Acta psychiat. scand. (1975) 52, 171-181 Department of Neurology and Psychiatry (Head: Professor G y . Pdlffy), University of PCcs Medical School, PCcs, Hungary
CORRELATION BETWEEN BLOOD GASES, GLYCOLYTIC ENZYMES A N D E E G D U R I N G ELECTROCONVULSIVE TREATMENT I N RELAXATION
Twenty-three psychiatric patients were investigated during electroconvulsive treatment in relaxation. The blood gases, pH and serum bicarbonate levels in blood samples from the internal jugular vein and the femoral artery were measured radiometrically. The LDH fractions were separated electrophoretically and their activity, along with the activity of aldolase, was then determined on test materials. EEG recordings were made during the seizure and also during postconvulsive restitution. The following conclusions were drawn: (1) There was no evidence of anoxic anoxia in the brain during and after seizures. (2) A close relationship was found between the corresponding phases of electrical activity and brain metabolism as indicated by the blood gas changes during postconvulsive restitution. (3) On the basis of the increased glycolytic activity in the sera it is probable that glucose metabolism was shifted in the anaerobic direction during postconvulsive restitution of the brain tissues.
- blood gases - EEG restitution - brain metabolism - glycolytic enzymes.
Key words. Electroconvulsive treatment
The electric current passing through the brain during electroshock causes serious injury to its tissues (Alexander & Lowenbach (1944), Quandr & Sommer (1966)). The immediately damaging effect of the current (Zsombdk & Kaffka (1955), Nyiro et al. (1956)) is further increased by the anoxaemic action of the induced seizure (Himwich (1944)). The predominantly vascular origin of the damage was stressed by Scholz (1951). Apnoea and intensive muscular contractions may lead to acidosis (Delmas-Marsalet (1946)) and to disturbances of microcirculation in the brain. In the course of electroconvulsive treatment in relaxation (R-ETC) the physiological conditions are considerably changed by the administration of narcotics, by the transient paralysis of the skeletal muscles and by the artificial respiration. Most investigators report an increase in cerebral blood flow and oxygen consumption during epileptic fits (Gibbs et al. (1934), Kefy et d.(1948), Meyer e? al. (1966). However, during generalised epileptic seizures in artificially ventilated, paralysed animals the 0,content of the cerebral venous blood was found to be 11.
172 increased in comparison with the control values (Plum er a f . (1968)). This fact would seem to indicate that cerebral oxygen consumption did not increase proportionally with the blood flow in spite of the extreme paroxysmal activity. Similarly, in R-ECT the 0, content of the internal jugular vein (IJV) did not change in comparison with the control value (Posner et ul. (1969)). The lactate difference between the IJV and the femoral artery (FA) was not greater than the control value, but increased after the seizure (Beresjord et ul. (1969)). The latter experiments were performed on relaxed animals. O n the basis of these observations it may be assumed that during or after epileptic seizures the glucose metabolism of the brain is shifted in the anaerobic direction. The purpose of our investigations was to determine (under EEG control) the following: (1) The relationship between the electric activities of the brain and the changes in cerebral blood gases in the postconvulsive period, (2) The activities of the anaerobic glycolytic enzymes of the serum (lactate dehydrogenase (LDH), aldolase) during seizures and during postconvulsive restitution. We also wished to decide whether or not there was anoxic anoxia in the brain during and after a seizure produced by electric current in relaxation. METHODS Twenty-three psychiatric patients aged from 19 to 48 years were investigated. Twenty-two of them were diagnosed as schizophrenics and one as suffering from endogenous depression. Physically all the patients were healthy. Before the electroconvulsive treatment they received 0.5 mg atropine subcutaneously. In 18 patients narcosis was introduced with Sombrevin (propanidium, 8-10 mg/kg) and in five cases with Venobarbital (thiobarbiturate-Nay5-8 mg/kg). Hereafter these two groups will be referred to as the “Sombrevin group” and the “barbiturate group”, respectively. The skeletal muscles were paralysed with succinylcholine (1 mg/kg). Relaxation having been achieved, artificial. respiration was instituted with a gas mixture of N,O:O, containing 30% 0,. The volume of respiration was at 0.5 1, its rate at 16/min. The ECT was applied at 3-6 minutes after intubation, by which time the blood gases had become stabilised. In 16 patients the electrical activity of the brain was recorded with a 12-channel EEG apparatus (“Hellige”) using four pairs of electrodes placed symmetrically over the central regions of the skull. ECG and pulse rate were recorded with a “Disa” polygraph. Puncture of the IJV was performed with the method of Gibbs (1945) on the right side, with simultaneous puncture of one of the femoral arteries. No complications were encountered during these procedures. The shock was delivered by the Nyiro-KujjkaZsombdk ECT apparatus. The electrodes were placed bifrontally. Intensity of the current was 19 mA;its duration 2 to 3 sec. The input of the EEG apparatus was automatically blocked by a relay during the shock. Arterial and venous blood samples were drawn from the patients (and from the cephalic veins of three patients serving as controls) before and during the seizure as well as during characteristic periods of EEG restitution. The average- number of the samples was six to
173 nine. After spontaneous respiration had been reinstated, the cannulaswere removed. The blood samples were analysed by means of a blood gas analyser (“Radiometer Copenhagen”), and oxygen saturation (Opat.), oxygen tension (PO,), carbon dioxide tension (pCO,), pH and base excess were determined. Hereafter these data will be referred to as the “Astrup values”, Serum aldolase and total amount of LDH in the sera of the arterial and venous blood samples were determined on test materials, and the LDH fractions separated by electrophoresis (Frohlich (1965)). The “Astrup values” of identical EEG periods in different patients were averaged by means of the two-tailed “t-probe” statistical test.
RESULTS At the time the control samples were drawn, fast EEG activity - characteristic of the early phase of Sombrevin and N,O sleep - was recorded in ten cases. In the seizure period the well-known polyspilres (8-12 cps frequency, 300 PV in amplitude) appeared. In eight cases an electrical silence (Fig. 1) was recorded
.
CrP, _----
5-01
nTj\-
+ q i
L-v,,-.~\>
-JkPlP=-.w
FrFi
G
F4-
.-TLl/V%X ---L4--L
-\-
.IsecriOqIlV
Fig. 1. Investigations during R-ECT (S.M., female, aged 28 years). The EEG periods at the top of the figure were recorded when the blood samples were drawn. From left to right: First column: Control (C), fast activity in barbiturate - N20 narcosis; second column: Seizure (S); third column: Electrical silence (E); fourth column: Periodic delta waves (PA); fifth column: Theta-alpha waves (Ta); sixth column: Alpha waves (a).NO sample was taken in the delta phase in this case. Pulse curve (P) in channel 9, and ECG in channel 10. T = times of drawing postictal blood samples. The columns of ‘*Astrup values” are below the time marking. V = internal jugular vein, A = femoral artery, p = partial pressure (mmHg), sat. = saturation (%). In the first column: BE = base excess and pH. For explanation see text.
174
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-
-
-
-
CORRELATION BETWEEN BLOOD GASES, GLYCOLYTIC ENZYMES A N D E E G D U R I N G ELECTROCONVULSIVE TREATMENT I N RELAXATION
Twenty-three psychiatric patients were investigated during electroconvulsive treatment in relaxation. The blood gases, pH and serum bicarbonate levels in blood samples from the internal jugular vein and the femoral artery were measured radiometrically. The LDH fractions were separated electrophoretically and their activity, along with the activity of aldolase, was then determined on test materials. EEG recordings were made during the seizure and also during postconvulsive restitution. The following conclusions were drawn: (1) There was no evidence of anoxic anoxia in the brain during and after seizures. (2) A close relationship was found between the corresponding phases of electrical activity and brain metabolism as indicated by the blood gas changes during postconvulsive restitution. (3) On the basis of the increased glycolytic activity in the sera it is probable that glucose metabolism was shifted in the anaerobic direction during postconvulsive restitution of the brain tissues.
- blood gases - EEG restitution - brain metabolism - glycolytic enzymes.
Key words. Electroconvulsive treatment
The electric current passing through the brain during electroshock causes serious injury to its tissues (Alexander & Lowenbach (1944), Quandr & Sommer (1966)). The immediately damaging effect of the current (Zsombdk & Kaffka (1955), Nyiro et al. (1956)) is further increased by the anoxaemic action of the induced seizure (Himwich (1944)). The predominantly vascular origin of the damage was stressed by Scholz (1951). Apnoea and intensive muscular contractions may lead to acidosis (Delmas-Marsalet (1946)) and to disturbances of microcirculation in the brain. In the course of electroconvulsive treatment in relaxation (R-ETC) the physiological conditions are considerably changed by the administration of narcotics, by the transient paralysis of the skeletal muscles and by the artificial respiration. Most investigators report an increase in cerebral blood flow and oxygen consumption during epileptic fits (Gibbs et al. (1934), Kefy et d.(1948), Meyer e? al. (1966). However, during generalised epileptic seizures in artificially ventilated, paralysed animals the 0,content of the cerebral venous blood was found to be 11.
172 increased in comparison with the control values (Plum er a f . (1968)). This fact would seem to indicate that cerebral oxygen consumption did not increase proportionally with the blood flow in spite of the extreme paroxysmal activity. Similarly, in R-ECT the 0, content of the internal jugular vein (IJV) did not change in comparison with the control value (Posner et ul. (1969)). The lactate difference between the IJV and the femoral artery (FA) was not greater than the control value, but increased after the seizure (Beresjord et ul. (1969)). The latter experiments were performed on relaxed animals. O n the basis of these observations it may be assumed that during or after epileptic seizures the glucose metabolism of the brain is shifted in the anaerobic direction. The purpose of our investigations was to determine (under EEG control) the following: (1) The relationship between the electric activities of the brain and the changes in cerebral blood gases in the postconvulsive period, (2) The activities of the anaerobic glycolytic enzymes of the serum (lactate dehydrogenase (LDH), aldolase) during seizures and during postconvulsive restitution. We also wished to decide whether or not there was anoxic anoxia in the brain during and after a seizure produced by electric current in relaxation. METHODS Twenty-three psychiatric patients aged from 19 to 48 years were investigated. Twenty-two of them were diagnosed as schizophrenics and one as suffering from endogenous depression. Physically all the patients were healthy. Before the electroconvulsive treatment they received 0.5 mg atropine subcutaneously. In 18 patients narcosis was introduced with Sombrevin (propanidium, 8-10 mg/kg) and in five cases with Venobarbital (thiobarbiturate-Nay5-8 mg/kg). Hereafter these two groups will be referred to as the “Sombrevin group” and the “barbiturate group”, respectively. The skeletal muscles were paralysed with succinylcholine (1 mg/kg). Relaxation having been achieved, artificial. respiration was instituted with a gas mixture of N,O:O, containing 30% 0,. The volume of respiration was at 0.5 1, its rate at 16/min. The ECT was applied at 3-6 minutes after intubation, by which time the blood gases had become stabilised. In 16 patients the electrical activity of the brain was recorded with a 12-channel EEG apparatus (“Hellige”) using four pairs of electrodes placed symmetrically over the central regions of the skull. ECG and pulse rate were recorded with a “Disa” polygraph. Puncture of the IJV was performed with the method of Gibbs (1945) on the right side, with simultaneous puncture of one of the femoral arteries. No complications were encountered during these procedures. The shock was delivered by the Nyiro-KujjkaZsombdk ECT apparatus. The electrodes were placed bifrontally. Intensity of the current was 19 mA;its duration 2 to 3 sec. The input of the EEG apparatus was automatically blocked by a relay during the shock. Arterial and venous blood samples were drawn from the patients (and from the cephalic veins of three patients serving as controls) before and during the seizure as well as during characteristic periods of EEG restitution. The average- number of the samples was six to
173 nine. After spontaneous respiration had been reinstated, the cannulaswere removed. The blood samples were analysed by means of a blood gas analyser (“Radiometer Copenhagen”), and oxygen saturation (Opat.), oxygen tension (PO,), carbon dioxide tension (pCO,), pH and base excess were determined. Hereafter these data will be referred to as the “Astrup values”, Serum aldolase and total amount of LDH in the sera of the arterial and venous blood samples were determined on test materials, and the LDH fractions separated by electrophoresis (Frohlich (1965)). The “Astrup values” of identical EEG periods in different patients were averaged by means of the two-tailed “t-probe” statistical test.
RESULTS At the time the control samples were drawn, fast EEG activity - characteristic of the early phase of Sombrevin and N,O sleep - was recorded in ten cases. In the seizure period the well-known polyspilres (8-12 cps frequency, 300 PV in amplitude) appeared. In eight cases an electrical silence (Fig. 1) was recorded
.
CrP, _----
5-01
nTj\-
+ q i
L-v,,-.~\>
-JkPlP=-.w
FrFi
G
F4-
.-TLl/V%X ---L4--L
-\-
.IsecriOqIlV
Fig. 1. Investigations during R-ECT (S.M., female, aged 28 years). The EEG periods at the top of the figure were recorded when the blood samples were drawn. From left to right: First column: Control (C), fast activity in barbiturate - N20 narcosis; second column: Seizure (S); third column: Electrical silence (E); fourth column: Periodic delta waves (PA); fifth column: Theta-alpha waves (Ta); sixth column: Alpha waves (a).NO sample was taken in the delta phase in this case. Pulse curve (P) in channel 9, and ECG in channel 10. T = times of drawing postictal blood samples. The columns of ‘*Astrup values” are below the time marking. V = internal jugular vein, A = femoral artery, p = partial pressure (mmHg), sat. = saturation (%). In the first column: BE = base excess and pH. For explanation see text.
174
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c
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