Electro - Convulsive Therapy (ECT)

INTRODUCTION:-

Electroconvulsive Therapy (ECT) is a treatment method used for people who suffer from severe depression or bipolar disorders. In this therapy, a small electric current is passed through the patient’s brain, which is under general anesthesia, for inducing a brief seizure in the brain. Inducing such seizures causes a change in brain chemistry that reduces the symptoms of some mental illness, slowly bringing back the patient to his/her original condition. ECT is preferred only when all other treatments seem to be unsuccessful.

In earlier days, people had negative feedback about ECT as it used high electric current without anesthesia, leading to many serious side effects such as memory loss and bone fractures. But now ECT is considered much safer, with less side effects as it uses a small electric current, that too with general anesthesia. ECT therapy is generally carried out by a group of trained medical professionals including a psychiatrist, anesthesiologist, and physician assistants.

HISTORY OF ECT THERAPY

ECT therapy is one of the oldest treatment methodology used in the field of psychiatry. Roman psychiatrists, Ugo Cerletti and Lucio Bini developed the first ECT machine in 1938. Patient diagnosed with Schizophrenia was first treated with this machine and it was found successful. Ugo Cerletti and Lucio Bini were awarded Nobel Prize in medicine in 1930s.

The idea of inducing epileptic seizures for treating patients was proposed by Meduna, a Hungarian neuropathologist and psychiatrist. In 1940, ECT was used worldwide and was considered an effective technique for treating severe mental illness. In the 1960s, psychiatrist Thomas Szasz pioneered the ‘anti-psychiatry movement’ which criticized psychiatry and considered ECT as inhumane and torturous. Due to this reason, ECT took a back seat during 1960-1970 but returned to the mainstream mode of treatment in the 1980s.

PSYCHIATRIC DISORDERS TREATED WITH ECT

ECT can provide significant improvement in certain mental illness conditions. ECT is used to treat:-

• Major depression, including a desire to commit suicide.
• Severe mania, it is a bipolar disorder that includes intense euphoria, agitation, or hyperactivity. Impaired decision-making, impulsive or risky behavior, substance abuse, and psychosis are other signs of mania.
• Schizophrenia, it is a disorder that affects a person’s ability to think, feel and behave properly.
• Catatonia, it is associated with Schizophrenia and some other psychiatric disorders and is characterized by lack of movements, lack of speech, fast or strange movements, etc...
• Treatment-resistant depression, depression that doesn’t get improved with other treatments.

TYPES OF ECT THERAPY

There are two types of ECT:

• Bilateral ECT: In bilateral ECT, the current is passed through both sides of the head. The position of electrodes is that one electrode is placed on the left side of the head and the other on the right side.
• Unilateral ECT: In unilateral ECT, the current is passed only through one side of the head. One of the two electrodes is placed at the top of the head and the other at the right side.

WHEN IS ECT THERAPY USED?

Electroconvulsive Therapy (ECT) is a medical treatment used to cure severe symptoms of several mental health conditions like:-

• Severe Depression:    It is a mental health issue accompanied by detachment from reality (psychosis) sleep problems and frequent thoughts of death or suicide.

• Severe Mania: It is a mental health issue that triggers a person from reality and is a state of intense euphoria, agitation, or hyperactivity. This can also occur as a part of bipolar disorder. Some other signs of severe mania are impaired decision-making, impulsive or risky behavior, substance abuse, and psychosis.

• Catatonia: Symptoms are lack of movement, fast or strange movements, lack of speech.

• Treatment-resistant depression: These are depressions that cannot be improved with medications or other treatments. ECT therapy is a good treatment option when drugs or other therapies haven’t worked. 

• So ECT is used in cases of patients like pregnant women, in older adults.

• Agitation & aggregation in people with dementia.

HOW IS ECT PERFORMED?  

• ECT is performed under the prescription of an experienced psychiatrist.

• Prior to ECT treatment, a patient is put into sleep using general anesthesia and a muscle relaxant is given. 

• Since the muscles are relaxed, the seizure will usually be limited to slight movement of the head and feet.

• After taking all the prerequisites electrodes are placed on the patient’s scalp and a finely controlled electric current is applied, which causes a brief seizure (a sudden electrical disturbance in the brain) in the brain. 

• These changes the brain chemistry that can quickly reverse symptoms of certain mental health conditions. 

• During treatment, the patient is carefully monitored by the doctor. 

• A few minutes later the patient will get awakens and he/she will not remember the events surrounding the treatment and may also feel confused for a short period of time. 

• ECT is given up to three to two times a week for 2 to 4 weeks.

• A single course of ECT is followed by psychotherapy and medicine under a psychiatrist’s care.

PREPARATIONS FOR ECT 

A full evaluation is usually needed before the first ECT treatment. These evaluation results help the Psychiatrists to make sure that ECT is safe for the patient. Some of the evaluation methods include:- 

• Psychiatric assessment 
• Medical History
• Complete Physical exam 
• Basic Blood test
• Electrocardiogram (ECG) to check the heart health
• Discussion of the risks of anesthesia

Steps to be followed before the treatment are as follows:

• General anesthesia will be given to the patient so that some dietary restrictions need to be followed . This means no food or water after midnight and only a sip of water to take any morning medications.

• A brief physical examination of lungs and heart.

• An extra IV tube is inserted into the patient’s arm through which medications like anesthesia can be provided.

• Electrode pads will be placed on the patient’s head for the treatment. Based on which ECT can be of two types unilateral and bilateral. In unilateral electric currents focus only on one side of the brain while in bilateral both sides of the brain receive focused electric currents. 

PROCEDURE OF ECT THERAPY

• When the procedure begins, the doctor can monitor seizure activity. A blood pressure cuff placed on one ankle stops the muscle relaxant medication from entering the foot and affecting the muscle there. 

• Monitors check the patient’s brain, heart, oxygen use, and blood pressure.

• Oxygen will be given through an oxygen mask and a mouth guard is also provided to protect the patient’s teeth and tongue from injury.

• When you're asleep from the anesthetic and your muscles are relaxed, the doctor presses a button on the ECT machine. This causes a small amount of electric current to pass through the electrodes to your brain, producing a seizure that usually lasts less than 60 seconds.

• The patient will remain unaware of the seizure because of the effect of anesthetic and muscle relaxant. 

• The only indication of the seizure inpatient will be a rhythmic movement of the foot if there is a blood pressure cuff around the ankle.

• As a result of the seizure, the internal activity of the brain will get increased dramatically which will be recorded using  EEG.

• The effects of the short-acting anesthetic and muscle relaxant begin to decrease after a few minutes. 

• Then the patient will be taken to a recovery area, where he/she will be monitored for any potential problems. 

• When the patient wakes up they may experience a period of confusion lasting from a few minutes to a few hours or more

RESULT

The patient’s improvement in symptoms will be incredible after six treatments with ECT. So ECT is an amazing treatment method to treat severe depression and some other mental illnesses. Many chemical aspects of the brain are changed during seizure activity as a result the symptoms of severe depression and mental illness are reduced.

To prevent the recurrence of the mental illness, mild medications or psychological counseling should be given to the patient periodically.

EFFECTIVENESS AND SUCCESS RATE OF ECT

ECT therapy has a 70 to 90 percent success rate in normal cases and this percent of success reduces  50  to 60 percent for those taking medications. Some researchers believe that ECT is so effective because it helps to correct an imbalance in the brain’s chemical messenger system. Another theory is that the seizure somehow resets the brain. Whether inpatient or outpatient ECT is given two to three times a week for a total of six to twelve sessions and these sessions help in reducing depression to a greater extent than comparing with some antidepressant drugs.

BENEFITS  OF ECT OVER OTHER THERAPIES

ECT is somewhat more beneficial and lesser side effects in comparing with medications.ECT helps many people when drugs and psychotherapy are not effective. ECT has so many advantages that it quickly relieves psychiatric symptoms, depression, or mania. Medications actually need much time to come into effect. So ECT can be especially beneficial for those who are:

• suicidal
• psychotic
• catatonic

ECT can also be safely used on pregnant women and heart patients.

RISKS AND SIDE EFFECTS OF ECT THERAPY:

Although ECT is generally safe, risks and side effects may include:

MEMORY LOSS:

Some people have difficulty remembering events that occurred right before treatment or in the weeks or months before treatment. This condition is called retrograde amnesia. You may also have trouble recalling events that occurred during the weeks of your treatment. For most people, these memory problems usually improve within a couple of months after treatment ends.

CONFUSION:

Immediately after treatment, you may experience confusion, which can last from a few minutes to several hours.  confusion may last several days or longer. Confusion is  more seen in older adults.

PHYSICAL SIDE EFFECTS:

During the days of an ECT treatment, people may experience nausea, headache, jaw pain or muscle ache. These  can be treated with medications.

MEDICAL COMPLICATIONS:

As with any type of medical procedure, especially one that involves anesthesia, there are risks of medical complications. During ECT, heart rate and blood pressure increase, and in some cases, that can lead to serious heart problems. If you have heart problems, ECT may be more risky.The most common side effects of ECT on the day of treatment include nausea, headache, fatigue, confusion and grogginess, slight memory loss, which may last minutes to hours ,muscle aches and soreness. 

PROS AND CONS OF ECT

ECT is one of the best tool for treating depression. But it is not the only way to treat, and however ECT does  have so many disadvantages on individuals. 

Firstly, ECT requires sedation which causes recovery complex and time consuming. 

Second, ECT has serious side effects on some people includes memory loss and several other health issues.

PROS OF ECT:

• It is safer today than previous ECT treatments
• No medication side effects
• It work slightly quicker than TMS

CONS OF ECT:

• May not    be  able  to do works   up to    2 weeks after treatment
• Treatment sessions are done 2    to 3   times a week for up to 4 weeks
• Requires   sedation    through anesthesia and muscle relaxers
• Confusion  post-treatment
• Typically   not     well  tolerated in   the  elderly  population
• Memory  loss (retrograde amnesia) which  usually improves within    a  couple months of the  procedure
• Physical side effects related to tension (nausea, headache, jaw aches, and muscle aches
• Not tolerated well  in people with heart problems

PRECAUTIONS

• BEFORE YOUR PROCEDURE:

Electroconvulsive therapy is performed under general anesthesia, so that you should not eat, drink, or smoke ,do not drink alcohols and certain other illegal drugs on the days of your treatments. On the day of your procedure, do not wear jewelry or contact lenses. You’ll receive an intravenous line (IV), so dress comfortably and opt for a I-shirt or tank top.

AFTER YOUR PROCEDURE:

You must have an adult present to drive you home and remain with you for the next 6-8 hours.You are not to drive over the treatment course and for two weeks after treatments end.

Article Contributers:-

1. Niya Nelson - https://www.linkedin.com/in/niya-nelson-045174200 

2. Jithi K J - https://www.linkedin.com/in/jithi-k-j-baa398195

3. Devika S - https://www.linkedin.com/in/devika-s-876b2821a

Intra-Aortic Balloon Pump Therapy (IABP)

 Introduction:

           An Intra-Aortic Balloon Pump (IABP) is a type of therapeutic device which helps the heart to pump more blood when it is needed. That is when the heart is unable to pump enough blood, this device will come into action with the help of the physicians. This process is used when the body undergoes any cardiogenic shock.

Fig.1: whole setup of IABP therapy

First invented and used by:-

The IABP therapy was first invented by “Adrian Kantrowitz” an American surgeon in the year 1967. Its first clinical application was implemented successfully to a forty-five-year-old female who had sustained a myocardial infarction.

Fig.2: Adrian Kantrowitz- inventor of IABP therapy

Constructions:-

The IABP device has two important portions: they are,

1) A large-bore catheter with a long sausage-shaped balloon at the distal end.

2) A console containing a pump that inflates and deflates the balloon.

Steps to be followed in the console:-

• First power on the balloon pump by pressing the button in the console. After receiving lines from the sterile field, insert its cables to the console from where the helium is shuttled back and forth. And the fiber optic cable is connected which measures the blood pressure directly from the tip of the balloon catheter. The EKG and the pressure monitoring lines are connected at the proper place in the console. Lines from the patient’s monitor are also ducked down on the console.

• After the connections are made and the power is set ON, the EKG and the pressure traces are seen in one of the two screens. In the upper screen, the two traces, beats per minute, and the diastolic and systolic pressure after it is calibrated with the pressure transducer are seen. The lower line represents the augmentation or the balloon inflation and deflation. In the lower screen the trigger, the trigger source, the ballooning frequency, augmentation, and timing are all controlled. And the device is started by pressing the button on the screen and standby to pause it.

• Hence the balloon is controlled by the console according to the needs of the patients and under the supervision of the physicians.

Fig.3: A console used for IABP therapy

Insertion of balloon catheter:

• Usually, the intra – aortic balloon catheter is inserted through the femoral artery and it goes all the way to the heart through the our iliac artery, descending aorta and it sits right around the descending aorta starting below the subclavian artery and the outer tip goes right to the renal arteries.

• This is the reason why the urine outputs are constantly measured and monitored, as there is a good chance if things go wrong as the balloon pump can damage the renal arteries, destroying or harming the kidneys of the patients. Since special care is taken while inserting the device and should be done by well-trained people.

 Fig.4: Insertion of a balloon catheter

Working:-

The main function of the device is that contraction and relaxation (systole and diastole). It also reopens the blocked artery near the heart and it is just the reverse to the normal pumping action of the heart. In the sense that the device relaxes when the heart muscle relaxes(diastole) and contracts when the heart muscle contracts(systole) and reducing the afterload which is one of the main functions of the IABP device.

Fig.5:  The balloon contract and relax in accordance with diastole and systole

The balloon catheter is connected to the console for the purpose of inflating and deflating the balloon according to the rhythm of the heartbeat. In this process, helium is used to blow up the balloon. 

And the helium here is safe and it won’t cause any problems to the body if it leaks somewhere. 

IABP also provides modest ventricular unloading while also increasing mean arterial pressure and coronary blood flow.

 Fig.6: Helium cylinder fixed inside a console

In a properly timed waveform, the inflation point lies at or slightly above the dicrotic notch. The amount of aid a balloon pump can provide a quantified ratio of 1:1. 

Fig.7: The waveforms formed during the process

It is mostly used for two to a few days alone but it can stay in place for up to a month. For this process, the IABP uses helium to inflate the balloon as it is low density and means there is little turbulent flow. So the balloon inflates fast deflate slowly but as soon as any leak or rupture in the balloon, it is eliminated quickly.

Fig.8: A physician inserting the catheter into the patient model

Some medical disorders which require IABP therapy:-

• Unstable angina 
• Heart attack
• Certain abnormalities in heart rhythms
• Heart failure
• Other heart defects

    Fig.9: Figure showing stable and unstable angina

Fig. 10: An  image depicting a person with a heart attack

Future use of IABP Therapy:-

Intra - aortic balloon pumps have been used for many heart conditions for the part of forty years. In general, the device is used for the problems such as transient angina, arrhythmia, and myocarditis. The currently completed researches are for the use of IABP before surgery or for conditions that do not normally require the use of  IABP for treatment. Some researchers have suggested that the IABP could be used as a great support in high-risk cardiac surgery, meaning that if a patient has a heart transplant, IABP can be used in the body after a new heart transplant to reduce stress.

This is important because heart transplantation is difficult for the body and the surgeons need to make sure whether it fits the body. With some support, it can put less pressure on the patient and the implant can be inserted properly into the body. Another proposed idea for IABP is to use it to treat left ventricular obstruction on extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation is life support commonly used in infants, children, and adults with heart conditions.

It is a form of heart-lung bypass, which means it takes over the function of the heart and lungs during the surgery. Researchers hope that IABP will help with inflammation of the ventricles in this process. This means that there is less chance of a negative reaction to this bypass procedure. Overall the future of IABP seems to be related to whether or not it is approved for use in patients with disorders other than the specific heart conditions listed. 

Researchers have made a great effort to use the intra-aortic balloon pump for a variety of procedures that can help patients in an amazing way.

Advantages of IABP Therapy:-

• It is available all over the world in most cardiac catheterization laboratories and in other required laboratories.
• It is easy for percutaneous implantation.
• It is available in several sizes like 7fr, 7.5fr, and 8fr according to the needs and for minimizing the thread of vascular complications.
• For the purpose of neglecting risks associated with a fluid-filled pressure line, contemporary systems use fiber optic technology.
• The newer systems are usually calibrated automatically in vivo accelerating the time to effective diastolic augmentation.
• A wide range of balloon sizes is available to accommodate the need of patients of all heights.
• This therapy involves safe and quick insertions.
• Big size balloons displace more blood providing enhanced diastolic augmentation and systolic unloading.

Disadvantages of IABP Therapy:-

• This device can able to only supplement cardiac outputs up to 0.3-0.5 I/min and it requires a degree of native cardiac output to function.
• There is a risk of balloon displacement, rupture, leak, and entrapment.
• Relies on synchronization with the cardiac cycle to circulatory support may not be reliable with dysrhythmia.
• There is a disadvantage of twisting/kinking and clot formation in the pressure line or catheter.
• A small but tangible risk of aortic dissection or rupture.
• It has a risk ok systemic embolization (e.g. cholesterol, helium)
• Sometimes it may cause a stroke.
• And also it causes some abnormalities like infection, lower limb ischemia, hemolysis, and bleeding at the insertion site.

Applications:-

• IABP device acts as hemodynamic support in medical conditions.
• And also acts as prophylactic hemodynamic support.
• Cardiac support for hemodynamically challenged patients with mechanical defects prior to correction.
• It is a mechanical device used to assist cardiac circulatory function in patients suffering from cardiogenic shock, congestive heart failure, refractory angina and complications of myocardial infarction, etc...  

Some manufacturers of IABP devices:-

• SENKO MEDICAL INSTRUMENTS Mfg. co., ltd
• Teleflex corporation
• Insight Medical, Inc
• Tokai medical products Inc
• Zeon corporation

Article Contributors:-

1. Snekha. R:- https://www.linkedin.com/in/snekha-r-0b68051b0

2. Sindhuja. G:- https://www.linkedin.com/in/sindhuja-g-796b0821b

3. Ranjani.S:- https://www.linkedin.com/in/ranjani-s-4b299821b

Cryotherapy

Introduction:

Cryo-therapy is also known as Cryo-surgery or Ice-surgery. It uses cold temperature to damage tissue to treat disease.

What is Cryotherapy?

• Cryotherapy means it’s the process of using high or extremely cold temperatures in order to destroy or damage the tissue by freezing those.

• It helps to treat various skin diseases and also some cancer.

• Substance like liquid nitrogen is used by doctors.

• Cryotherapy reduces muscle pain, swelling twist in ankles or in wrists.

Principles of Cryotherapy

Lewis Hunting Reaction:

“The process of alternating vasodilation and vasoconstriction in extreme exposure to cold is called the Lewis Hunting Reaction”. 

At first, vasoconstriction occurs first to reduce extremities. This is the result of the sudden decrease in the release of neurotransmitters due to local cold from the sympathetic nerves to the muscular coat of the arteriovenous anastomoses. This increases blood flow and the temperature of the fingers. Vasodilation is followed by the new phase of vasoconstriction after that the process repeats itself.

When cold is maintained for more than 15 minutes or reduced below 10 degrees Celcius, vasodilation is cold-induced after the initial time of vasoconstriction.

Cryobiology :

Cells of mammals can be destroyed by cooling to the temperature of -20 degrees Celcius. Information of ice crystals of both intracellular and extracellular begins the primary injury. The outer membrane of the cells ruptures by intracellular crystals and ice formation outside the cell which dehydrates the cellular environment which results in lethal electrolyte concentrations and changes in pH. The time cell organelles are damaged, the cell loses the ability to regulate ions which ensures cell death.

Even though liquid nitrogen, nitrous oxide, and carbon dioxide are all cryogens used in many medicines. Liquid nitrogen is the most versatile. Hence it is most commonly used. The boiling point of liquid nitrogen is -195.8 degrees Celsius. The liquid form of cryogens stored in Dewar flasks can be delivered as a spray. 

Mechanism of Action:

Cryotherapy can be also known as cryosurgery. It is commonly used to treat a variety of Benign and Malignant Lesions. In Cryotherapy the mechanism of destruction is necrosis. Necrosis is the result of the freezing and Thawing of cells. Tissue injury begins with prolonged tissue cooling, metabolic disruption, ice crystal formation, and cellular rupture. Microcirculatory failure and Ischemia lead to cell death, resulting in coagulative necrosis after having.

Physical destruction procedures are effective immediately, but physiological effects which include induction of apoptosis and cytokine release and secondary necrosis produce damaging effects over several days.

The mechanism of action in cryotherapy is divided into 3 Phase as below:-

• Heat transfer.
• Cell Injury.
• Inflammation.

a) Heat Transfer:- 

                There is a mechanism by which cryotherapy destroys the targeted cells. The mechanism involves the quick transfer of heat from the skin to a heat sink. Liquid nitrogen is the most commonly used cryogen, which has a boiling point of 196 degrees celsius. The rate of heat transfer depends on the temperature difference between the skin and the liquid nitrogen. In the spray cryotherapy technique, the liquid nitrogen is directly applied to the skin and the heat in the skin is transferred to the liquid nitrogen. This process results immediately. If a cryoprobe is used in the cryotherapy conduction heat transfer occurs in which the heat is transferred via the copper-metal probe.

b) Cell injury:-

    Once the cell is frozen, cell injury occurs during the thaw. Ice crystals do not form until the temperature reaches –5 to -10 degrees Celsius because of hyperosmotic intracellular conditions. The water to ice transformation concentrates the extracellular solutes and leads to an osmotic gradient across the cell membrane, leads to further damage. 

The tissue of epithelial cells damage maximum with rapid freezing and slow thaw and are suitable for the malignancies treatment. After rapid thaw fibroblasts produce less collagen. Hence a rapid thaw is much more suitable for the treatment of keloids or benign lesions. When a steak is defrosted from the freezer freeze damage occurs.

When fully thawed the steak juices come out which represents that the intracellular liquid that has escaped because of the damage to the cell wall. By concentrating electrolytes intracellularly low temperature also ensures maximum damage. Benign lesions need a temperature of -20 to -25 degrees Celsius, whereas malignant skin cancers require a temperature of -50 degrees Celsius.

c) Inflammation:-

   Inflammation is the last response to cryotherapy which is seen as erythema and edema. Inflammation helps in cell destruction and is the response to cell death. Cryotherapy treatment causes separation of basement membrane and which may also result in blister formation.

Procedure Performed During The Cryotherapy:

Cryotherapy is performed by a well-trained radiologist in a radiology suite or in the operating room. It is an image-guided procedure. On the procedure table patient will be positioned and it is an outpatient basis procedure. Doctors will apply liquid nitrogen to the area with a spray device or cotton swab if cryotherapy is done topically.

 A percutaneous procedure is performed for tumors that are deep inside the body and can be approached through the skin. A thin, needle–size applicator or cryoprobes are inserted.

• Monitors are used to tracking blood pressure, heart rate, oxygen level, and pulse. 
• The patient will be connected to the monitors. 
• An intravenous(lV) line is inserted into a vein in the arm or hand of the patient by a technologist or nurse to administer a sedative. 
• Breathing tubes may not be required in this process. 
• General anesthesia is required in some patients may be. 
• The surface will be shaved, sterilized, and covered with a sterile drape where the applicators or cryoprobes are to be inserted. 
• A small skin incision is made at the site.
• Through the guidance of imaging, applicators or cryoprobes will be inserted through the skin to the site of the diseased tissue. 
• Argon gas or liquid nitrogen is delivered once the applicators are in place. 
• A rapid decrease in the temperature at the tip of the probe leads to the creation of an “ice ball”. 
• Due to this all the water around the tip of the probe freezes. 
• Ultrasound, CT, or MRI are used to visualize ice balls. 
• lV line and applicator are removed. 
• Application of pressure stops the bleeding and skin will be covered with a bandage. 
• Here sutures are not required. 

Types of Cryotherapy

1. Ice Packs:- It is the most common method of cryotherapy. There are different types of ice used in ice packs. The most common types are ice packs made with cubed, crushed, and wetted ice.  It was discovered that wetted ice is better to lower surface temperature during treatment and maintaining the lower temperature during recovery. It is also more effective in lowering the intramuscular temperature during treatment.

2. Ice Spray:-  A cooling effect can also be produced by icing spray for a similar effect.

3. Immersion:- Simple or whirlpool immersion.

4. Ice Massage:- slow strokes in a circular motion for  5-10 mins.

More recently whole body cryotherapy has become popular for athletes, to help aid recovery, as well as in persistent pain patients such as rheumatological conditions. More research is needed to understand the effect on the body and its relation to pain.

Benefits Of Cryotherapy

1. Helps to reduce migraine:- Cryotherapy helps in treating migraines as it cools and numbs the nerves around the neck area. By applying a neck wrap containing 2 frozen ice packs to the carotid arteries reduces migraine pain. The carotid arteries are accessible and also they are close to the carotid arteries.

2. Irritation of Numbs nerve:- Cryotherapy has been using to treat injuries of athletes. The cold can actually numb an irritated nerve.

3. Helps to treat mood disorder:-  The ultra-cold temperature in whole-body cryotherapy can cause It includes the release of adrenaline, noradrenaline, and endorphins. It was actually effective in short-term treatment.

4. Reduces arthritic pain:-  The whole–body cryotherapy significantly reduced pain in people with arthritis. As a result, it has also allowed for physiotherapy and occupational therapy.

5. May help treats low-rise tumors:-  It can be used as a cancer treatment.  It is done by freezing cancer cells and surrounding them with the help of ice crystals. It is used to treat some low-risk tumors.

6. May also help to prevent Alzheimer's disease and dementia:-  It may be an effective treatment because the anti-oxidative and anti-inflammatory effects of cryotherapy could help combat the inflammatory and oxidative stress responses that occur with Alzheimer's.

Advantages Of Cryotherapy:

• It can temporarily reduce nerve activity, which can also relieve pain.
• This therapy can treat tissue externally and internally.
• It can be used to treat a variety of skin conditions and some cancers.

Disadvantages Of Cryotherapy:

• Cramping around the cervix after cryotherapy and bleeding.
• Skin infection, scarring, and swelling.
• Bone fractures
• Headache, hair loss, and hypopigmentation.

Article Contributors:-

1. Kalpana Guggari - https://www.linkedin.com/in/kalpana-guggari-99796020b 

2. Mahalaxmi Echalgar - https://www.linkedin.com/in/mahalaxmi-echalgar-4b401b220

3. Ashwini Akkur - https://www.linkedin.com/in/ashwini-t-akkur-888024220

4.Sharmada Kashikar - https://www.linkedin.com/in/sharmada-kashikar-955559220

Fluoroscope

 INTRODUCTION 

What is Fluoroscopy?

Fluoroscopy is a medical imaging procedure that uses an x-ray beam that goes continuously through the body to make an image and it is also a sort of x-ray that displays organs, tissues, or other interior structures moving in real-time. The image is projected on a monitor, allowing the doctor to watch the inside organs move in real-time.

Fluoroscopy is used to aid in the diagnosis of abnormalities with your,

1. Esophagus

2. Stomach 

3. Duodenum

4. Small bowels

Doctors can use this approach to see the flow of oral contrast through the digestive system in real-time.

The fluoroscopy examination will scan your,

1. Upper GI

2. Small bowel

Inform the nurse or technologist if you are allergic to any medications or if you have recently undergone a high-density contrast procedure. You may take your normal medication with modest amounts of water the day before and after the exam. The stomach and small intestine will be shown in the small bowel series. You should not undergo any contrast studies within 24 to 48 hours of this exam.

Fluoroscopy Machine:

 

An endless stream of x-ray images. Around 25-30 images per second. Images are shown on a computer monitor. Similar to a television screen.

HISTORY OF FLUOROSCOPY.

Roentgen's X-Ray: 

1895 Thomas Edison exposed over 8000 chemicals four months later. Calcium tungstate has the most fluorescence and was used to make the Edison Vitascope (device for recreational Fluoroscopy). After the death of his assistant, Thomas never returned to X-Ray research. He examined his hand with a custom-made fluoroscope. Clarence Dally, his aide, died as a result of radiation. 

Early fluoroscopes were basically cardboard funnels, open at the narrow end of the observer and closed with a skinny cardboard piece coated on the inside with a film of fluorescent metal salt. The fluorescent screen produces only a small limited light. The fluoroscope image was faint, so the radiologist went into the darkroom to adjust their eyes to the darkness. William Trendelenburg created red adaptation goggles. 

Russel H. Morgan invented the image intensification tube in the 1940s. Image visibility is improved, the radiation dose is reduced, and a persistent image is recorded out of light.

How It Works?

The machine utilized in fluoroscopy is called fluoroscope. The fluoroscope is a sort of x-beam machine that can either utilize a beating or steady x-beam bar. The x-beam machine has an x-beam tube that is either made of glass or metal and has a vacuum seal inside. It produces an x-beam by changing over power from its electrical cable. The electrical cable has a flow of 120-480 volts, anyway it should be changed over into a 25-150 kilovolt range. 

Then, at that point, it creates a current of electrons that are taken shots at a tungsten target. At the point when the electrons strike this objective, the electrons stop and make the arrival of the body being imaged. These electromagnetic waves can go through the body and make images of the inside structures. Various tissues in the body have various densities; along these lines, the tissues that are less thick ingest less of the x-beam. 

The diverse in the measure of waves being assimilated is the thing that makes a distinction in the openness and permits the image to be more definite. With the fluoroscope, when the pillar goes through the body, it hits an image intensifier, which builds the splendor of the picture, so it very well may be seen on a presentation screen. 

The picture intensifier likewise contains a camcorder that catches the two-dimensional examples of light as a video from the x-beam machine. Then, at that point, the sign is changed over once more into an example of light, which can be seen on the screen, as an image Illustrate the parts of an analog fluoroscopy image intensifier tube.

There is an input phosphor there is a photocathode right behind the phosphor. Then there are series of electrostatic lenses that push electrons towards a focal point & this accelerating anode towards. Which the electrons are being attracted and finally there is an output phosphor. 

So, what we are doing is we are converting the x- rays ate coming into the fluoroscopy. They are hitting this input phosphor and the input phosphor is glowing. It's giving off light x- rays hit the phosphor and the glow right. Then this photo Catherine picks up the light and turns that into electrons. Right turns the light into electrons which are then accelerated towards this anode. 

Very similar to what's happening inside of an x-ray tube right. We had the production of electrons they are accelerated towards an anode in this case. They are not going to strike the image instead. 

The Physics of Image Intensifier that which Used in Fluoroscopy:

Originally the conventional fluoroscopy way back when they didn't have a way to do that so the images that they were looking at were very dim and they had to use what are called rods in the eye & the rods see dim objects. They see black & whites and so the whole purpose of bringing the brightness up the brightness level up is to change the vision into the co vision which have they see much better & we'll get into a little bit more of that just a minute. So, a bottom line is they were developed to increase the brightness & they increase it a great deal 

We are just increasing the brightness exponentially over the original image, this particular image shows us the entire system, and also on the side, you're going to see an eye - without casing on its side.

The eye itself and in this particular image, you can see the x-ray tube below the table. The beam interacting with the patient & the remnant beam coming into the image intensifier itself. 

The remnant beam radiation coming from the patient interacts with the input phosphor and at the input phosphor radiation. The information it carries is changed into light photons and then the light photons hit the photocathode where they're changed into electrons & they are accelerated at a very high speed as well as being compressed by the electrostatic lenses which are following the size of the periphery of the image intensifier tube. 

They come to a focal point and at that point, they actually cross over, and then they come out of a very small output phosphor it's about one inch. You have a very large curve for the input phosphor & the very small output phosphor. 

This whole process is what gives us that extreme brightness that we have in our image and then once it comes out of the output phosphor there are some things that happen to it.

Flux Gain: Measurement of the input light photons due to the conversion efficiency of the output screen.

Brightness = Flux Gain X Magnification Gain

Fluoroscopy Quality Control:

Exposure rate:-

• Normal fluoro: ESE < 10 R / Min 
• Interventional fluoro: ESE < 20 R / Min
• Cineradiography: Unlimited exposure rates. 

Spot film exposure:-

• Cassette ESE approximately 200mR per spot.
• Photo fluoro spot ESE approximately 100mR per spot.

Automatic brightness control (ABC):-

• Evaluate annually. 

Patient dose during fluoro: Conventional vs Digital 

Patient dose	Conventional	Digital
5-minute fluoro	200mGy (20 rad)	100mGy (10 rad)
3 spot films - normal mode	6mGy (0.6 rad)	2mGy (0.2 rad)
3 spot films – mag mode	10mGy (1.0 rad)	3mGy (0.3 rad)
Total Dose	216mGy (2.16 rad)	105mGy (10.5 rad)

Image Intensification

Input phosphor:

• Mad of cesium iodide (CsI)
• Receives radiation exiting patient. 
• Emits light photons.

Photocathode:

• Responds to the light exiting input phosphor. 
• Emits electrons. 

Electrostatic lenses:

• Focus electrons. 

Output phosphor:

• Receives electrons from the photocathode. 
• Emits 50 – 75 × more than received by the photocathode

Distortion.

As the size of the input phosphor is usually very large as the size of the input phosphor is increased or decreased. You're increasing and decreasing just the Distortions. If you have left it wide open say 25cm is your largest size if you leave it at 25. You will see in your image is quite a bit of distortion in the periphery.

1. Pincushion distortion:

    Caused by projecting an image formed on a curved input phosphor to a flat output phosphor.

2. Vignetting:

    Decrease in brightness or light intensity- periphery of the image.

3. Veiling Clare:

•     Scattered light in the output window 
•     Increase your background signal &it decreases the actual contrast of your image. 

Charge Couple Device:- 

Advantage of the charge-coupled device for medical imaging. 

• High spatial resolution. 
• High signal to noise ratio. 
• High detective quantum efficiency (DQE).
• No warm-up is required. 
• No leg or blooming. 
• Lower patient dos. 
• Unlimited life. 
• No spatial distortion. 

Creating a Fluoroscopy Image:-

The amount of radiation required varies and it’s based on the procedure. A necessary characteristic of Fluoroscopy is sensitivity. Amount of exposure needed to form an image. Non-intensified Fluoroscopy utilizes a fluorescent screen only just for a receptor. Key facts

• Generally real-time exams

• Typically uses an under-table tube and radiation is shooting upward

• Exam dependent
• May needs the use of contrast media 
• X-ray altering media that either positively or negatively affects the image counting on what is used to make something stand.

• X-ray tube & imaging device mounted on C-arms to keep up SID

PROCEDURE OF FLUOROSCOPY 

What happens during a fluoroscopy procedure?

• We will be asked to remove any clothing or jewelry that may interfere with the procedure, and depending on the type of procedure, we may be asked to: assume different positions, move a specific body part, or hold our breath at intervals while the fluoroscopy is performed.

• A special x-ray machine will produce fluoroscopy views of the body structure being examined or treated.

CONTRAST PROCEDURE

• During the test, you will be asked to change into scrubs or a hospital gown. Your personal item will be secured in a looker you will stand between a table and a fluoroscopy machine. 

• You will drink contrast medium. You will be asked to turn in different positions. This will allow the camera to take images of your abdomen from all angles. 

• Multiple peeping sounds can be heard during the exam.
• Upper GI exams will take approximately 30 minutes. 
• Small bowel series exams will take 1 to 4 hours longer. 

• After the test, you will be discharged. Immediately after the exam, there are no driving restrictions. Drink at least 6 to 8 ounces of fluids preferably water. You may eat a regular diet include Fiber unless otherwise instructed to do so by your doctor. There is no radiation to concerned with your doctors will discuss the results with you at your next appointment 

Barium X-Rays procedure 

• Fluoroscopy used alone.
• Give the physician the opportunity to check movement in the intestines.
• Barium moves through them during the procedure.
• Aids physicians in inserting a catheter.
• Likewise helps them in identifying blockages in arteries.
• Physicians can see the flow of blood.

Overall Procedure of Fluoroscopy

• Inclusion of an IV into the patient’s arm or hand.
• The patient moved onto the X-Ray table.
• Additional lines could also be inserted for catheter procedures.
• X-Ray scanner helps to make Fluoroscopic images of the body.
• Dye could also be injected into the IV at this point.
• The type of care is going to be selected after the procedure has finished.

What is it used for:-

Fluoroscopy and other medical imaging procedures serve an important role in avoiding health problems and identifying diseases. Our doctor may request that we undergo fluoroscopy during a hospital stay or outpatient procedure to determine treatment options for a specific health condition.

Fluoroscopy is a technique that is utilized in a variety of imaging treatments. The following are some of the most prevalent fluoroscopy applications:

• Barium swallow or Barium enema:- Fluoroscopy is used to show the movement of the gastrointestinal (digestive) system during various procedures. 

• Cardiac catheterization:- Fluoroscopy is used to visualize blood flow through the arteries, during this treatment. It's used to diagnose and treat some heart problems. 

• Placement of catheter or stent inside the body:- Catheters are hollow, thin tubes. They are used to get fluids into the body or to remove excess fluids. Stents are medical devices that help unblocked blocked or narrowed blood arteries. Fluoroscopy is used to check that these devices are properly placed. 

• Hysterosalpingogram:- Fluoroscopy is utilized to produce a view of a woman's reproductive organs in this operation. 

• Guidance is orthopedic surgery:- A surgeon may utilize fluoroscopy to aid in the guidance of surgeries such as joint replacement and fracture repair. 

• Electrophysiologic procedure:- The doctor employs fluoroscopy to treat patients with abnormal heartbeats during an Electrophysiologic procedure. 

• Arthrography:-  An X-ray is used to examine one or more joints. Catheter arthrography is one of the most common applications of chest fluoroscopy nowadays. 

• Percutaneous kyphoplasty or vertebroplasty:- The method is used by a specialist to treat spinal vertebrae fractures. 

• Needle or trans bronchial biopsies:- This procedure is used by a clinician to get a sample of lung tissue. 

Fluoroscopy Risks.

Fluoroscopy uses X-Ray technology, we have some radiation exposure. So, there are some minor risks associated with fluoroscopy. The amount we absorb varies and it depends on the procedure length and our size. 

There is always a slight danger of acquiring radiation-induced sensors regardless of how much radiation we are exposed to. Additionally, some people may experience radiation-induced harm to their skin, resulting in burns of their skin tissue. 

Furthermore, if we are pregnant or suspect we may be pregnant we should avoid having a fluoroscopy operation because radiation can affect an unborn child's body. 

However, if a fluoroscopy procedure is required, the benefits frequently outweigh the dangers. While the fluoroscopy procedure is not inherently uncomfortable. It may be painful at times. Some components of the test preparation, such as obtaining access to a vein or artery for angiography or injecting drugs into joints. 

In these circumstances, a technician is called upon measures that could be taken to make as more uncomfortable;

a) Conscious sedation. 

b) Local anesthesia.

c) General anesthesia. 

Trouble & Troubleshooting 

• If fluoroscopy doesn't measure anything of those parts first thing, we must check the power cable. because, if the main cable is disconnected or loosely connected, we can't see any parameters or any results from fluoroscopy. So, we must see the main cable with the machine and connect correctly. And then we can move next step. This is the main trouble and troubleshooting for all kinds of devices. 

• The second one is we must check the input voltage. Because, if we'll put the main cable in high voltage all systems will destroy. It is not a minor mistake it's a major mistake nowadays on the healthcare side. For example, if fluoroscopy’s input voltage is like 100V, so we must connect the machine input cable to a 100V power source. But if we didn't consider that's a thing, we can put cable regular source in our country standard 220 - 240V. So, this voltage is very over for machine. If we put it in this voltage supply the machine must damage out of our mind prediction. So, Technicians or Engineers must be known about machine input voltage and read service book of that machine & then move to installation or something. 

• Another thing is we can't see any movement by machine. So, we can check the main cable & the input voltage, if those things are correct, we should off the main power supply and be ready to troubleshoot the machine. So senior Engineers & Technicians are with their safety precautions. They should see the main part of the machine-like check the power board, motherboard, & processor from the senior Engineer's idea.

• Sometimes resistors, capacitors had disappeared so we can remove that and replace the same kind of things. If they won't find any damaged things, they must check the power board with multimeters like that. If they won't find trouble after that should inform the company of this particular machine and who does use this machine during treatment and then submit final reports to the company. 

These are the main procedures to find trouble and give the solution in the health care sector. 

The Above Article is Jointly Contributed By:-

• Juthindhara Madhavee Siriwardena - https://www.linkedin.com/in/juthindhara-siriwardena-467087220

• Muhammadhu Ihzan - https://www.linkedin.com/in/muhammadhu-ihzan-021a0a1a9

• Lakshana Kanagalingam - https://www.linkedin.com/in/lakshana-kanagalingam-9aa086220