DIFFUSE ALVEOLAR DAMAGE COMPLICATING ELECTROCONVULSIVE THERAPY

Abstract

TOPIC: Diffuse Lung Disease TYPE: Fellow Case Reports INTRODUCTION: Electroconvulsive therapy (ECT) has been increasingly used over the last few years for various indications, of the rare complications described in the literature is pulmonary edema, only 9 case reports described this complication, 8 of which were attributed to none cardiogenic cause and one had a cardiology component. Here we present a case of pulmonary edema and diffuse alveolar damage (DAD) with hemorrhage with no cardiac component CASE PRESENTATION: 41 years old female smoker, known to have fibromyalgia, systemic lupus erythematosus (SLE) in remission for years, diabetes and severe bipolar disorder refractory to medical therapy' Patient were admitted to the hospital for ECT, shortly after the procedure she developed hemoptysis and shortness of breath requiring oxygen therapy, chest tomography ruled out pulmonary embolism but showed evidence of diffuse alveolar process with ground glass pacification (Image 2). no inhaled medications were used in anesthesia and other inhalational injuries ruled out by history, also vasculitis and infectious process were ruled out. bronchoscopy suggestive of DAD with hemorrhage (Image 1). review of the patient's anesthesia report showed no variation in vital signs during the procedure and ECHO was within normal. the patient recovered with supportive care and advised to be intubated on subsequent sessions DISCUSSION: None cardiogenic pulmonary edema has been described as a complication of ECT, while most cases describe it as a subsequence of variation in blood pressure during the procedure few described it as a result of pressure variation. The theory used to explain the development of pulmonary edema / diffuse alveolar damage is explained as the partially paralyzed diaphragm (Paralytic in smaller dose are used that doesn't result in complete paralysis of the diaphragm as the procedure is aimed to be short with minimal sedation) contract against a close epiglottis with abducted vocal cords from the ECT current. This will result in negative pressure inside the chest cavity and the development of shearing force resulting in damage of the small blood vessels and extravasation of blood and plasma into the alveolar space, which was the case in our patient. Other contributory causes were ruled out. recurrence is not common but precautions in subsequent sessions are warranted. the development of noncardiogenic edema is not a contraindication for further sessions. CONCLUSIONS: ECT is being widely used as a new modality for therapy for refractory psychiatric diseases, precautions to the possible complications are warranted, shortness of breath or hemoptysis post the procedure should raise the suspension of noncardiogenic pulmonary edema / diffuse alveolar damage. treatment is supportive with diuretics being the first line. no other therapies have been described. this complication warranted precautions in the following sessions but doesn't contraindicate them. REFERENCE #1: Manne JR, Kasirye Y, Epperla N, Garcia-Montilla RJ. Non-cardiogenic pulmonary edema complicating electroconvulsive therapy: a short review of the pathophysiology and diagnostic approach. Clin Med Res. 2012 Aug;10(3) 131-136. doi:10.3121/cmr.2011.1030. PMID: 22031475; PMCID: PMC3421372. REFERENCE #2: Hatta K, Kitajima A, Ito M, Usui C, Arai H. Pulmonary edema after electroconvulsive therapy in a patient treated for long-standing asthma with a beta2 stimulant. J ECT. 2007 Mar;23(1) 26-27. doi:10.1097/01.yct.0000263258.52162.63. PMID: 17435570. REFERENCE #3: Myers, Christopher & Gopalka, Ajay & Glick, David & Goldman, Morris & Dinwiddie, Stephen. (2008). A Case of Negative-Pressure Pulmonary Edema After Electroconvulsive Therapy. The journal of ECT. 23. 281-3. 10.1097/yct.0b013e3180de5d44. DISCLOSURES: No relevant relationships by Amro Alastal, source=Web Response No relevant relationships by Rami Batarseh, source=Web Response No relevant relationships by Christopher Lipinski, source=Web Response