Características clínicas y sociodemográficas de pacientes tratados con terapia electroconvulsiva bajo anestesia y relajación (TECAR) en una institución de salud mental de Risaralda, Colombia; 2020-2021

El presente es un estudio descriptivo de corte transversal, donde se evaluaron pacientes que recibieron TEC-AR en el período comprendido entre enero de 2020 y diciembre de 2021 en una unidad mental del departamento de Risaralda (Colombia). Se construyó una base de datos compilando los datos de cada...

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Autores:
López Pineda , Juliana María
Trujillo Gutiérrez , Ana Carolina
Tipo de recurso:
Work document
Fecha de publicación:
2022
Institución:
Universidad Tecnológica de Pereira
Repositorio:
Repositorio Institucional UTP
Idioma:
spa
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oai:repositorio.utp.edu.co:11059/14115
Acceso en línea:
https://hdl.handle.net/11059/14115
https://repositorio.utp.edu.co/home
Palabra clave:
610 - Medicina y salud
Psiquiatría - Medicina
Terapia - Tramiento medico
Terapia Electroconvulsiva
Terapia electroconvulsiva
Tratamiento
Evento adverso
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openAccess
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Atribución-NoComercial-SinDerivadas 4.0 Internacional (CC BY-NC-ND 4.0)
id UTP2_cf6165656945a3fbcecd17d649059702
oai_identifier_str oai:repositorio.utp.edu.co:11059/14115
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network_name_str Repositorio Institucional UTP
repository_id_str
dc.title.spa.fl_str_mv Características clínicas y sociodemográficas de pacientes tratados con terapia electroconvulsiva bajo anestesia y relajación (TECAR) en una institución de salud mental de Risaralda, Colombia; 2020-2021
title Características clínicas y sociodemográficas de pacientes tratados con terapia electroconvulsiva bajo anestesia y relajación (TECAR) en una institución de salud mental de Risaralda, Colombia; 2020-2021
spellingShingle Características clínicas y sociodemográficas de pacientes tratados con terapia electroconvulsiva bajo anestesia y relajación (TECAR) en una institución de salud mental de Risaralda, Colombia; 2020-2021
610 - Medicina y salud
Psiquiatría - Medicina
Terapia - Tramiento medico
Terapia Electroconvulsiva
Terapia electroconvulsiva
Tratamiento
Evento adverso
title_short Características clínicas y sociodemográficas de pacientes tratados con terapia electroconvulsiva bajo anestesia y relajación (TECAR) en una institución de salud mental de Risaralda, Colombia; 2020-2021
title_full Características clínicas y sociodemográficas de pacientes tratados con terapia electroconvulsiva bajo anestesia y relajación (TECAR) en una institución de salud mental de Risaralda, Colombia; 2020-2021
title_fullStr Características clínicas y sociodemográficas de pacientes tratados con terapia electroconvulsiva bajo anestesia y relajación (TECAR) en una institución de salud mental de Risaralda, Colombia; 2020-2021
title_full_unstemmed Características clínicas y sociodemográficas de pacientes tratados con terapia electroconvulsiva bajo anestesia y relajación (TECAR) en una institución de salud mental de Risaralda, Colombia; 2020-2021
title_sort Características clínicas y sociodemográficas de pacientes tratados con terapia electroconvulsiva bajo anestesia y relajación (TECAR) en una institución de salud mental de Risaralda, Colombia; 2020-2021
dc.creator.fl_str_mv López Pineda , Juliana María
Trujillo Gutiérrez , Ana Carolina
dc.contributor.advisor.none.fl_str_mv Gutiérrez Segura, Julio Cesar
Caicedo González, Claudia María
dc.contributor.author.none.fl_str_mv López Pineda , Juliana María
Trujillo Gutiérrez , Ana Carolina
dc.subject.ddc.none.fl_str_mv 610 - Medicina y salud
topic 610 - Medicina y salud
Psiquiatría - Medicina
Terapia - Tramiento medico
Terapia Electroconvulsiva
Terapia electroconvulsiva
Tratamiento
Evento adverso
dc.subject.decs.none.fl_str_mv Psiquiatría - Medicina
Terapia - Tramiento medico
Terapia Electroconvulsiva
dc.subject.proposal.spa.fl_str_mv Terapia electroconvulsiva
Tratamiento
Evento adverso
description El presente es un estudio descriptivo de corte transversal, donde se evaluaron pacientes que recibieron TEC-AR en el período comprendido entre enero de 2020 y diciembre de 2021 en una unidad mental del departamento de Risaralda (Colombia). Se construyó una base de datos compilando los datos de cada paciente: datos sociodemográficos, historia de enfermedad mental, uso de psicofármacos y respuesta a la TECAR. Además, se recolectaron el número de sesiones recibidas por paciente con sus respectivos parámetros de TECAR y las complicaciones que se presentaron en el procedimiento. Se estableció una potencia del 80% con un intervalo de confianza del 95%; una p menor a 0.05 fue considerada significativa. Se generaron medidas de frecuencia, de tendencia central y dispersión; posteriormente, se evaluó sí se producían diferencias significativas entre los signos vitales pre y post TECAR a través de una comparación de medianas mediante una prueba de U-Mann de Whitney. Se evaluaron las variables que pudieran estar asociadas a mayor frecuencia de complicaciones y a no mejoría posterior a la TECAR mediante pruebas de chi-cuadrado y aquellas que tuvieron un valor de p menor a 0.2 fueron incluidas en un modelo de regresión logística binomial para cada desenlace.
publishDate 2022
dc.date.accessioned.none.fl_str_mv 2022-05-23T16:31:22Z
dc.date.available.none.fl_str_mv 2022-05-23T16:31:22Z
dc.date.issued.none.fl_str_mv 2022
dc.type.none.fl_str_mv Trabajo de grado - Especialización
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dc.type.content.none.fl_str_mv Text
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dc.identifier.uri.none.fl_str_mv https://hdl.handle.net/11059/14115
dc.identifier.instname.none.fl_str_mv Universidad Tecnológica de Pereira
dc.identifier.reponame.none.fl_str_mv Repositorio institucional Universidad Tecnológica de Pereira
dc.identifier.repourl.none.fl_str_mv https://repositorio.utp.edu.co/home
url https://hdl.handle.net/11059/14115
https://repositorio.utp.edu.co/home
identifier_str_mv Universidad Tecnológica de Pereira
Repositorio institucional Universidad Tecnológica de Pereira
dc.language.iso.none.fl_str_mv spa
language spa
dc.relation.references.none.fl_str_mv Whiteford HA, Ferrari AJ, Degenhardt L, Feigin V, Vos T. Global Burden of Mental, Neurological, and Substance Use Disorders: An Analysis from the Global Burden of Disease Study 2010. In: Patel V, Chisholm D, Dua T, Laxminarayan R, Medina-Mora ME, editors. Mental, Neurological, and Substance Use Disorders: Disease Control Priorities, Third Edition (Volume 4). Washington (DC)2016.
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Ocampo MV, Ramírez CI, Franco JG, Gómez LM, Cardona G, Restrepo C. Características clínicas de 276 pacientes tratados con terapia electroconvulsiva en una clínica universitaria de Medellín, Colombia. Revista Colombiana de Psiquiatría. 2012;41:357-70
Wei Q, Bai T, Chen Y, Ji G, Hu X, Xie W, et al. The Changes of Functional Connectivity Strength in Electroconvulsive Therapy for Depression: A Longitudinal Study. Front Neurosci. 2018;12:661
Geduldig ET, Kellner CH. Electroconvulsive Therapy in the Elderly: New Findings in Geriatric Depression. Curr Psychiatry Rep. 2016;18(4):40
Tejada ARTYGP. Terapia electroconvulsiva: experiencia en la Clínica Universitaria Teletón. Revista Facultad de salud. 2011;3:29-35.
Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet (London, England). 2003;361(9360):799-808.
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Jiménez-Cornejo M, Zamorano-Levi N, Jeria Á. Is electroconvulsive therapy during pregnancy safe? Medwave. 2016;16(Suppl5):e6790
McCall WV, Lisanby SH, Rosenquist PB, Dooley M, Husain MM, Knapp RG, et al. Effects of continuation electroconvulsive therapy on quality of life in elderly depressed patients: A randomized clinical trial. Journal of psychiatric research. 2018;97:65-9
Zheng W, Tong G, Ungvari GS, Ng CH, Chiu HFK, Xiang YQ, et al. Memory Impairment Following Electroconvulsive Therapy in Chinese Patients with Schizophrenia: Meta-Analysis of Randomized Controlled Trials. Perspectives in psychiatric care. 2018;54(2):107-14
Fraser LM, O'Carroll RE, Ebmeier KP. The effect of electroconvulsive therapy on autobiographical memory: a systematic review. J ect. 2008;24(1):10-7.
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Weiner RD, Reti IM. Key updates in the clinical application of electroconvulsive therapy. Int Rev Psychiatry. 2017;29(2):54-62.
Kellner CH, Obbels J, Sienaert P. When to consider electroconvulsive therapy (ECT). Acta Psychiatr Scand. 2020;141(4):304-15.
Weiss A, Hussain S, Ng B, Sarma S, Tiller J, Waite S, et al. Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of electroconvulsive therapy. Aust N Z J Psychiatry. 2019;53(7):609-23
Romero-Tapia AE, Gamboa-Bernal GA. ¿Es bioéticamente adecuada la aplicación de la terapia electroconvulsiva? Cuadernos de bioética. 2018;29.
Sienaert P, Stek ML, Comijs H, de Winter F, Dols A, Eikelenboom P, et al. [ResPECT - a decade of Flemish-Dutch ECT research]. Tijdschr Psychiatr. 2017;59(10):626-31.
Song TY. Neuroplasticity hypothesis of the mechanism of electroconvulsive therapy: a proton magnetic resonance and functional connectivity investigation: Boston University; 2016.
Perugi G, Medda P, Barbuti M, Novi M, Tripodi B. The Role of Electroconvulsive Therapy in the Treatment of Severe Bipolar Mixed State. Psychiatr Clin North Am. 2020;43(1):187-97.
Hermida AP, Mohsin M, Marques Pinheiro AP, McCord E, Lisko JC, Head LW. The Cardiovascular Side Effects of Electroconvulsive Therapy and Their Management. J ect. 2022;38(1):2-9.
Arroyo MB, González-Pinto A, Urretavizcaya M. Consenso Español sobre la Terapia Electroconvulsiva Sociedad Española de Psiquiatría Biológica. 2018.
Cristancho MA, Alici Y, Augoustides JG, O'Reardon JP. Uncommon but serious complications associated with electroconvulsive therapy: recognition and management for the clinician. Curr Psychiatry Rep. 2008;10(6):474-80.
Zielinski RJ, Roose SP, Devanand DP, Woodring S, Sackeim HA. Cardiovascular complications of ECT in depressed patients with cardiac disease. Am J Psychiatry. 1993;150(6):904-9.
Levin L, Wambold D, Viguera A, Welch CA, Drop LJ. Hemodynamic responses to ECT in a patient with critical aortic stenosis. J ect. 2000;16(1):52-61.
O'Reardon JP, Lott JP, Akhtar UW, Cristancho P, Weiss D, Jones N. Acute coronary syndrome (Takotsubo cardiomyopathy) following electroconvulsive therapy in the absence of significant coronary artery disease: case report and review of the literature. J ect. 2008;24(4):277-80.
Andrade C, Arumugham SS, Thirthalli J. Adverse Effects of Electroconvulsive Therapy. Psychiatr Clin North Am. 2016;39(3):513-30.
Mankad MV, Beyer JL, Weiner RD, Krystal A. Clinical manual of electroconvulsive therapy: American Psychiatric Pub; 2010.
Soehle M, Bochem J. Anesthesia for electroconvulsive therapy. Curr Opin Anaesthesiol. 2018;31(5):501-5.
van Diermen L, van den Ameele S, Kamperman AM, Sabbe BCG, Vermeulen T, Schrijvers D, et al. Prediction of electroconvulsive therapy response and remission in major depression: meta-analysis. Br J Psychiatry. 2018;212(2):71-80
Haq AU, Sitzmann AF, Goldman ML, Maixner DF, Mickey BJ. Response of depression to electroconvulsive therapy: a meta-analysis of clinical predictors. J Clin Psychiatry. 2015;76(10):1374-84
Zhang J, Wang G, Yang X, Gao K. Efficacy and safety of electroconvulsive therapy plus medication versus medication alone in acute mania: A meta-analysis of randomized controlled trials. Psychiatry Res. 2021;302:114019
Lally J, Tully J, Robertson D, Stubbs B, Gaughran F, MacCabe JH. Augmentation of clozapine with electroconvulsive therapy in treatment resistant schizophrenia: A systematic review and meta-analysis. Schizophr Res. 2016;171(1-3):215-24
Salik I, Marwaha R. Electroconvulsive Therapy. StatPearls. Treasure Island (FL): StatPearls Publishing
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Mirás Veiga A, Moreno DC, Menéndez AI, Siscart IM, Fernández MD, Sánchez EG, et al. Effectiveness of Electroconvulsive Therapy for Refractory Status Epilepticus in Febrile Infection-Related Epilepsy Syndrome. Neuropediatrics. 2017;48(1):45-8.
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Pitts FN, Jr., Patterson CW. Electroconvulsive therapy for iatrogenic hypothalamic hypopituitarism (CRF-ACTH type). The American journal of psychiatry. 1979;136(8):1074-7.
Takamiya A, Seki M, Kudo S, Yoshizaki T, Nakahara J, Mimura M, et al. Electroconvulsive Therapy for Parkinson's Disease: A Systematic Review and Meta-Analysis. Mov Disord. 2021;36(1):50-8.
Kaliora SC, Zervas IM, Papadimitriou GN. [Electroconvulsive therapy: 80 years of use in psychiatry]. Psychiatrike = Psychiatriki. 2018;29(4):291-302.
Saito S. Anesthesia Management for Electroconvulsive Therapy. Springer, editor2016.
Moirand R, Galvao F, Lecompte M, Poulet E, Haesebaert F, Brunelin J. Usefulness of the Montreal Cognitive Assessment (MoCA) to monitor cognitive impairments in depressed patients receiving electroconvulsive therapy. Psychiatry Res. 2018;259:476-81.
Meyer JP, Swetter SK, Kellner CH. Electroconvulsive Therapy in Geriatric Psychiatry: A Selective Review. Psychiatr Clin North Am. 2018;41(1):79-93.
The U. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. The Lancet. 2003;361(9360):799-808
Warren N, Eyre-Watt B, Pearson E, O'Gorman C, Watson E, Lie D, et al. Tardive Seizures After Electroconvulsive Therapy. J ect. 2022.
Perugi G, Medda P, Toni C, Mariani MG, Socci C, Mauri M. The role of electroconvulsive therapy (ECT) in bipolar disorder: effectiveness in 522 patients with bipolar depression, mixed-state, mania and catatonic features. Current neuropharmacology. 2017;15(3):359-71
Duma A, Maleczek M, Panjikaran B, Herkner H, Karrison T, Nagele P. Major adverse cardiac events and mortality associated with electroconvulsive therapy: a systematic review and meta-analysis. Anesthesiology. 2019;130(1):83-91.
Duma A, Pal S, Johnston J, Helwani MA, Bhat A, Gill B, et al. High-sensitivity cardiac troponin elevation after electroconvulsive therapy: a prospective, observational cohort study. Anesthesiology. 2017;126(4):643-52.
Rönnqvist I, Nilsson FK, Nordenskjöld A. Electroconvulsive therapy and the risk of suicide in hospitalized patients with major depressive disorder. JAMA network open. 2021;4(7):e2116589-e.
Sánchez JS, David MD, Setó AT, Alonso MM, Moll MJP, Paredero JP, et al. Electroconvulsive therapy clinical database: Influence of age and gender on the electrical charge. Revista de Psiquiatría y Salud Mental (English Edition). 2017;10(3):143-8.
Asnis GM. Catatonia Secondary to Hypothyroidism May Be Very Responsive to Electroconvulsive Therapy: A Case Study. The Journal of ECT. 2020;36(4):e46-e7
Tost M, Monreal JA, Armario A, Barbero JD, Cobo J, García-Rizo C, et al. Targeting hormones for improving cognition in major mood disorders and schizophrenia: thyroid hormones and prolactin. Clinical drug investigation. 2020;40(1):1-14.
Pratchayasakul W, Sa-Nguanmoo P, Sivasinprasasn S, Pintana H, Tawinvisan R, Sripetchwandee J, et al. Obesity accelerates cognitive decline by aggravating mitochondrial dysfunction, insulin resistance and synaptic dysfunction under estrogen-deprived conditions. Hormones and behavior. 2015;72:68-77.
Soria V, González-Rodríguez A, Huerta-Ramos E, Usall J, Cobo J, Bioque M, et al. Targeting hypothalamic-pituitary-adrenal axis hormones and sex steroids for improving cognition in major mood disorders and schizophrenia: a systematic review and narrative synthesis. Psychoneuroendocrinology. 2018;93:8-19.
Taubøll E, Sveberg L, Svalheim S. Interactions between hormones and epilepsy. Seizure. 2015;28:3-11.
Anderson IM, McAllister-Williams RH, Downey D, Elliott R, Loo C. Cognitive function after electroconvulsive therapy for depression: relationship to clinical response. Psychological medicine. 2021;51(10):1647-56.
Martin DM, Wong A, Kumar DR, Loo CK. Validation of the 10-item orientation questionnaire: A new tool for monitoring post–electroconvulsive therapy disorientation. The Journal of ECT. 2018;34(1):21-5.
Simon L, Blay M, Galvao F, Brunelin J. Using EEG to Predict Clinical Response to Electroconvulsive Therapy in Patients With Major Depression: A Comprehensive Review. Frontiers in Psychiatry. 2021;12:941.
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spelling Atribución-NoComercial-SinDerivadas 4.0 Internacional (CC BY-NC-ND 4.0)Manifiesto (Manifestamos) en este documento la voluntad de autorizar a la Biblioteca Jorge Roa Martínez de la Universidad Tecnológica de Pereira la publicación en el Repositorio institucional (http://biblioteca.utp.edu.co), la versión electrónica de la OBRA titulada: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ La Universidad Tecnológica de Pereira, entidad académica sin ánimo de lucro, queda por lo tanto facultada para ejercer plenamente la autorización anteriormente descrita en su actividad ordinaria de investigación, docencia y publicación. La autorización otorgada se ajusta a lo que establece la Ley 23 de 1982. Con todo, en mi (nuestra) condición de autor (es) me (nos) reservo (reservamos) los derechos morales de la OBRA antes citada con arreglo al artículo 30 dehttps://creativecommons.org/licenses/by-nc-nd/4.0/http://purl.org/coar/access_right/c_abf2info:eu-repo/semantics/openAccessGutiérrez Segura, Julio CesarCaicedo González, Claudia MaríaLópez Pineda , Juliana MaríaTrujillo Gutiérrez , Ana Carolina2022-05-23T16:31:22Z2022-05-23T16:31:22Z2022https://hdl.handle.net/11059/14115Universidad Tecnológica de PereiraRepositorio institucional Universidad Tecnológica de Pereirahttps://repositorio.utp.edu.co/homeEl presente es un estudio descriptivo de corte transversal, donde se evaluaron pacientes que recibieron TEC-AR en el período comprendido entre enero de 2020 y diciembre de 2021 en una unidad mental del departamento de Risaralda (Colombia). Se construyó una base de datos compilando los datos de cada paciente: datos sociodemográficos, historia de enfermedad mental, uso de psicofármacos y respuesta a la TECAR. Además, se recolectaron el número de sesiones recibidas por paciente con sus respectivos parámetros de TECAR y las complicaciones que se presentaron en el procedimiento. Se estableció una potencia del 80% con un intervalo de confianza del 95%; una p menor a 0.05 fue considerada significativa. Se generaron medidas de frecuencia, de tendencia central y dispersión; posteriormente, se evaluó sí se producían diferencias significativas entre los signos vitales pre y post TECAR a través de una comparación de medianas mediante una prueba de U-Mann de Whitney. Se evaluaron las variables que pudieran estar asociadas a mayor frecuencia de complicaciones y a no mejoría posterior a la TECAR mediante pruebas de chi-cuadrado y aquellas que tuvieron un valor de p menor a 0.2 fueron incluidas en un modelo de regresión logística binomial para cada desenlace.This is a cross-sectional study, which included patients that received ECT between January 2020 and December 2021, in a mental health unit in the city of Pereira/Colombia. A database was built by compiling each patient’s data: sociodemographic data, history of mental illness, psychoactive drug use, and response to ECT. Moreover, several sessions per patient with their respective ECT parameters and the complications that occurred during or after the procedure were collected. A power measure of 80% with a confidence interval of 95% was established; a pless than 0.05 was considered statistically significant. Measures of frequency, central tendency, and dispersion were generated. Additionally, it was evaluated whether there were significant differences between vital signs before and after ECT through a comparison of medians using a Mann-Whitney U test. Variables that could be associated with a higher frequency of complications and no improvement after ECT were evaluated using chi-square tests, and those with a p value lower than 0.2 were included in binomial logistic regression analysis for each outcome.TABLA DE CONTENIDO RESUMEN ____________________________________________________ 12 ABSTRACT ___________________________________________________ 14 INTRODUCCIÓN ______________________________________________ 16 PLANTEAMIENTO DEL PROBLEMA____________________________ 18 Formulación del Problema __________________________________21 JUSTIFICACIÓN_______________________________________________ 22 OBJETIVOS ___________________________________________________ 24 Objetivo general ___________________________________________24 Objetivos específicos _______________________________________ 24 MARCO REFERENCIAL ________________________________________25 Marco teórico ___________________________________________________25 Terapia electroconvulsiva _________________________________________25 Mecanismo de acción _______________________________________26 Efectividad________________________________________________26 Efectos adversos____________________________________________27 Indicaciones _______________________________________________33 Trastornos del afecto ________________________________________35 Depresión _________________________________________________35 Manía ____________________________________________________36 Trastornos del pensamiento __________________________________37 Esquizofrenia ______________________________________________37 Trastorno esquizoafectivo ____________________________________37 Otros trastornos psiquiátricos ______________________________________38 Condiciones médicas generales ______________________________________39 Contraindicaciones________________________________________________39 Descripción del procedimiento ______________________________________41 Características del aparato de TEC__________________________________45 MARCO LEGAL_________________________________________________46 MARCO GEOGRÁFICO __________________________________________46 MARCO POBLACIONAL _________________________________________46 MARCO BIOÉTICO ______________________________________________47 METODOLOGÍA _________________________________________________49 Diseño de la Investigación ___________________________________________49 Población y Muestra del Estudio _____________________________________49 Criterios de Inclusión _______________________________________________49 Criterios de Exclusión ______________________________________________49 Variables de Investigación ___________________________________________50 Clasificación SISBEN _______________________________________________51 Pobreza extrema _____________________________________________51 Pobreza moderada ___________________________________________51 Vulnerable __________________________________________________51 No pobre – No vulnerable ______________________________________52 Arritmia __________________________________________________________52 Elevación de presión arterial _________________________________________52 Bradicardia _______________________________________________________53 Taquicardia _______________________________________________________53 Convulsión prolongada _____________________________________________54 Relajación insuficiente ______________________________________________54 Desaturación ______________________________________________________55 Secreciones abundantes _____________________________________________55 Espasmo laríngeo __________________________________________________56 Efectos secundarios cognitivos, cambios cognitivos y memoria ____________56 Quejas subjetivas de memoria _________________________________57 Agitación postictal ___________________________________________57 Confusión __________________________________________________58 Lesiones en cavidad oral ____________________________________________58 Viraje a manía ____________________________________________________59 Evolución ________________________________________________________59 Mejoría parcial _____________________________________________60 Mejoría total _______________________________________________ 60 Sin mejoría _________________________________________________60 Tipo de ciclo aplicado_______________________________________________61 Ciclo agudo _________________________________________________61 Ciclo de mantenimiento _______________________________________62 Técnicas o procedimientos para la recolección de información _____________62 Análisis estadístico _________________________________________________62 RESULTADOS ____________________________________________________64 Características sociodemográficas_____________________________________64 Características clínicas ______________________________________________66 Características relacionadas con la administración de TECAR y sus complicaciones_____________69 Variables asociadas a la aparición de complicaciones posterior a la TECAR_74 Variables asociadas a mejoría clínica posterior a la TECAR ______________76 DISCUSIÓN ______________________________________________________79 LIMITACIONES __________________________________________________83 CONCLUSIONES Y RECOMENDACIONES __________________________84 REFERENCIAS ___________________________________________________85 ANEXOS _________________________________________________________89EspecializaciónEspecialista en Psiquiatría90 pag.application/pdfspaUniversidad Tecnológica de PereiraEspecialización en PsiquiatríaFacultad de Ciencias de la SaludPereira610 - Medicina y saludPsiquiatría - MedicinaTerapia - Tramiento medicoTerapia ElectroconvulsivaTerapia electroconvulsivaTratamientoEvento adversoCaracterísticas clínicas y sociodemográficas de pacientes tratados con terapia electroconvulsiva bajo anestesia y relajación (TECAR) en una institución de salud 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Frontiers in Psychiatry. 2021;12:941.PublicationORIGINALTRABAJO DE GRADO.pdfTRABAJO DE GRADO.pdfapplication/pdf1146631https://dspace7-utp.metabuscador.org/bitstreams/77f7d9c8-ce14-45c1-96f1-332225d5e419/downloadeafbeb55c1da56fefd46a1ca0777d5f2MD51LICENSElicense.txtlicense.txttext/plain; charset=utf-814828https://dspace7-utp.metabuscador.org/bitstreams/b407c5de-3a92-417b-b18b-ad62fb2ee74b/download2f9959eaf5b71fae44bbf9ec84150c7aMD52TEXTTRABAJO DE GRADO.pdf.txtTRABAJO DE GRADO.pdf.txtExtracted texttext/plain129599https://dspace7-utp.metabuscador.org/bitstreams/b202d18f-4b4b-4362-82c6-ca03655e2a1f/downloadafe56058135b1f2dbdead34743caa8adMD53THUMBNAILTRABAJO DE GRADO.pdf.jpgTRABAJO DE GRADO.pdf.jpgGenerated Thumbnailimage/jpeg6964https://dspace7-utp.metabuscador.org/bitstreams/d20ab6eb-6f3a-481d-9be5-86a647a80ccc/downloada3d00a317d87bfca9273b468714b2770MD5411059/14115oai:dspace7-utp.metabuscador.org:11059/141152024-09-05 16:44:44.202https://creativecommons.org/licenses/by-nc-nd/4.0/Manifiesto (Manifestamos) en este documento la voluntad de autorizar a la Biblioteca Jorge Roa Martínez de la Universidad Tecnológica de Pereira la publicación en el Repositorio institucional (http://biblioteca.utp.edu.co), la versión electrónica de la OBRA titulada: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ La Universidad Tecnológica de Pereira, entidad académica sin ánimo de lucro, queda por lo tanto facultada para ejercer plenamente la autorización anteriormente descrita en su actividad ordinaria de investigación, docencia y publicación. La autorización otorgada se ajusta a lo que establece la Ley 23 de 1982. Con todo, en mi (nuestra) condición de autor (es) me (nos) reservo (reservamos) los derechos morales de la OBRA antes citada con arreglo al artículo 30 deopen.accesshttps://dspace7-utp.metabuscador.orgRepositorio de la Universidad Tecnológica de 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