What is the recommended pre-procedure workup for patients undergoing Electroconvulsive Therapy (ECT)?

ECT Pre-Procedure Workup

Every patient undergoing ECT must receive a complete physical examination, comprehensive laboratory testing (CBC with differential, electrolytes, liver and thyroid function, urinalysis with toxicology screen, and ECG), pregnancy testing for females, baseline cognitive assessment, and documented informed consent. 1

Essential Laboratory and Diagnostic Testing

Mandatory Baseline Tests

• Complete blood count with differential white blood cell count to assess hematologic status before anesthesia 1
• Comprehensive metabolic panel including electrolytes, liver function tests, and thyroid function tests to identify physiological parameters affecting ECT or anesthesia administration 1
• Electrocardiogram to screen for cardiac abnormalities given the cardiovascular stress of ECT 1
• Urinalysis and toxicology screen to identify substance use and renal function 1
• Pregnancy test (serum or urine) for all female patients of childbearing age to enable appropriate precautions if pregnant 1

Neuroimaging Considerations

• MRI or CT scan should be obtained if not already completed as part of treatment-refractory depression workup, particularly since adults referred for ECT show higher rates of CNS pathological lesions that may affect treatment outcome or seizure duration 1
• EEG, skeletal x-rays, or additional neuroimaging should be obtained on a case-by-case basis when clinically indicated 1

Cognitive Assessment Protocol

Perform age-appropriate memory assessment focusing on short-term memory and new knowledge acquisition before treatment initiation 1. This baseline is critical because:

• Memory assessment must be repeated at treatment termination 1
• Follow-up cognitive testing should occur 3-6 months post-treatment 1
• This allows quantification of any persistent cognitive effects 1

Informed Consent Requirements

Documentation Standards

• Obtain written consent from the patient or authorized representative (parent for adolescents) 1, 2
• Obtain independent second opinion from a psychiatrist knowledgeable about ECT 2
• Secure assent from adolescent patients whenever possible, recognizing that severely ill, manic, confused, or psychotic patients may be unable to provide assent 1

Patient Education Components

The consent process must include:

• Discussion with the treating physician about the procedure, risks, and benefits 1
• Written educational materials explaining ECT 1
• Videotape demonstrations of the procedure, ideally including interviews with former ECT patients 1
• Clear disclosure that ECT benefits are short-lived without continued treatment and that there is risk of permanent severe memory loss 1
• Information about the typical treatment course (6-15 treatments or as clinically indicated) 1
• State-mandated waiting periods between consent and treatment initiation, where applicable 1

Pre-Anesthesia Evaluation

Comprehensive medical evaluation must identify relative contraindications (there are no absolute contraindications to ECT) that require special management 1. The evaluation should:

• Assess cardiovascular risk factors given the hemodynamic stress during ECT 2, 3
• Identify pulmonary conditions that may complicate anesthesia 3
• Screen for cerebrovascular disease that increases risk of adverse events 3
• Review current medications for potential interactions with anesthetic agents 1

Common Pitfalls to Avoid

• Do not skip neuroimaging in treatment-refractory cases, as CNS lesions are more common in ECT candidates and may affect outcomes 1
• Do not assume adolescents can provide informed consent without careful assessment of their capacity, particularly when severely ill 1
• Do not proceed without baseline cognitive testing, as this makes it impossible to quantify treatment-related cognitive changes 1
• Do not overlook pregnancy testing in females, as special precautions are needed for pregnant patients 1