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Perioperative seizures

Perioperative seizures. Dr. S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab.DCA , Dip. Software statistics- Phd Mahatma Gandhi Medical college and research institute , puducherry , India. Definition.

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Perioperative seizures

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  1. Perioperative seizures Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab.DCA, Dip. Software statistics- Phd Mahatma Gandhi Medical college and research institute , puducherry , India

  2. Definition • A seizure can be defined as the clinical manifestation of an abnormal and excessive discharge of neurones, seen as alteration of consciousness, motor, sensory or autonomic events. • Epilepsy is defined as recurrent (two or more) epileptic seizures unprovoked by any immediately identifiable cause. • Epilepsy includes seizures but seizures ??

  3. Incidence • Only epilepsy – incidence • 0.5 – 1 % • But peri operative seizures – incidence ?? • EEG monitoring in potential patients ?? • It can also miss ??

  4. Classification • General • Partial • Unclassified

  5. Causes • Epilepsy • Tumours • Infections • Metabolic • Alcohol • Stroke • Its Same

  6. Differential diagnosis • Syncope • Migraine • Narcolepsy • Non epileptic seizures

  7. Investigations • EEG • CT scan • MRI • PET scan

  8. How does it relate to us ?? • Sudden seizures – periop • Epilepsy – anaesthetic considerations • ICU status epilepticus

  9. Clinical setting • Commonest setting • LA toxicity • Intercostal • IVRA • Cervical plexus • Epidural then others

  10. Test dose • There may be premonitory symptoms, such as peri oral tingling, or feelings of dissociation following a test dose. • Epinephrine ?? • Catheter malfunction • Catheter position change • Axillary ?? • Field blocks

  11. Maximum dose for infiltration (mg/kg) • Lidocaine 3 - 4 • With adrenaline 7 • Bupivicaine 2 • With adrenaline 3 • Prilocaine 6 • With adrenaline/octapressin 8 • Additive

  12. Basic treatment • Airway • Oxygen • Ventilate • Support • Other than benzodiazepines

  13. Surgery – what type ??

  14. What Type of Surgery Places the Patient at Risk for Seizures? • Neuro surgery 20 % • Leave alone head injury • Supratentorial tumors • Cerebral abscess 90 % • Drainage 15 – 20 % • Preop seizure history -- incidence is very much higher

  15. CAROTID AND CARDIAC SURGERY • Clamping • Emboli • Stents and tubes

  16. Other surgeries • extensive bowel surgeries • Burns and plastic surgeries • Gut obstruction • Fluid shifts – seizures

  17. Electrolytes • Clinical settings

  18. Hyponatremia – usually 115 is cut off • TURP syndrome • Extensive bowel surgeries • Other scopies where irrigation is done • Plastic and burn reconstruction – massive fluid shifts • Drugs like diuretics • Water intoxication • SIADH. Vomiting • Renal and hepatic disorders

  19. Hypocalcemia • Low albumin; • abnormal acid-base status and electrolytes; • drugs used during the peri-operative period • transfusion of large volumes of citrated blood; • Parathyroid surgeries ,thyroid , CPBs • Sepsis , CRF • Calcium chelators in radiographic contrast

  20. Eclampsia

  21. In pregnant – other than • Epilepsy, eclampsia, drugs • Posterior reversible encephalopathy • Amniotic fluid embolism • Cortical vein thrombosis

  22. Intraop seizures – wrong drugs • Tranexemic acid into the intrathecal space

  23. In an ICU • Seizures • Posttraumatic brain injury • CNS infections • Endocrine and metabolic disorders • Drugs or toxins

  24. Seizure prone electrolyte disturbances • Hyponatremia • Hypokalemia • Hypocalcemia • Hypoglycemia and hyperglycemia • Hypomagnesemia

  25. Drugs • Amphetamine • SSRIs • Tricyclics • Levodopa • Deriphyllin • Phencyclidine • Withdrawal of antiepileptics • Methergin

  26. Alcohol related • hyponatremia, hypomagnesemia, or hypoglycemia • Thiamine

  27. Anesthesia related • TramadolPethidine , • etomidate • Enflurane ,sevo • Atracurium • Flumezanil • Ketaminemethohexital ??, propofol • Hypocapnia ??

  28. EEG monitoring in sevo

  29. Other settings • Renal failure --- erythropeitin ?? • Hepatic failure • Hypothyroidism • Hashimato s • Inciting factors • Fever , infection , sleeplessness

  30. Reflex Anoxic Seizures and Anaesthesia • What is this ?? • ocular pressure, venepuncture, accidental trauma and fear  • Young female school children • Grand mal like • EEG changes may not be present

  31. What should we do • Patient Should not fall • Oxygen • Bag and mask • Two IV lines • Glucose • Thiamine • Benzodiazepines

  32. Settings at a glance • Local anaesthetic toxicity • TURP • Eclampsia • Neuro surgeries • CPBs • Drug intake • Drug withdrawal

  33. Post operative period • Postoperative generalized shaking is usually because of shivering, which may be thermoregulatory or non-thermoregulatory. • The latter is thought to be secondary to the effects of volatile anaesthetics, pain or both.

  34. Pseudoepileptic seizures • common in the postoperative period. • resemble tonic–clonic seizures • NO abnormal electrical discharges • history of convulsions and/or psychosomatic illness. • flamboyant, last longer than 90 s , asynchronous limb movements, side-to-side head movements, closed eyes (including a resistance to eye opening). • There is no cyanosis or post-ictal period • may be incontinence or tongue-biting. • Seizures may settle with reassurance. • Plasma prolactin concentrations tend to be raised after epileptic seizures and normal after pseudo-seizures.

  35. In fits • Case ?? • Massive fluid shifts • Epileptic • Systemic illness • Drugs, alcohol • Hypoxemia • Electrolytes , blood glucose, RFT, LFT • CT brain • Oxygenation, benzodiazepines

  36. Status epilepticus • The traditional definition of status epilepticus as a seizure lasting or recurring without regaining of consciousness over a 30 min period is primarily useful for epidemiological purposes. • Can we wait for 30 minutes ?? • In clinical practice, most convulsive seizures abate within 2–3 min and a seizure that continues for more than 5 min has a low chance of terminating spontaneously.

  37. Physiological changes • Increased cerebral metabolism • Increased blood flow, • increased glucose and lactate concentration • Increased catecholamine secretion • 30 – 60 minutes • hyponatraemia, potassium imbalance, • evolving metabolic acidosis, consumptive coagulopathy, rhabdomyolysis, and multi-organ • failure

  38. Stages • Premonitory (0 -5 min) • Early (5-10 minutes) • Established ( 10 – 30 minutes ) • Refractory ( 30 – 60 minutes)

  39. Pre-monitory stage (out of hospital or first 5 min) • BUCCAL OR RECTAL MIDAZ

  40. Early stage (first 5–10 min) • Iv ACCESS • OXYGEN • GLUCOSE , THIAMINE • BENZODIAZIPINES

  41. Established CSE (5–30 min) • Phenytoin • Phenobarbital • Valproate • levetiracetam

  42. Refractory status (30–60 min) • Refractory CSE (RSE), where SE continues in spite of administration of two AEDs (e.g. benzodiazepines and phenytoin), is associated with a high risk of complications. • These include tachyarrhythmias, pulmonary oedema, hyperthermia, rhabdomyolysis, and aspiration pneumonia.

  43. To continue till ?? • Maximal therapy should be maintained until 12–24 h after the last clinical or electrographic seizure, after which the dose should be tapered. If seizures recur, therapy can be re-instituted or altered

  44. Non-convulsive status epilepticus • Impaired consciousness • Automatism • EEG patterns

  45. Summarize • Status definition • Complications • Stages • Treatment

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