ECT: Contraindications

Before discussing contraindications, it is important to first understand the physiologic effects of ECT. These include :

• Large increases in cerebral blood flow and intracranial pressure
• Initial parasympathetic discharge manifested by bradycardia, occasional asystole, premature atrial and ventricular contraction, hypotension and salivation
• Following parasympathetic reaction is a sympathetic discharge associated with tachycardia, hypertension, premature ventricular contractions, and rarely, ventricular tachycardia and ECG changes, including ST-segment depression and T-wave inversion, may also be seen.
• Glucose homeostasis is also affected. Hyperglycemia seen in insulin dependent patients

Absolute contraindications:

• Known pheochromocytoma

Relative contraindications: The risk of the patient’s psychiatric illness, side effects of antidepressant medications must be weighed against the risk of ECT and anesthesia. These conditions include :

• Increased intracranial pressure, ok if there is not a mass effect
• Brain tumors, same recommendation as above
• Recent stroke- ECT has been performed successfully
• Cardiovascular conduction defects. Pacemaker is not a contraindication to ECT- AICD function can be deactivated and magnet should be available if needed
• High-risk pregnancy- OB consult and fetal monitoring is recommended
• Aortic and cerebral aneurysms
• Asthma/COPD- some suggest that you should discontinue theophyline because of its potential to cause status epileptics

Recommendations:

• Delay ECT for patients with unstable angina, decompensated heart failure, or severe symptomatic valvular disease until these conditions are stabilized or optimized. Cardiology consultation may be of benefit
• For high-risk neurosurgical lesions including recent stroke and brain tumor, neurosurgical consultation is recommended
• Diabetic patients should hold oral hypoglycemic, short acting insulin and halve their long acting dose with fasting
• Warfarin can be continued in high risk patients with INR <3.5
• In severe GERD antacids can be taken or intubation considered