Modified Anesthesia Protocol for Electroconvulsive Therapy Permits Reduction in Aerosol-Generating Bag-Mask Ventilation during the COVID-19 Pandemic

Abstract

Introduction: Electroconvulsive therapy (ECT) is a critical procedure in psychiatric treatment, but as typically delivered involves the use of bag-mask ventilation (BMV), which during the COVID-19 pandemic exposes patients and treatment staff to potentially infectious aerosols. Objective: To demonstrate the utility of a modified anesthesia protocol for ECT utilizing preoxygenation by facemask and withholding the use of BMV for only those patients who desaturate during the apneic period. Methods: This chart review study analyzes patients who were treated with ECT using both the traditional and modified anesthesia protocols. Results: A total of 106 patients were analyzed, of whom 51 (48.1%) required BMV using the new protocol. Of clinical factors, only patient BMI was significantly associated with the requirement for BMV. Mean seizure duration reduced from 52.0 ± 22.4 to 46.6 ± 17.1 s, but seizure duration was adequate in all cases. No acute physical, respiratory, or psychiatric complications occurred during treatment. Conclusions: A modified anesthesia protocol reduces the use of BMV by more than 50%, while retaining adequate seizure duration.

Electroconvulsive Therapy Practice Changes in Older Individuals Due to COVID-19: Expert Consensus Statement

“…Some sites have used pre-oxygenation to avoid bagged mask ventilation (BMV) use during the procedure for appropriate patients. 6 Pre-oxygenation is done with a regular or non-rebreather mask (slight difference between sites) for several minutes pre-treatment, and then having the patients self-hyperventilate as they go off to sleep to try to minimize BMV. While some patients still require BMV, it is avoided as much as possible, which has the advantage of cutting down the risk of aerosolization, and helps preserve HEPA filters.…”

Anesthesia for electroconvulsive therapy during the COVID-19 pandemic

“…Regarding patient testing, the centers have started to implement it according to their protocols and possibilities. The suspected or positive patients for SARS-CoV-2 are not referred for ECT [10][11][12], a recommendation also followed by the IPUB. The ECT procedure is postponed until patients have a negative test result [8].…”

“…The use of the traditional bag-valve-mask hyperventilation prior to ECT generates aerosols and should be avoided during the COVID-19 pandemic [4,8,10,11,14] for not exposing health professionals and patients to unnecessary risks of infection. Pre-oxygenation by face mask for 3-5 min should be prioritized for reducing the need for MV [4,8,10,11,14], and apneic oxygenation via nasal prongs should be considered [17]. If hyperventilation is necessary, the use of a laryngeal mask allowing capnography [17] is preferred to MV.…”

“…If hyperventilation is necessary, the use of a laryngeal mask allowing capnography [17] is preferred to MV. A high efficiency particle filter (HEPA) must be placed between the Y-piece of the breathing circuit and the patient's mask [8,11,12]. Luccarelli et al [11] developed an anesthesia protocol for modified ECT, prioritizing pre-oxygenation for reducing the need for MV.…”

“…A high efficiency particle filter (HEPA) must be placed between the Y-piece of the breathing circuit and the patient's mask [8,11,12]. Luccarelli et al [11] developed an anesthesia protocol for modified ECT, prioritizing pre-oxygenation for reducing the need for MV. The usual hyperventilation was not used prior to ECT, and rescue MV was provided only to patients who desaturated at the discretion of the anesthesiologist.…”