 44, 707. Hey, V. M. (1972) : .. Hyperpyrexia after Anaesthesia ", Lancet, 2, 230. Holmberg, A. G., Thesleff, S. (1951) : "Succinylkolin Jodid Som Muskelavslappande Medel via Elektroshock Behandling ", 5. Nord. Med., 46, 42, 1567. Huguenard, P., Boue', A. (1948) : " Un Nouvel OrthoCurare Francais de Synthese le 3697 RP., .. Raport a' la Sac d' Anesthesie di Paris, 5cande du '7. Hussar, A. E., Patcher, M. (1968): .. Myocardial Infarction and Fatal Coronary Insufficiency During Electroconvulsive Therapy", j. Amet'. Med. Ass., 104, 1004. Impastato, D. J. (1957): .. Safer Administration of Succinyl Choline Without Barbiturates", A mer, ]. Psychiat., 113, I, 257.
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Impastato, D. J., Karlinger, \V. (I !l66) : "Control of Memory Impairment in E.S.T. by Unilateral Stimulus ", Dis. Ncrv. Syst., 27, 182. Kline, E. M., Fcltcrman, J. L. (1942): "Electrocardiographic Changes Following Electrically Induced Convulsions ", AlIley. Heart j., 24. 66;";. Kolb, L., Vogel, V. (1942): "Electroconvulsive Treatment ", A mer. j. Psyehiat., 99. La Cour, D. (Hi6H): " Rise in lntragastric Pressure Caused hv Suxametiloniull1 Fasciculations ", Acta. Anaesthi;l Seand., 13, 255. Lancaster, N. P., Steinart, K C, Frost, T. (1958): " Unilateral Electroconvulsive Therapy", j. lvlent. Sei., 104, 221. Mclnnes, E. J., James, N. M. (l!l72) : "Comparison of Ketamine and l\Iethohexitol in Electroconvulsive Therapy", Med. j. Aust., 1, 1031. MacLay, \V. S. (IH53): "Death Due to Electroconvulsive Treatment ", Proc. Roy. Soc. Med., 46, 13. Major, K H. (1954): History of M.edicine, Vol. 11, Thomas, Illinois. Martin, W. E., Ford, H. F., McDonald, E. C., Tower, M. L. (1\)65): "Clinical Evaluation Unilateral E.s.T. ", Amer. j. Psychiat., 121, 1087. Miller, R. D., Way, W. L. (IH71): "Inhibition of Succinyl Choline~Induced Intragastric Pressure by Non-Depolarizing Muscle Relaxants and Lidocaine", A nesthesiology, 34, 185. Patterson, .\. S., King, D. \V. (1!)74) "Electrocon"ulsive Fractures ", Brit. ,1Ied. J., 1, 11l8. l'ilditch, F. D., Baker, A. B. (1974) : " Effects Modified Electroconvulsive Therapy on Four Induction Agcnt~J{elaxant Regimes on Plasma Potassium ", Anaeslh. Intens. Care, 2, 142. Pitts, F. W., Woodruft, R. A., Craig, A. G., Hich, C. L. (1962) : " Drug Modification of Electroconvulsive Therapy", Arch. Gen. Psychiat., 19, 51)5.
W. D.
BLAKEMORE
Practising Psychiatrict (l!l53) : "The Experiences of Electroconvulsive Therapy", Brit. J. Psychiat., 3, :165. Prett, R c., Warrington, E. K, Halliday, A. M. (1971) : " tOnilateral E.C.T. as Test Cerebral Dominance ", Brit. j. Psychiat., 119, 4H. l{eebcn, R L. (IH54): "Liability for Injury Caused by Shock Treatment ", Kansas Law Review, 2, 393. Shagass, C., and Schwartz, M. (1962): "Cerebral Cortical Reactivity in Psychotic Depressions", Arch. Gen. Psyehiat., 6, 235. Sonnenklar, N., Rendell-Bakcr, L. (lH72): "Hyperpyrexia During Pregnancy", Lancet, 2, 43. Snow, K G. (1963) : " :\Iuscle l{elaxants in the Cardia Including Clinical Management of Patients Likely to Vomit or Regurgitate ", Brit. j. A naesth., 35, 541. Thes1cff, S. (1952): "Pharmacological Principles Succinyl Choline Iodide ", Acta. Physiol. Seand., 26, 103. Thomas, E., Honan, B. F. (lH53) : "Electroconvulsive Therapy", Brit. lVled. j., 2, 97. Triesse, 1'. S., Stenhouse, N. S. (1968): "Electroconvulsive Treatment Phases with/without Anaesthesia ", Brit. j. Psyehiat., 114, 1383. Yalentine, M., Keddie, K. M. G., Dunne, D. (1968): "Comparison, Techniques in Electroconvulsive Therapy", Brit. J. Psychiat., 114, 98!l. Waiter, C. J., l\litchell-Heggs, N., Sargant, N. (1972) : "Modified Narcosis, E.C.T. and Antidepressant Drugs. A Review of Technique and Immediate Outcome ", Brit. j. Psyehiat., 120, 651. Waters, D. J., Mapleson, W. M. (1971) : "Suxamethonium Pains~Hypothesis and Observation ", Anaesthesia, 26, 127. Zamora, E. W., Kalbing, R. (1966): "Memory and Electroconvulsive Therapy", A mer. J. Psychiat., 122,546.
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