Editorial on ECT Anesthesia During the COVID Pandemic
PMID: 33043717
From the text:
...the anesthesia procedure should be adjusted for avoiding the contamination of patients and healthcare professionals, following the recently published consensus guidelines. Aerosol-generating procedures, such as high-flow nasal oxygen, MV, and tracheal suction, should be avoided [14]. It can often be difficult to identify and isolate infected patients; therefore, it is recommended to take precautions during airway management of all patients [4]. Ideally, patients should be treated in rooms with negative pressure, if available [4,8,10,14]. It is recommended to use glycopyrrolate for minimizing salivation [15] and remifentanil and lidocaine for reducing cough upon awakening [16]. The induction agents that provide the best seizure quality, such as ketamine, etomidate, or methohexital, should be selected [5]. The airway management is undoubtedly the most important issue in the current recommendations. 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. 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. Using this protocol, only 48.1% of the patients required rescue MV. Similar procedures were adopted at the IPUB and it was observed that with a rigorous pre-oxygenation, a good part of the patients went through the procedure without the need for MV. In terms of breathing circuits, the closed circuit, such as anesthetic circle circuit, is ideal [14] for ventilation and preferred to a bag-valve-mask that expels the expired gas into the environment, but the use of Mapleson C [14] and Jackson-Rees [12] circuits has also been mentioned. For awakening from anesthesia, a disposable transparent plastic curtain [18] can be used on the patient’s face between the filter and the mask for retaining aerosols, in cases MV is required. If ventilation is required, the technique of two people and two hands should be used for improving the sealing, low flow, and low O2 pressure [12,14]. If airway suction is required, a closed suction system [8] should be used, if available. After recovery, the patient must immediately wear a surgical mask [10,12]. Although orotracheal intubation is rarely required in the context of ECT, the requirement cannot be prevented. The guidelines recommend that the most experienced professional at the site should perform the intubation using video laparoscopy and minimize the MV [10]. At the end of each treatment, the room should be thoroughly disinfected and there should be a minimum interval of 30 min between each patient [10], depending on the air exchange rate of the institution’s room.
This is a straightforward synopsis of the recent literature on how ECT services, and particularly ECT anesthesia delivery, have needed to be modified for safety during the global pandemic.
While there is nothing new here, it is nice to have another contribution to this literature from Brazil.
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