Clinical 2nd Rotation Week 1: Part 2 - ECTs and Thyroidectomy
I split this initial post into two because I can get a little long winded. However, I did some interesting cases this week, so I'd like to share!
Clinical Experience
Today I did anesthesia for ECT's (electroconvulsive therapy) and a Thyroidectomy.
ECT:
My first day, I did 11 ECTs. Yes, 11. It is a wake up call because you think you're good at bag-mask ventilation... then you do ECTs and realize how much you SUCK. Haha... no seriously... everyone told me that's how it was going to be, but I thought I had my masking skills down. Uh no.
People really hype up intubation and it's obviously a skill you need to have to do this job, but people don't die from not being intubated. They die from not being able to VENTILATE ! So, please, don't downplay masking. It's essential to keeping your patient alive.
I’m going to keep it 100% with y’all. For the longest time I thought they didn’t even do ECT's anymore. Forreal. If any of you have seen the 1975 film, One Flew Over the Cuckoo’s Nest, its portrayal played a major role discrediting its use. As psychotropic medications came into play, performing ECTs diminished, then over the last 50 years or so it’s regained its reputation many disorders such as severe depression and other affective disorders.
Here's the rundown of how I learned to do ECTs:
Monitors are placed on the patient (HR, BP, SpO2, nasal cannula w/ETCO2).
Special leads are placed on the patients head (I did bilateral ECTs).
Once the patient is prepped, the medication Methohexital is given. It is considered the "gold-standard" and is a barbiturate that works on the GABA (a) receptors causing sedation.
After the patient is asleep, a small dose of succinylcholine, a paralytic is administered. Rocuronium/Sugammadex can also be used.
A special bite block is placed in the patient’s mouth that has an oral airway implemented into it.
Begin bagging the patient with the Ambu bag.
The patient is shocked, then the patient will seize.
Seizures lasting longer than 120secs generally require immediate administration of Propofol or Ativan.
During this time, you are monitoring the patients vital signs, and maintaining a patent airway.
The electric shock causes the activation of the autonomic nervous system with a parasympathetic discharge causing a brief bradycardia or pause (yes, it looks like your patient just went asystolic, but don’t push the code button!)
After this, a sympathetic response causes an increase in heart rate and blood pressure causing profound hypertension and tachycardia that can last 3-5 minutes. Antihypertensives such as Labetalol can be used if the hypertension is sustained.
Glycopyrrolate or Atropine is also given as a pre-mediation if the patient is bradycardic at baseline or if they become bradycardic from the procedure.
After the patient seizes, you continue to bag them until they begin spontaneously breathing!
Usually the patients aren't here for their first time. Look up what they've received before and prepare those drugs.
Some additional things that I've learned,
Other medications like Propofol and Etomidate can be used, but with some caveats. Etomidate doesn’t blunt the sympathetic responses to the seizure, and also lowers the seizure threshold causing a longer seizure. Propofol has its benefits of blunting that response. Methohexital is used because it does not change the duration of the seizure. Propofol can also be used but it can decrease the seizure duration. Ketofol = Ketamine & Propofol has been shown to also be a great alternative to general anesthesia & paralysis. However, at my clinical facility we did not use this approach.
Some contraindications: Recent MI, stroke, aneurysm, & osteoporosis
Onto the Thyroidectomy...
This was a cool case to do because I used a NIM (nerve integrity monitor) tube. This tube has special leads in it that connect to a monitoring system to ensure that the Recurrent Laryngeal Nerve (RLN) is not damaged during surgery. It literally acts like the game Operation. You touch the nerve, & the machine buzzes! Pretty cool.
So, to jog your memory, the RLN innervates the posterior and lateral cricoarytenoid muscles, which adduct and abduct the vocal cords. Remember, ADDuct = together, ABduct = apart. The Superior Laryngeal Nerve has two branches, the internal and external. The internal is sensory, and the external is motor. The external SLN provides innervation of the cricothyroid muscle and tenses the vocal cords! Bilateral injury to the RLN will cause stridor and paralysis of the cords... this can lead to re-intubation then tracheostomy. If you have unilateral damage, this will cause hoarseness as it only causes ipsilateral paralysis!