1 / 49

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.

catalina-amora
Download Presentation

Perioperative seizures

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related