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Navidomskis Ann-Marie 8) A patient is admitted for electroconvulsive treatment (ECT). The physician orders the neuromuscular UID: 814762348 blocking agent metocurine iodide (metubine) to reduce trauma by relaxing skeletal muscles. Explain the October 18, 2007 process of muscle contraction and how a neuromuscular blocking agent such as metubine would Question 8 interfere with muscle contraction. 11 am Lab Electroconvulsive Treatment, more widely known as ECT and sometimes Electroshock Treatment, is not a form of patient control as it is presumed to be by the ill-informed. Electroconvulsive Treatment is actually a medical procedure in which the patient, likely suffering from severe depression or schizophrenia, has seizures induced with electricity for a calming and therapeutic effect. There are 3 types of ECT; the difference lying in electrode placement, length of time the stimulus is administered, and the properties of the stimuli; all 3 types of ECT having vastly different side effects and outcomes. During ECT electrodes are placed on the patient s forehead (position defines which type of ECT being administered), a type of barbiturate is administered to put the patient to sleep, and then the drug, usually succinycholine, is administered to temporarily paralyze and relax muscles to prevent bone fractures during muscle contractions. Alternatively, you could inject the patient with the neuromuscular blocking agent metocurine iodide, also known as metubine, instead of succinycholine; which would provide the same effects. The seizure, in order to be effective, usually lasts between 30-60 seconds. The small current provided through the electrodes is sent through the brain activating the small seizure. It is still undecided as to why this procedure actually works; however more is learned annually as Electroconvulsive Treatment is continually and vastly researched. Electroconvulsive Therapy has received some bad press as a result of what the treatment used to be. Yet "ECT has a higher success rate for severe depression than any other form of treatment." It has also been shown to be an effective form of treatment for schizophrenia accompanied by catatonia, extreme depression, mania, or other affective components. The following excerpt on its use in depression from Overcoming Depression by Dr. Demitris Popolos should help shed some light on the issue. There's been a resurgence of interest in ECT because it has evolved into a safe option, one that works. But for a public influenced by Ken Kesey's One Flew Over the Cuckoo's Nest, whose associations with ECT start with the electric chair & move on to lightning bolts, electric eels & third rails, it makes for queasy conversation. For all of us. Let's replace a few of the myths with facts. ECT has a higher success rate or severe depression than any other form of treatment. It can be life-saving & produce dramatic results. It is particularly useful for people who suffer from psychotic depressions or intractable mania, people who cannot take antidepressants due to problems of health or lack of response & pregnant women who suffer from depression or mania. A patient who is very intent on suicide, & who would not wait 3 weeks for an antidepressant to work, would be a good candidate for ECT because it works more rapidly. In fact, suicide attempts are relatively rare after ECT. ECT is usually given 3 times a week. A patient may require as few as 3 or 4 treatments or as many as 12 to 15. Once the family & patient consider that the patient is more or less back to his normal level of functioning, it is usual for the patient to have 1 or 2 additional treatments in order to prevent relapse. Today the method is painless, & with modifications in technique it bears little relationship to the unmodified treatments of the 1940s. The patient is put to sleep with a very short-acting barbiturate, & then the drug succinycholine is administered to temporarily paralyze the muscles so they do not contract during the treatment & cause fractures. An electrode is placed above the temple of the nondominant side of the brain, & a second in the middle of the forehead (this is called unilateral ECT); or one electrode is placed above each temple (this is called bilateral ECT). A very small current is passed through the brain, activating it & producing a seizure. Because the patient is anesthetized & his body is totally relaxed by the succinycholine, he sleeps peacefully while an electroencephalogram (EEG) monitors the seizure activity & an electrocardiogram (EKG) monitors the heart rhythm. The current is applied for one second or less, & the patient breathes pure oxygen through a mask. The duration of a clincally effective siezure ranges from 30 seconds to sometimes longer than a minute, & the patient wakes up 10 to 15 minutes later. Upon awakening, a patient may experience a brief period of confusion, headache or muscle stiffness, but these symptoms typically ease in a matter of 20 to 60 minutes. During the few seconds following the ECT stimulus there may be temporary drop in blood pressure. This may be followed by a marked increase in heart rate, which may then lead to a rise in blood pressure. Heart rhythm disturbances, not unusual during the period of time, generally subside without complications. A patient with a history of high blood pressure or other cardiovascular problems should have a cardiology consultation first. Because as many as 20 to 50 percent of the people who respond well to a course of ECT relapse within 6 months, a maintenance treatment of antidepressants, lithium or ECT at monthly or 6 week intervals might be advisable. Short-term memory loss has always been a concern to patients who receive ECT, but several studies conclude that patients who received unilateral ECT performed better on attention/memory tests than those who received bilateral ECT. However, there is a question as to whether unilateral is as effective. Experts agree that changes in memory function do occur & persist for a few days following treatment, but that patients return to normal within a month. A 1985 NIMH Consensus Conference concluded that while some memory loss is frequent after ECT, it is estimated that one-half of 1 percent of ECT patients suffer severe loss. Memory problems usually clear within 7 months of treatment, although there may be a persistent memory deficit for the period immediately surrounding the treatment. How distressing is ECT to Patients? While there are certainly patients who perceive the treatment as terrifying & shameful, & some who report distress about persistent memory loss, many speak positively of the benefits. An article entitled "Are Patients Shocked by ECT?" reported on interviews with 72 consecutive patients treated with ECT. The patients were asked whether they were frightened or angered by the experience, how they looked back at the treatment, & whether they would do it again. Of the patients interviewed, 54% considered a trip to the dentist more distressing, many praised the treatment, & 81% said they would agree to have ECT again. Those are comforting statistics about a treatment that has an ugly name & ugly connotations but beautiful & even life-saving results.... . . . . . . . . Why is there a resurgent interest in ECT The scientific evidence regarding the efficacy of the treatment has been firmly established in the professional literature. In addition, decades old studies showing brain cell death have been refuted in recent studies (but some anti-ECT activists still quote them). However, ECT is like all other treatments. Doctors often underplay the potential side-effects. In addition, it is sometimes prescribed for conditions it is not medically appropriate for. And like other treatments, the effective is not always permanent. Like with medicines, ECT is not used and once you are better forever. Maintenance ECT may be required. Unfortunately, some well-intentioned activists, received ECT inappropriately; were erroneously told the effects were always permanent; and/or suffered side effects (ex. memory loss) that their doctors did not explain. Some of these activists have attacked the treatment itself when it is really the doctor who delivered the treatment who was at fault. NAMI's official policy is that while it does not endorse particular forms of treatment, it believes informed individuals with neurobiological disorders have the right to receive NIMH approved treatments like ECT from properly trained practitioners. NAMI opposes actions intended to limit this right. http://www.medhelp.org/lib/ect.htm You may be surprised to learn that electroconvulsive therapy (ECT) is still being practiced in most, if not all, psychiatric units in general hospitals and mental institutions. The original use of electricity as a cure for insanity dates back to the beginning of the 16th century when electric fish were used to treat headaches. ECT originates from research in the 1930 s into the effects of camphor-induced seizures in people with schizophrenia. In 1938, two Italian researchers, Ugo Cerletti and Lucio Bini, were the first to use an electric current to induce a seizure in a delusional, hallucinating, schizophrenic man. The man fully recovered after 11 treatments which led to a rapid spread of the use of ECT as a way to induce therapeutic convulsions in the mentally ill. When we think of ECT many of us recall the terrifying image of Jack Nicholson in One Flew Over the Cuckoo s Nest . This is not an accurate portrayal of the present day application of ECT. Certainly, before the development of effective muscle relaxants, it was not unusual for patients to suffer broken bones as a result of these electrically induced seizures. Many people opposed to ECT are against it because they feel it is being used to control patients. Many years ago when psychiatry was less advanced, ECT was used for a much wider range of mental illnesses and sometimes, unfortunately, it was used to control troublesome patients. Today, the American Psychiatric Association has very specific guidelines for the administration of ECT. It is to be used only to treat severe, debilitating mental disorders and not to control behavior. In most states, written and informed consent is required. The doctor will explain in detail to the patient and or family the reasons why ECT is being considered along with the potential side effects. ECT is generally used in severely depressed patients for whom psychotherapy and medication are proving ineffective. It may also be considered when there is an imminent risk of suicide because ECT often has much quicker results than antidepressant remedies. The procedure is usually performed on an inpatient basis although maintenance ECT may be performed once a week or so as an outpatient. The patient is required to fast for 8-12 hours prior to treatment. Involved in the administration of ECT are usually a psychiatrist, anesthesiologist, and other supportive medical personnel. The patient is anesthetized with an intravenous injection of a barbiturate or other anesthetic. The muscles are temporarily paralyzed with the drug succinylcholine which prevents the violent jerking motions that used to break bones. The heart rate and other vital signs are monitored throughout the procedure. In bilateral ECT, electrodes are placed above each temple. In unilateral ECT, the electrodes are placed above the temple of one side of the brain and in the middle of the forehead. An electrical current is then passed through the brain, inducing a grand mal seizure. Evidence of the seizure may show in twitching toes, an increased heart rate, clenched fists or a chest heave. Clinically effective seizures generally last from about 30 seconds to just over a minute. The patient s body does not convulse and the patient feels no pain. During the seizure there are a series of changes in brain waves on an electroencephalogram (EEG) and when the EEG tracing levels off this is an indication that the seizure is over. As the patient awakens there may be headache,nausea, temporary confusion and muscle stiffness. There are varying opinions as to how the memory is affected by ECT. Many patients report loss of memory for events that occurred in the days, weeks or months surrounding the ECT. Many of these memories may return, although not always. Some patients have also reported that their short-term memory continues for months to be affected by ECT although there is the argument that this may be the type of amnesia that is sometimes associated with severe depression. In the first few decades of ECT s use, death occurred in 1 in 1,000 patients. Current studies report a very low mortality rate of 2.9 deaths per 10,000 patients or, in another study, 4.5 deaths per 100,000 treatments. Much of this risk is due to the anesthetic although the risk is no greater than the use of anesthetic for any minor surgical procedure. There is no doubt that, properly used, ECT can be an effective procedure in the treatment of severe depression. Surprisingly, experts are still uncertain as to why it works. It is thought that ECT acts by temporarily altering some of the brain s electrochemical processes. Electroconvulsive therapy is the most controversial treatment in psychiatry. It s history of abuse, unfavorable media presentation and compelling testimony of former patients all contribute to the controversial context in which ECT is viewed. There are clearly significant side effects, especially acute confusion and persistent memory deficits. http://ky.essortment.com/whatiselectroc_riek.htm Drug Type Drug Category Approved Drug Anesthetics, Local Neuromuscular Nondepolarizing Agents ATC:M03AA04 For use as an anesthesia adjunct to induce skeletal muscle relaxation and to reduce the intensity of muscle contractions in convulsive therapy. Metocurine iodide is a benzylisoquinolinium competitive nondepolarizing neuromuscular blocking agent. Metocurine iodide has a moderate risk of inducing histamine release and has some ganglion blocking activity. Metocurine iodide can be used most advantageously if muscle twitch response to peripheral nerve stimulation is monitored to assess degree of muscle relaxation. As with other nondepolarizing neuromuscular blockers, the time to onset of paralysis decreases and the duration of maximum effect increases with increasing doses of metocurine iodide. Repeated administration of maintenance doses of metocurine iodide has no cumulative effect on the duration of neuromuscular block if recovery is allowed to begin prior to repeat dosing. Moreover, the time needed to recover from repeat doses does not change with additional doses. Repeat doses can therefore be administered at relatively regular intervals with predictable results. Metocurine iodide antagonizes the neurotransmitter action of acetylcholine by binding competitively with cholinergic receptor sites on the motor end-plate. This antagonism is inhibited, and neuromuscular block reversed, by acetylcholinesterase inhibitors such as neostigmine, edrophonium, and pyridostigmine. Not Available Excessive doses can be expected to produce enhanced pharmacological effects. Overdosage may increase the risk of histamine release and cardiovascular effects, especially hypotension. 35% in plasma Indication Pharmacology Mechanism of Action Absorption Toxicity Protein Binding Biotransformation Not Available Half Life Dosage Forms Drug Reference 3 to 4 hours Liquid (for injection) http://www.pharmgkb.org/views/index.jsp?objId=PA450478&objCls=Drug http://redpoll.pharmacy.ualberta.ca/drugbank/cgibin/getCard.cgi?CARD=APRD01318.txt

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