Chapter 6. Pre-ECT Evaluation

Although components of the evaluation of patients for ECT will vary on a case-by-case basis, each facility should have a minimal set of procedures to be undertaken in all cases (Coffey 1998). A psychiatric history and examination, including past response to ECT and other treatments, is important to ensure that an appropriate indication for ECT exists. A careful medical history and examination, focusing particularly on neurological, cardiovascular, and pulmonary systems, as well as upon effects of previous anesthesia inductions, are crucial to establishing the nature and severity of medical risks. Inquiry about dental problems and a brief inspection of the mouth, looking for loose or missing teeth and noting the presence of dentures or other appliances should be carried out. The evaluation of risk factors prior to ECT should be performed by individuals privileged to administer ECT and ECT anesthesia. Findings should be documented in the clinical record by a note summarizing the indications and risks and suggesting any additional evaluative procedures, alterations in ongoing medications (see Chapter 7), or modifications in ECT technique that may be indicated. Procedures for obtaining informed consent should be carried out.

Laboratory tests required as part of the pre-ECT workup vary considerably. Young, physically healthy patients may not require any laboratory evaluation. Nevertheless, common practice is to perform a minimum screening battery of tests, often including a CBC, serum electrolytes, and an electrocardiogram. A pregnancy test should be considered on women of childbearing age, although ECT is not generally of increased risk in pregnant women (see Section 4.3). Some facilities have protocols whereby laboratory tests are specified on the basis of age or certain medical risk factors such as cardiovascular or pulmonary history (Beyer et al. 1998). Spine x-rays are no longer routinely necessary, now that the risk of musculoskeletal injuries with ECT has been largely obviated by the use of muscular relaxation, unless pre-existing disease affecting the spine is suspected or known to exist. EEG, brain computed tomography (CT), or magnetic resonance imaging (MRI) should be considered if other data suggest that a brain abnormality may be present. There is now some evidence that abnormalities found on structural brain images or EEG may be useful in modifying treatment technique. For example, since subcortical hyperintensities on MRI have been linked to a greater risk of post-ECT delirium (Coffey 1996; Coffey et al. 1989; Figiel et al. 1990), such a finding might encourage the use of right unilateral electrode placement and conservative stimulus dosing. Likewise, the finding of generalized slowing on a pre-ECT EEG, which has been linked to greater post-ECT cognitive impairment (Sackeim et al. 1996; Weiner 1983) might also encourage the above technical considerations. The potential use of pre-ECT cognitive testing is discussed elsewhere.

Although no data exist on the optimal interval in time between the pre-ECT evaluation and the first treatment, the evaluation should be performed as close as possible to the initiation of treatment, keeping in mind that it often must be spread over a number of days, due to need for specialty consultations, waiting- for laboratory results, meetings with patient and significant others, and other factors. The treatment team should be aware of pertinent changes in the patient's condition over this time interval and should initiate further evaluation as indicated.

The decision to administer ECT is based on the type and severity of the patient's illness, treatment history, and a risk-benefit analysis of available psychiatric therapies, and requires agreement among attending physician, ECT psychiatrist, and consentor. Medical consultation is sometimes used to obtain a better understanding of the patient's medical status, or when assistance in the management of medical conditions is desirable. To ask for "clearance" for ECT, however, makes the assumption that such consultants have the special experience or training required to assess both risks and benefits of ECT as compared to treatment alternatives -- a requirement that is unlikely to be met. Likewise, determinations made by individuals in administrative positions regarding the appropriateness of ECT for specific patients are inappropriate and compromise patient care.

RECOMMENDATIONS:

Local policy should determine the components of the routine pre-ECT evaluation. Additional tests, procedures, and consultations may be indicated, on an individual basis. Such a policy should include all the following:

1. psychiatric history and examination to determine the indication for ECT. The history should include an assessment of the effects of any prior ECT.
2. a medical evaluation to define risk factors. This should include medical history, physical examination (including assessment of the teeth and mouth), and vital signs.
3. an evaluation by an individual privileged to administer ECT (ECT psychiatrist --Section 9.2), documented in the clinical record by a note summarizing indications and risks and suggesting any additional evaluative procedures, alterations in ongoing medications, or modifications in ECT technique that may be indicated.
4. anesthetic evaluation, addressing the nature and extent of anesthetic risk and advising of the need for modification in ongoing, medications or anesthetic technique.
5. informed consent.
6. appropriate laboratory and diagnostic tests. Although there are no absolute requirements for laboratory tests in a young, healthy patient, a hematocrit, serum potassium and an electrocardiogram should be considered in most patients. Consideration should be given to performing a pregnancy test in women of childbearing age prior to the first ECT. More extensive laboratory evaluation may be indicated, depending on the patients' medical history or current status.

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