FRINK Linked Data Fragments server

Matches in SemOpenAlex for { <https://semopenalex.org/work/W2066133477> ?p ?o ?g. }

• W2066133477 endingPage "117" @default.
• W2066133477 startingPage "111" @default.
• W2066133477 abstract "Access the CPD MCQs for this issue online here Key points•Epilepsy is a common neurological disorder affecting 600 000 people in the UK.•The standard treatment for adults with epilepsy is antiepileptic drug (AED) therapy, but resective surgery may be considered in those patients in whom seizure control is not achieved.•AEDs have multiple drug interactions, which need to be considered in the perioperative period.•Perioperative care of patients with epilepsy should focus on minimization of interference in normal AED regimes and avoiding physiological or pharmacological disturbances that may lower the seizure threshold.•Status epilepticus is a common medical emergency with significant morbidity and mortality. •Epilepsy is a common neurological disorder affecting 600 000 people in the UK.•The standard treatment for adults with epilepsy is antiepileptic drug (AED) therapy, but resective surgery may be considered in those patients in whom seizure control is not achieved.•AEDs have multiple drug interactions, which need to be considered in the perioperative period.•Perioperative care of patients with epilepsy should focus on minimization of interference in normal AED regimes and avoiding physiological or pharmacological disturbances that may lower the seizure threshold.•Status epilepticus is a common medical emergency with significant morbidity and mortality. Epilepsy is a disorder of the brain characterized by a predisposition to generate abnormal synchronous neuronal activity. This results in recurrent and unpredictable interruptions of normal brain function, observed clinically as epileptic seizures.1Fisher RS van Emde Boas W Blume W et al.Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE).Epilepsia. 2005; 46: 470-472Crossref PubMed Scopus (2428) Google Scholar Epilepsy is common; 50 million people worldwide are affected and the estimated prevalence of active epilepsy [continuing seizures or the need for antiepileptic drug (AED) treatment] is 4–10 per 1000 people.2WHO epilepsy factsheet. 2012http://www.who.int/mediacentre/factsheets/fs999/en/index.htmlGoogle Scholar Within the UK, ∼600 000 people have a diagnosis of epilepsy and take antiepileptic medication.3Joint Epilepsy Council of the UK and Ireland Epilepsy prevalence, incidence and other statistics. 2011http://www.jointepilepsycouncil.org.uk/downloads/2011/Joint Epilepsy Council Prevalence and Incidence September 11.pdfGoogle Scholar All anaesthetists will regularly encounter patients with epilepsy in their practice and should be aware of the special considerations when managing patients with this disorder. Planned and thoughtful care of these patients can minimize the risk of seizure occurrence in the perioperative period. Epilepsy is conventionally diagnosed after two unprovoked seizures occurring at least 24 h apart. This reflects the fact that after two non-febrile seizures, more than 70% of people will have another seizure within 4 yr,4Hauser W Rich S Lee JR Annegers JF Anderson VE Risk of recurrent seizures after two unprovoked seizures.N Engl J Med. 1998; 338: 429-434Crossref PubMed Scopus (309) Google Scholar whereas only 40–50% of people will go on to develop epilepsy after a single unprovoked seizure.5Berg AT Risk of recurrence after a first unprovoked seizure.Epilepsia. 2008; 49: 13-18Crossref PubMed Scopus (30) Google Scholar The diagnosis of epilepsy depends on a convincing history, witnessed seizures, or both in combination with investigations including EEG to detect abnormal neuronal discharges and computed tomography (CT) or magnetic resonance imaging (MRI) to detect underlying structural brain abnormalities.6Nunes VD Sawyer L Neilson J Sarri G Cross JH Diagnosis and management of the epilepsies in adults and children: summary of updated NICE guidance.Br Med J. 2012; 344: e281Crossref PubMed Scopus (90) Google Scholar More than 60% of patients with epilepsy may have normal investigations (idiopathic epilepsy) and diagnosis is often difficult. As a result, it is believed that 5–30% of people diagnosed with epilepsy in the UK may have an incorrect diagnosis.7National Institute for Health and Clinical Excellence The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care (update) (Clinical guideline 137). 2012http://guidance.nice.org.uk/cg137Google Scholar Epilepsy is not a single condition. There are more than 40 different types of epilepsy consisting of at least 29 syndromes and a further 12 or so clinically distinct groups defined by the specific cause.8Berg AT Berkovic SF Brodie MJ et al.Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 2005–2009.Epilepsia. 2010; 51: 676-685Crossref PubMed Scopus (3246) Google Scholar Classification systems typically focus on underlying aetiology or descriptions of clinical features such as seizure type.8Berg AT Berkovic SF Brodie MJ et al.Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 2005–2009.Epilepsia. 2010; 51: 676-685Crossref PubMed Scopus (3246) Google Scholar Common causes of epilepsy include congenital neurological or metabolic conditions, traumatic brain injury, stroke, brain tumours, and central nervous system (CNS) infections. Underlying genetic susceptibility and environmental factors may also contribute to this condition. The precise aetiology of epilepsy is often not important in the perioperative environment, but anaesthetists should note if epilepsy is part of a multisystem syndrome or disease process. Epileptic seizures are subdivided into focal and generalized types. Focal seizures originate within neuronal networks limited to one hemisphere, whereas generalized seizures rapidly engage bilaterally distributed neuronal networks. Focal and generalized epileptic seizures present with variable signs and symptoms that depend on the spatial origin and extent of abnormal synchronous activity (Table 1). Within the UK, 60% of patients with epilepsy have tonic–clonic seizures, 20% have complex focal seizures, 12% have a mixed picture of several seizure types, 3% have simple focal seizures, and <5% have other seizure types.3Joint Epilepsy Council of the UK and Ireland Epilepsy prevalence, incidence and other statistics. 2011http://www.jointepilepsycouncil.org.uk/downloads/2011/Joint Epilepsy Council Prevalence and Incidence September 11.pdfGoogle Scholar8Berg AT Berkovic SF Brodie MJ et al.Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 2005–2009.Epilepsia. 2010; 51: 676-685Crossref PubMed Scopus (3246) Google ScholarTable 1Major seizure type and subtype classificationsGeneralized seizures Tonic–clonic Absence Myoclonic Clonic Tonic AtonicFocal seizures Simple Complex Evolving to generalizedMixed seizures (focal and generalized)Unclassified Open table in a new tab The standard management of adults with a confirmed diagnosis of epilepsy is AED therapy. The mechanism of action of AEDs is via either suppression of excitatory impulses or facilitation of inhibitory impulses in the brain (Fig. 1).9Bialer M White HS Key factors in the discovery and development of new antiepileptic drugs.Nat Rev Drug Discov. 2010; 9: 68-82Crossref PubMed Scopus (415) Google Scholar Therapy choices are based on the seizure type and aetiology of epilepsy, with consideration taken of the patient's comorbidities and medications and the AED side-effect profile. The National Institute for Clinical Excellence (NICE) produced recommended treatment guidelines in 2012 (Table 2).7National Institute for Health and Clinical Excellence The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care (update) (Clinical guideline 137). 2012http://guidance.nice.org.uk/cg137Google Scholar AED monotherapy is preferable, but if this fails, patients may be managed on more than one AED. The characteristics of the major AEDs are shown in Table 3.10Kofke WA Anesthetic management of the patient with epilepsy or prior seizures.Curr Opin Anaesthesiol. 2010; 23: 391-399Crossref PubMed Scopus (51) Google ScholarTable 2NICE guidelines for AED treatment7National Institute for Health and Clinical Excellence The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care (update) (Clinical guideline 137). 2012http://guidance.nice.org.uk/cg137Google ScholarSeizure typeFirst lineAdjunctiveGeneralized tonic–clonicCarbamazepineLamotrigineOxcarbazepineSodium valproateClobazamLamotrigineLevetiracetamSodium valproateTopiramateTonic or atonicSodium valproateLamotrigineAbsenceEthosuximideLamotrigineSodium valproateEthosuximideLamotrigineSodium valproateMyoclonicLevetiracetamSodium valproateTopiramateLevetiracetamSodium valproateTopiramateFocalCarbamazepineLamotrigineOxcarbazepineSodium valproateCarbamazepineClobazamGabapentinLamotrigineLevetiracetamOxcarbazepineSodium valproate Open table in a new tab Table 3Characteristics of AEDs (adapted with permission from Kofke).10Kofke WA Anesthetic management of the patient with epilepsy or prior seizures.Curr Opin Anaesthesiol. 2010; 23: 391-399Crossref PubMed Scopus (51) Google Scholar CNS, central nervous system; CYP2B, cytochrome P450 2B; DIC, disseminated intravascular coagulation; t½, elimination half-life; UGT, UDP-glucuronosyltransferaseDrugProtein binding (%)Effects on enzymes involved in drug metabolismt½ (h)Elimination route (%)Disadvantages and adverse effectsRenalLiverCarbamazepine75Broad-spectrum inducer9–15199Diplopia, nystagmus, blurred vision, ataxia, dizziness, sedation, hyponatraemia, rashClonazepam85Induce CYP2B family20–60<5>90SedationEthosuximide0None30–60<20<80Nausea, vomiting, gastrointestinal distress, drowsiness, ataxiaFelbamate25Mixed inducer and inhibitor13–225050Risk of aplastic anaemia and liver toxicity, CNS and gastrointestinal side-effects, drug interactions, dizziness, blurred vision, ataxia, weight lossGabapentin0None5–71000Efficacy limited to partial epilepsies, multiple daily dosing, high cost, mild drowsiness, encephalopathy, weight gain, peripheral oedema, weight changeLamotrigine55Induces UGTs12–621090Need for slow titration, hypersensitivity reactions, rash, Stevens–Johnson syndrome, toxic epidermal necrolysis (especially with concurrent valproate), hepatic and renal failure, DIC, arthritis, fever, red cell aplasia, tics, insomniaLevetiracetam<10None6–81000Irritability, behaviour change, somnolenceOxcarbazepine40Mixed inducer and inhibitor9199Interaction with oral contraceptives, hyponatraemia, rashPhenobarbitol45Broad-spectrum inducer75–1102575Drowsiness, slurred speech, nystagmus, confusion, somnolence, ataxia, respiratory depression, coma, hypotension, sedation, behaviour disordersPhenytoin90Broad-spectrum inducer9–36595Vertigo, ataxia, slurred speech, nystagmus, diplopia, somnolence, stupor, coma, gingival hyperplasia, hirsutism. Hypotension and arrythmias (i.v.)Primadone0Broad-spectrum inducer6–81000Sedation and dizziness acutely, then similar to phenobarbitalTigabine96None7–9298CNS side-effects, interactions with oral contraceptives, nephrolithiasis, open-angle glaucoma, hypohidrosis, metabolic acidosis, weight lossTopiramate15Mixed inducer and inhibitor12–246535CNS side-effects, nephrolithiasis, open-angle glaucoma, hypohidrosis, metabolic acidosis, weight loss, language dysfunctionValproate90Broad-spectrum inhibitor6–18298Sedation, gastric disturbance, weight gain, diarrhoea, tremors, ataxia, somnolence, coma, thrombocytopenia, platelet dysfunction, hepatic failure, hair loss, drowsinessVigabatrin0None5–71000Visual field defects, weight gainZonisamide40None633565CNS side-effects, allergic reactions, rash, nephrolithiasis, hypohidrosis, irritability, photosensitivity, weight loss Open table in a new tab Patients with poor seizure control despite AED polytherapy should be referred to a specialist multidisciplinary epilepsy clinic. Epilepsy surgery is a treatment option in these cases and may be curative or palliative. Surgical options include implantation of a vagal nerve stimulator to reduce seizure frequency, curative resective surgery such as an anterior temporal lobectomy, or disconnective procedures that interrupt the propagation of seizures such as a corpus callosotomy or a multiple pial transection. Women of childbearing age should be counselled regarding the risk of teratogenicity from AEDs and the potential interaction between AEDs and oral contraceptive drugs. Although some AEDs are linked to fetal malformations, data especially from newer drugs are limited and there are definite risks to the fetus and mother if a woman has a tonic–clonic seizure during pregnancy. In the period 2006–8, the UK Confidential Enquiries into Maternal Deaths recorded 14 deaths during pregnancy as a consequence of epilepsy.11Centre for Maternal and Child Enquiries (CMACE) Saving mothers’ lives. Reviewing maternal deaths to make motherhood safer: 2006–2008.BJOG. 2011; 118: 1-203Google Scholar Decisions regarding epilepsy treatment during pregnancy are therefore complex and should be made in consultation with a neurologist and obstetrician. Individuals are no longer considered to have epilepsy if they have remained seizure-free for at least 10 yr off antiseizure medicines and there are no known risk factors associated with a high probability (≥75%) of future seizures or if they had an age-dependent epilepsy syndrome but are now past the applicable age. This reflects the finding that the risk of recurrent seizures is very low after 10 yr being seizure-free off antiepileptic medication.12Chadwick D Taylor J Johnson T Outcomes after seizure recurrence in people with well-controlled epilepsy and the factors that influence it.Epilepsia. 1996; 37: 1043-1050Crossref PubMed Scopus (76) Google Scholar In those patients with a defined epilepsy aetiology, their prognosis will depend on the underlying cause. Patients with idiopathic epilepsy have a normal lifespan if their seizures are well controlled, but this falls if seizure control is not achieved. This reflects the higher incidence of accidents and suicides in this group and also the risk of sudden unexpected death in epilepsy (SUDEP). SUDEP is the sudden death of a seemingly healthy individual with epilepsy, usually occurring during, or immediately after, a tonic–clonic seizure. The mechanisms are incompletely understood, but seizure-related respiratory depression, cardiac arrhythmias, cerebral depression, and autonomic dysfunction are all implicated.13Shorvon S Tomson T Sudden unexpected death in epilepsy.Lancet. 2011; 378: 2028-2038Abstract Full Text Full Text PDF PubMed Scopus (326) Google Scholar Risk factors for SUDEP include male sex, long duration of epilepsy, frequent occurrence of tonic–clonic seizures, and AED polytherapy. Patients should be counselled and given advice regarding treatment and lifestyle choices to avoid poor seizure control and minimize the risk of SUDEP. In addition to the standard preoperative history and examination, specific considerations in patients with epilepsy are described below. For patients with epilepsy of defined aetiology, there may be important effects on other organ systems. For example, congenital syndromes often have multisystem involvement, and epilepsy secondary to stroke is associated with other significant cardiovascular disease. It is important to establish how well a patient's epilepsy is controlled to predict the risk of postoperative seizure occurrence. Awareness of the patient's normal seizure pattern helps to determine if postoperative events are likely to be part of their underlying disorder. Current drug therapy, dosage regimes, time of most recent dose, and any recent changes in the medication regime should be established. Attempts should be made to minimize disruption to treatment regimes and anaesthetists should ensure that a patient has taken their scheduled medication on the morning of surgery. Patients with epilepsy will usually be allowed to hold a driving licence if they have been totally seizure-free, or have only had seizures in their sleep, or only had simple focal seizures with no functional impairment over a 1 yr period (sometimes 6 months in the case of a first seizure). A perioperative seizure in patients who hold driving licences can therefore have significant implications. The Driving and Vehicle Licensing Agency (www.gov.uk/government/organisations/driver-and-vehicle-licensing-agency) has detailed advice. Patients should have preoperative tests in line with National Institute of Clinical Excellence guidelines (NICE, www.nice.org.uk) depending on age, surgical severity, and ASA status. Within these guidelines, there are no specific recommendations regarding preoperative measurement of AED levels, and levels are not routinely measured. Exceptions to this are in patients who have poorly controlled epilepsy or a history of unstable AED levels and before major gastrointestinal surgery to establish baseline levels. Consultation with the patient's neurologist before surgery is probably appropriate in such circumstances. The multiple interactions between AEDs and anaesthetic agents are complex and beyond the scope of this article. However, a number of common and important interactions will be discussed with practical tips for management. The effects of i.v. anaesthetic agents on the EEG are complex, but they are generally proconvulsant at low levels and anticonvulsant at doses used for general anaesthesia. Thiopental is safe to use and is an established treatment for refractory status epilepticus because of its powerful anticonvulsant properties at anaesthetic doses. Propofol was previously avoided in patients with epilepsy because of the high rate of excitatory movements on induction and emergence. However, it is now widely used because of the recognition of its anticonvulsant properties at anaesthetic doses and because the abnormal movements are usually easy to distinguish from epileptic seizures. Etomidate has been reported to be more frequently associated with postoperative seizures and prolongs seizures when used for electroconvulsive therapy, and is therefore generally avoided. Ketamine is often avoided, particularly as a co-induction agent, because of its proconvulsant properties at low doses. However, it is anticonvulsant at anaesthetic doses. Benzodiazepines are all potent anticonvulsants and safe to use. Nitrous oxide has been observed to provoke seizures in animal models, but this has not been replicated in humans and it is considered safe to use. Most inhalation agents cause burst suppression on the EEG and again are safe to use. The exception to this is enflurane, which can produce epileptiform discharges on the EEG and postoperative seizures, so should be avoided. Opioid analgesics all possess some degree of proconvulsant activity and are used to enhance EEG activity during seizure focus localization in epilepsy surgery. However, most opioids have a long history of safe use in patients with epilepsy. An exception to this is alfentanil, a particularly potent enhancer of EEG activity, which should be avoided or used with caution. Meperidine and tramadol should also be avoided as they increase the risk of seizures. Meperidine's metabolite normeperidine is a potent proconvulsant, and tramadol lowers the seizure threshold (probably because of its inhibition of monamine reuptake). Although succinylcholine has been observed to produce increased EEG activation, this has not been associated with seizure activity.14Perks A Cheema S Mohanraj R Anaesthesia and epilepsy.Br J Anaesth. 2012; 108: 562-571Crossref PubMed Scopus (77) Google Scholar It is therefore considered safe to use except after prolonged status epilepticus where it may cause dangerous elevations in serum potassium. Non-depolarizing neuromuscular blockers (NMBs) are safe, but the enzyme-inducing effects of AEDs may cause resistance to the effects of aminosteroid NMBs such as rocuronium, pancuronium, and vecuronium. It is advisable to monitor the neuromuscular block with a nerve stimulator, as the dose and frequency of these drugs may need to be adjusted. Laudanosine, a metabolite of atracurium, has epileptogenic potential, but seizures have only been reported in animal studies. Dopamine antagonists are particularly associated with extrapyramidal effects and acute dystonic reactions, which might be confused with seizure activity. It is therefore advisable to avoid phenothiazines (e.g. prochlorperazine), benzamindes (e.g. metoclopramide), and butyrophenones (e.g. droperidol). Regional techniques are safe in patients with epilepsy and may help to minimize disruption of normal AED regimes. However, close attention should be paid to safe dosing as local anaesthetics can readily cross the blood–brain barrier and result in seizures if plasma levels are too high. Seizures under general anaesthesia are relatively rare, but may occur in patients with poorly controlled epilepsy or in the context of high-risk surgery such as neurosurgery. They are difficult to diagnose, especially if NMBs have been used, but suggestive signs include increasing end-tidal carbon dioxide, tachycardia, hypertension, increased muscle tone, pupillary dilatation, and increased oxygen consumption. Immediate management includes deepening of anaesthesia, administration of 100% oxygen, correction of precipitating factors such as hypoglycaemia, hypoxia, and hypercarbia, and also consideration of differential diagnoses. If available, EEG may help with diagnosis. Of particular importance in the management of patients with epilepsy is minimization of disruption of their normal AED regime. I.V. forms of phenytoin, sodium valproate, and leviteracetam exist and carbamazepine can be given rectally. Early input from a neurologist should be sought if a patient is likely to be unable to resume their normal regime of oral AEDs after operation. Postoperative prescriptions for patients with epilepsy should take into account the extensive pharmacokinetic and pharmacodynamic interactions of AEDs. Enzyme-inducing AEDs can reduce the serum concentration of multiple drugs, including some antimicrobials, paracetamol, and fentanyl. Conversely, drugs, including some antimicrobials, can increase the serum concentration of AEDs by inhibiting their metabolism, risking AED toxicity. In addition, highly protein-bound AEDs can compete with other protein-bound drugs for binding sites, altering free drug levels (Table 3). Proconvulsant drugs including tramadol, meperidine, and ketamine should be avoided, as should dopamine antagonists including haloperidol and antiemetics because of the risk of extrapyramidal side-effects. In view of the many and complex interactions, all postoperative medications should be checked for safety before prescribing. Abnormal movements in the postoperative setting may be seizures or a number of other diagnoses (Table 4). Management should focus on an ABC approach, determination of the likely cause and termination of seizures with benzodiazepines. If seizure resolution does not occur with benzodiazepine therapy, a loading dose of phenytoin (18 mg kg−1) should be given and neurology advice sought. Patients with known epilepsy should be informed of the event as it may affect their lifestyle, for example, driving or working with heavy machinery. In patients without known epilepsy, precipitating factors such as metabolic disturbances or drug effects should be corrected and they should be referred for an urgent neurology opinion. The diagnosis of a first seizure in the postoperative setting should be made cautiously in view of the multiple other pathologies that may mimic a seizure.Table 4Cause of postoperative seizure-type episodesEpileptic seizure Underlying epilepsy Post-neurosurgery Eclampsia Metabolic disturbance Alcohol withdrawalPostoperative shiveringAcute dystonic drug reaction Dopamine antagonistsPsychogenic non-epileptic seizureSyncopal episode Open table in a new tab Patients with epilepsy refractory to AEDs may be suitable for surgery to remove the epileptogenic foci. These patients can present to the anaesthetist in two situations: for the implantation of intracranial electrodes and for the resection of the epileptic focus. Electrode implantation surgery is commonly performed under general anaesthesia with propofol or low levels of inhaled agent. It is generally recommended that benzodiazepines be avoided to prevent abolition of interictal epileptiform activity. Intraoperative pharmacoactivation (to encourage seizure activity under anaesthesia with the aim of identifying the seizure focus) may occasionally precipitate generalized seizures, which are effectively managed by the application of cold saline to the exposed part of the brain, small doses of propofol (10–30 mg) or anticonvulsant drugs, or both. The patients subsequently undergo telemetry monitoring in the postoperative period in order to localize the focus of epileptiform activity before a planned craniotomy and resection of the appropriate brain area. Patients presenting for the surgical resection of the foci often have had accurate presurgical localization using a multitude of investigations [including CT, MRI, single photon emission computed tomography (SPECT), positron emission tomography (PET), and magnetoencephalography (MEG)] and may also have intracortical/subdural electrodes in situ. Surgery in such situations is facilitated by either general anaesthesia or local anaesthesia (‘awake craniotomy’) if indicated. The latter technique may be preferable when the epileptogenic zone is anatomically close to eloquent areas of the brain, as it allows cognitive testing to identify critical functional regions of the brain. The detailed perioperative management for these procedures is beyond the scope of this article and the reader is referred to recent comprehensive reviews on this topic.15Chui J Venkatraghavan L Manninen P Presurgical evaluation of patients with epilepsy: the role of the anesthesiologist.Anesth Analg. 2013; 116: 881-888Crossref PubMed Scopus (6) Google Scholar16Chui J Manninen P Valiante T Venkatraghavan L The anesthetic considerations of intraoperative electrocorticography during epilepsy surgery.Anesth Analg. 2013; 117: 479-486Crossref PubMed Scopus (33) Google Scholar Convulsive status epilepticus (CSE) is a common medical emergency and is conventionally defined as >30 min of continuous seizure activity or sequential seizures without full recovery of consciousness between seizures. However, it is recognized that after 5 min of continuous seizure activity, spontaneous resolution is unlikely to occur, so treatment is advised to start at this time point. Emergency pharmacological management of CSE is summarized in Figure 2. Of note is the addition of ketamine to the management options for refractory CSE. Ketamine has recently been shown to be effective for refractory CSE in a case series of patients where other i.v. anaesthetics had not terminated CSE and should be considered as a second-line option.17Synowiec AS Singh DS Yenugadhati V Valeriano JP Schramke CJ Kelly KM Ketamine use in the treatment of refractory status epilepticus.Epilepsy Res. 2013; 105: 183-188Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar The management of CSE should include resuscitative measures such as airway management, supplemental oxygen, and establishing large-bore i.v. access in addition to cardiorespiratory assessment, arranging emergency investigations, identification of and treatment of underlying aetiology, and arranging intensive care admission in established/refractory cases. Emergency investigations include arterial blood gases and venous blood sampling for glucose, calcium, and magnesium levels; renal and liver functions; a full blood count, clotting screen, AED level assay, and toxicology screen. Other investigations including microbiology, lumbar puncture, and brain imaging will depend on the presentation and likely aetiology. The EEG is useful to monitor seizure activity in the anaesthetized and paralysed patient. A neurologist opinion should be sought if non-epileptic seizures are suspected. Complications of refractory CSE include excitotoxic CNS injury, hyperthermia, pulmonary oedema, arrhythmias, cardiovascular collapse, metabolic derangement, acute kidney and liver injury, rhabdomyolysis, and fractures. Refractory CSE has a high-mortality rate and less than one-third of patients will return to their premorbid level of functioning.14Perks A Cheema S Mohanraj R Anaesthesia and epilepsy.Br J Anaesth. 2012; 108: 562-571Crossref PubMed Scopus (77) Google Scholar Non-convulsive status epilepticus (NCSE) refers to the finding of EEG evidence of uncontrolled seizures but without clinically apparent tonic–clonic convulsions. This may occur with uncontrolled absence or complex partial seizures or in the intensive care setting in unconscious patients. The underlying aetiology in intensive care is either advanced CSE or an underlying neurological condition such as encephalitis, traumatic brain injury, or post-cardiac arrest. The EEG is often difficult to interpret in these patients and a neurology/neurophysiology opinion should be obtained to aid diagnosis. I.V. AEDs, anaesthetic agents, or both should be titrated to seizure suppression on the EEG. The NCSE indicates a poor prognosis for the underlying neurological condition. Epilepsy is a common neurological condition that anaesthetists will frequently encounter in both the elective and emergency setting. Understanding the pathophysiology of epilepsy and its pharmacological therapies enables safe planning and delivery of care. Specific aims during routine anaesthetic care include minimizing disturbance of AED regimes and avoiding drugs that interact with AEDs or alter the seizure threshold. This reduces the chance of patients having seizures in the perioperative period. Prolonged non-resolving seizure activity is termed status epilepticus and is a medical emergency with significant associated morbidity and mortality. Prompt resuscitation, pharmacological management, and critical care support can maximize the chances of a good recovery for the patient. None declared." @default.
• W2066133477 created "2016-06-24" @default.
• W2066133477 creator A5042350454 @default.
• W2066133477 creator A5090150251 @default.
• W2066133477 date "2015-06-01" @default.
• W2066133477 modified "2023-09-27" @default.
• W2066133477 title "Adult epilepsy and anaesthesia" @default.
• W2066133477 cites W1545825327 @default.
• W2066133477 cites W1968259409 @default.
• W2066133477 cites W1994862799 @default.
• W2066133477 cites W2080289801 @default.
• W2066133477 cites W2099478180 @default.
• W2066133477 cites W2121921976 @default.
• W2066133477 cites W2123292389 @default.
• W2066133477 cites W2131979832 @default.
• W2066133477 cites W2138132463 @default.
• W2066133477 cites W2323577709 @default.
• W2066133477 cites W2326514561 @default.
• W2066133477 cites W2330174337 @default.
• W2066133477 cites W4248307879 @default.
• W2066133477 doi "https://doi.org/10.1093/bjaceaccp/mku014" @default.
• W2066133477 hasPublicationYear "2015" @default.
• W2066133477 type Work @default.
• W2066133477 sameAs 2066133477 @default.
• W2066133477 citedByCount "8" @default.
• W2066133477 countsByYear W20661334772019 @default.
• W2066133477 countsByYear W20661334772020 @default.
• W2066133477 countsByYear W20661334772021 @default.
• W2066133477 countsByYear W20661334772022 @default.
• W2066133477 countsByYear W20661334772023 @default.
• W2066133477 crossrefType "journal-article" @default.
• W2066133477 hasAuthorship W2066133477A5042350454 @default.
• W2066133477 hasAuthorship W2066133477A5090150251 @default.
• W2066133477 hasBestOaLocation W20661334771 @default.
• W2066133477 hasConcept C118552586 @default.
• W2066133477 hasConcept C2778186239 @default.
• W2066133477 hasConcept C2992111748 @default.
• W2066133477 hasConcept C42219234 @default.
• W2066133477 hasConcept C71924100 @default.
• W2066133477 hasConceptScore W2066133477C118552586 @default.
• W2066133477 hasConceptScore W2066133477C2778186239 @default.
• W2066133477 hasConceptScore W2066133477C2992111748 @default.
• W2066133477 hasConceptScore W2066133477C42219234 @default.
• W2066133477 hasConceptScore W2066133477C71924100 @default.
• W2066133477 hasIssue "3" @default.
• W2066133477 hasLocation W20661334771 @default.
• W2066133477 hasOpenAccess W2066133477 @default.
• W2066133477 hasPrimaryLocation W20661334771 @default.
• W2066133477 hasRelatedWork W1969863727 @default.
• W2066133477 hasRelatedWork W1992056480 @default.
• W2066133477 hasRelatedWork W2045187006 @default.
• W2066133477 hasRelatedWork W2143746981 @default.
• W2066133477 hasRelatedWork W2159396773 @default.
• W2066133477 hasRelatedWork W2170431845 @default.
• W2066133477 hasRelatedWork W2365776827 @default.
• W2066133477 hasRelatedWork W2969181163 @default.
• W2066133477 hasRelatedWork W4244582950 @default.
• W2066133477 hasRelatedWork W4249473039 @default.
• W2066133477 hasVolume "15" @default.
• W2066133477 isParatext "false" @default.
• W2066133477 isRetracted "false" @default.
• W2066133477 magId "2066133477" @default.
• W2066133477 workType "article" @default.