1TITLE: Occupational team safety in ECT practice during the COVID-19 pandemic

2Electroconvulsive therapy (ECT) is a procedure indicated for the treatment of several

3neuropsychiatric conditions, including severe and life-threatening conditions such as

4depression with risk of suicide, starvation, catatonia, refractory schizophrenia, mania

5with severe psychomotor agitation, and status epilepticus (1). Although this is a life-

6saving treatment, maintaining the functioning of ECT services during the COVID-19

7pandemic has become a challenge due to the intrinsic risks of the anesthetic and

8ventilatory approach during the procedure (2). Anesthesia for performing ECT consists

9in the use of a short-acting hypnotic (propofol, etomidate, thiopental) followed by a

10neuromuscular blocker, the most used being succinylcholine due to its rapid onset and

11offset of action. Oxygen support is provided through non-invasive ventilation via bag

12and mask (3). This is a critical point in the procedure because non-invasive ventilation

13poses a higher risk of contamination due to aerosol release from contaminated

14ventilated patients. To address this challenge, some services are using a laryngeal mask

15(LMA) for ventilation, others are trying not to ventilate patients during the procedure,

16using preoxygenation via a non-rebreather mask. The latter can be dangerous because

17the patient’s oxygen saturation may drop to a level that requires ventilatory support

18during the procedure. Although the procedure is fast enough to allow the use of LMA,

19the risk of contamination due to the aerosol spray does not decrease significantly; in

20addition, LMA can induce the patient to cough (4).

21 In our ECT service, we modified the non-invasive ventilation technique by

22installing a HEPA (high-efficiency particulate arrestance) filter between the bag and the

23mask to retain the viral particles. In addition, a sterile plastic bag surrounding the mask
24and the patient’s face was attached to the ventilation system. This device protects

25against the aerosol that may escape from between the mouth and the mask and

26spread viral particles around the ECT room. The edge of the plastic bag can be fixed

27with clamps. All ventilation material is replaced between patients. The use of low O 2

28flow during ventilation is also a recommended measure. The psychiatrist,

29anesthesiologist, and nurse should all use personal protective equipment such as an

30N95 mask and a face shield, gloves, and an impermeable gown. We believe this is a

31safe and effective way to reduce the risk of contamination during the ECT procedure.

32

33REFERENCES

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35 Essential Medical Procedure-Maintaining Service Viability and Accessibility. J ECT.

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38 19. J ECT ; 2020 Mar 31. Article En | MEDLINE | ID: mdl-32243336

393. AMERICAN PSYCHIATRIC ASSOCIATION. COMMITTEE ON ELECTROCONVULSIVE

40 THERAPY., WEINER RD. The practice of electroconvulsive therapy: recommendations for

41 treatment, training, and privileges: a task force report of the American Psychiatric

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434. Bryson EO, Aloysi AS. A strategy for management of ECT patients during the COVID-19

44 pandemic [published online ahead of print, 2020 May 12]. J ECT. 2020;

45 doi:10.1097/YCT.000000000702