Guest Auther: Dr.Sanjeev Deshpande
MD

It was year 1984 when I started my practice as a consultant in Anesthesia in Aurangabad.

Physicians used to treat psychiatry patients and also teach medical students , psychiatry. As undergraduates we were taught psychiatry by a prof. of psychology and our understanding was limited .To us, every psychiatric disease looked similar.

When working as a resident in anesthesia, I had a few opportunities to observe and then deliver anesthesia for ECT to some psychiatry patients. It was delivered in a room in medicine ward.

When during practice I met a qualified psychiatrist for the first time and had opportunity to work with him and for the first time I saw almost a dozen or two patients being given ECT.

I had little knowledge of Psychiatry. The psychiatrists used to call it modified ECT. Two types – A direct, without anesthesia, and modified, with general anesthesia. As ECT is a painless procedure, no analgesic was required.

The most intriguing thing of practice was that it was totally a catering practice. Psychiatry was then and even today is considered a stigma and ECT was given to patients in different nursing homes run by non psychiatrists and even at patients’ homes. No emergency drugs or equipments, no oxygen , not a single appropriate set up, only ambu bag and mask at hand. Injuries were common, especially to tongue, lips, teeth, and regurgitations and aspirations were quite common.

Our pharmacology text books warned that with Chlorpromazine [ Largactil ], sudden unexplained deaths in young otherwise healthy patients were not infrequent. It was used in heavy doses and to our experience the text books proved to be true. Every alternate year a patient or two used to fall in the washroom or fell down without reason and die on the spot. I happened to witness a couple of such patients and in spite of all resuscitation, could not save them. As there were very few investigations done in those days, no cause could be known.

We started introspecting ourselves and took some measures to prevent complications of ECT and anesthesia. First of all, we stopped giving ECTs at patients’ homes and places where facilities for emergencies were inadequate. Then came the time of giving ECTs. We decided to administer ECTs early in the morning as soon as patients got up from bed, as it was difficult to keep them nil orally in the daytime. Then our ECT set up started taking shape. A proper table with facility for head low position, in case the patient had regurgitation, a good suction machine, and an oxygen filled cylinder, and all necessary emergency drugs was set up.

Still very few investigations were done due to unawareness and to keep ECT an affordable procedure. No monitors other than hand on pulse was available. Then came the days of plateau and soon we experienced complications in spite of proper care. That led us to re assess our procedure, and a team was set up. Routine investigations were being done in every patient and to some extent the incidents of complications and sequelae were reduced. Then came the experience of cardiac arrest on table that led us to revamp all our setup.

An old man of 70 + yrs had an arrest on table and couldn’t be resuscitated. That was very much shocking. We made ECGs as a routine for all patients above 40 years. Yet a young female patient had a cardiac arrest on ECT table, but this time we could revive her successfully and shifted her to an ICU where she was properly treated and we came to know our deficits. She had high potassium levels and a very long QTc interval.

We started investigating all the patients in details and an ECG of every patient was made compulsory, with QTc chart for ready to refer which we prepared ourselves as no electronic ECG machines were available. Electrolyte levels were done for suspected and chronic patients.

Now we have a full fledged ECT room with two tables, A Boyles machine with central oxygen, a defibrillator, all the emergency medicines with all equipments for resuscitation including Laryngoscopes, endotracheal tubes, Laryngeal airways, a Jet ventilator. All patients posted for ECT are screened in details by at least three doctors, and anesthetist, the are thoroughly examined after a detailed history taking, well investigated and well prepared before posting for ECT. Proper informed consent is taken from next to keens. A team of medical officers and nursing staff closely monitor the patients till they recover.

We are proud to inform that all our hospital staff is trained in CPR, and can effectively administer quality resuscitation in case of emergencies. We are heading towards not only zero mortality but also towards minimum morbidity.

At the end I would like to strongly suggest that psychiatry patients differ from other patients in following aspects. So please be aware of these

1. They suffer from multiple organic diseases due to neglected health and nutrition.
2. Multiple sittings of ECTs are often required but every time the response to Anesthetics may not be same. We have to modify doses and even change hypnotics according to the individual response of the patient.
3. Multiple antipsychotics cause not only drug interactions but also cardiac arrhythmias and blocks. Extremes of pulse and blood pressure fluctuations are seen.
   Postural hypotension is quite common. So beware of it .
4. Secretions and regurgitations are frequent in spite of precautions.
5. Prolonged convulsions, secondary convulsions and rigors or shivering need to be distinguished and treated accordingly.
6. A proper informed consent, screening, detailed investigations, preparation is must.
   ECT set up should never be less than an operation theatre.
7. A good team is must for monitoring during recovery.

ECT anesthesia cause dynamic changes are much more severe than other procedures. A good amount of experience and precautions are necessary to be a psychiatric anesthetist.

For anesthetizing a psychiatric patient on medicines for non psychiatric cause apart from drug interactions, we should be aware of post operative or even intra operative excitation [in patients under regional / local anesthesia] not responding to routine sedatives, narcotics and even hypnotics. A magic drug like HALOPERIDOL 5mg IM/IV must be kept ready in every emergency medicine kit. Haloperidol can produce extra pyramidal symptoms with a single dose and that can be dealt with Promethazine [phenergan] 25 -50 mg IV/IM SOS

Anesthesia is an acute preventive medicine. Multiple organic problems, multiple drug interactions, cardiac , respiratory events, aspiration,and post operative excitation are main problems every medical person should keep in mind while treating such patients.

Dr.Sanjeev Deshpande
Senior Consultant Anaesthesiologist And Head of Anaesthesia at Shanti Nursing Home, Aurangabad.
He is having experience in Anaesthesia more than 35 yrs.