Case 42: Breathing Difficulties After an ECT
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You are scheduled to do an outpatient electroconvulsive therapy (ECT) on a 36-year-old female. This is her fourth ECT in a series of at least 8. She tells you that the previous ones have been uneventful and that her mood is better. She is 90 kg and 5′6″ in height. She works in her husband’s restaurant where she is a cook. Her medical history is significant for depression, hypertension, insulin-dependent diabetes mellitus, and hypothyroidism. She takes nifedipine, enalapril, insulin, thyroxine, paroxetine, and fluphenazine. After she arrives in the treatment room, an IV is started. You examine the patient and find nothing abnormal, including her airway exam. Her chest is clear to auscultation. Her heart rate is 90, BP is 130/70, respiratory rate is 12, and room air oxygen saturation is 97%. You place noninvasive monitors on the patient and start to preoxygenate her. Anesthesia is induced with etomidate 16 mg, followed by succinylcholine 1 mg/kg. The patient is hyperventilated, and the ECT procedure is done uneventfully, except excess salivation is noted after the treatment. The patient awakens from the anesthetic but suddenly sits up and starts to cough violently. Her saturation falls to 86%. You diagnose laryngospasm and provide positive pressure mask ventilation with 100% oxygen. After a few minutes, the laryngospasm is broken and she is now breathing easier. She sits up, and although her oxygen saturation is now 96% on nasal oxygen (6 liters/min), she complains that she does not get enough air. The nurse tells you now that this difficulty with breathing happened last time she had an ECT, but she slowly improved over a 20-min period and was discharged home. The nurse tells the patient to lie down, but she refuses. She again states that she cannot breathe. She rips off all her monitors and refuses to have them replaced. The nurse tells you she did that last time too.
KeywordsECT Oxygen saturation Respiratory failure Negative pressure pulmonary edema (NPPE) Furosemide Laryngospasm Succinylcholine