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Pupillary Response as Assessment of Effective Seizure Induction by Electroconvulsive Therapy
Summary April 11th, 2019
Pupillary responses (light reflex) were measured for assessment of adequate seizure induction by electroconvulsive therapy using an automated infrared pupillometer immediately after electrical stimulation. Constriction ratio was calculated and compared with seizure quality.
Transcript
The efficacy of ECT, electroconvulsive therapy, has been evaluated based on electroencephalography and increases in BP or HR, however, an increasing number of patient have adapted to ECT and rates of cardiovascular disease are increasing. On the other hand, pupillary responses can reflect sympathetic nervous activity or the degree of brain damage. This proposed method might be particularly useful for patients who have been administered anti-hypertensive drugs during ECT.
Pupillary response measurement using an automated infrared pupillometer can be conducted in a simple, precise, and objective way and not be affected by anesthetic agents or anti-hypertensive drugs. Additionally, the white light used for measuring light reflexes is not overly bright and harmful for patients. Begin by cleaning the right and left forehead and the area behind the ears with an alcohol cotton swab.
Next, attach electroencephalogram or EEG monitors at four symmetrical points. Clean bilateral temples with normal saline and then attach adhesive electrical stimulation pads to the bilateral temples to prevent interference in the stimulation due to hair. Then, attach the electrocardiogram or ECG monitors at the base of the heart and cardiac apex and monitor heart rate.
Next, prepare a tourniquet and belt it at the left thigh. Lastly, attach two electromyogram sensors to the left anterior tibial muscle with a distance of five centimeters to measure generalized seizure time in the lower leg. After anesthetizing the patient, begin the electroconvulsive therapy or ECT procedure by using an ECT instrument set at an initial electrical stimulus dose percentage at half the value of the patient's age.
Then, immediately after electrical stimulation, hold the automated infrared pupillometer over one of the patient's eyes. After the patient's eyes are opened by an examiner, press the device button and measure maximum resting pupil size or minimum pupil size after stimulation. Next, perform controlled ventilation using a face mask with 100%oxygen until the patient begins breathing spontaneously.
Finally, using EEG, measure ictal regularity, seizure time, and greater post-ictal suppression. Results indicate that pupillary diameter was increased after electrical stimulation, however, significant differences in constriction by the light reflex were caused immediately after electrical stimulation reflecting differences in seizure efficacy induced by ECT. For this study, automated infrared pupillometer is essential.
Measurements should be conducted immediately after electrical stimulation because pupillary reactions recover rapidly. For adequate seizure evaluation, pupillary reaction might be included in the future. Pupillary reaction might be one of the evaluations for degree of epilepsy or non-induced seizure.
Hemodynamics are dynamically changed immediately after electrical stimulation, therefore, the anesthesiologist should not excessively focus on evaluating pupillary response but ensure there is consistent monitoring of the patient's vital signs.
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