General Anesthesia in Status Epilepticus Presented by R2 簡維宏 / VS 黃謙琳.

Slides:



Advertisements
Similar presentations
Definition of Terms Seizure Epileptic Seizure Epilepsy
Advertisements

Coding of Seizures and Epilepsy Gregory L. Barkley, MD Vice President National Association of Epilepsy Centers.
Electrolyte and Metabolic Disturbances AHMED GHALI MD.
Katie Clement, MD PICU Resident Lectures 2011 Traumatic Brain Injury.
Status Epilepticus-Definition
A Randomized Trial of Protocol-Based Care for Early Septic Shock Andrea Caballero, MD January 15, 2015 LSU Journal Club The ProCESS Investigators. N Engl.
Status Epilepticus: Clinical Features, Pathophysiology, and Treatment
SEPSIS KILLS program Adult Inpatients
Epilepsy 5.Year Prof.Dr.S.Naz Yeni.
Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 24 Drugs for Epilepsy.
Seizures: Nuts and Bolts National Pediatric Nighttime Curriculum Written by Anna Lin, MD Lucile Packard Children’s Hospital.
Epilepsy 2 Dr. Hawar A. Mykhan.
What Do We Do When Benzodiazepines Fail?. Edward P. Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois College.
Sepsis.
REFRACTORY STATUS EPILEPTICUS USE OF ANAESTHETIC AGENTS R MAHARAJ.
Najwa Al-Bustani Neurology Resident July
Ives Hot, PharmD May 28, 2014 UW Medicine
When is EEG Indicated for ED Patients? When is EEG Indicated for ED Patients? J. Stephen Huff, MD, FACEP Emergency Medicine and Neurology University of.
Ass. Prof. Hadi Mujlli MSc, PhD Neurology Head of Med. Dep. Thamar Medical College, Thamar University.
Neurological Emergencies Dr. Amal Alkhotani MBBCH, FRCPC, Epilepsy and EEG.
Seizures: Nuts and Bolts Nightfloat Curriculum Lucile Packard Children’s Hospital Residency Program.
Febrile convulsions. Meest frequente vorm van epilepsie bij kinderen Koortsstuipen = Febriele convulsies Is een vorm van (gegeneraliseerde) epilepsie.
Clinical Policy: Critical Issues for the Evaluation and Management of Adult Patients Presenting With Seizures Andy Jagoda, MD, FACEP Professor of Emergency.
Status Epilepticus (SE): Rx Following Benzodiazepine Use Edward Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois.
Managing Seizure Patients in SE Following the Use of the Benzodiazepines.
First Line Therapy in Acute Seizure Management William C. Dalsey, MD, FACEP, MBA Department of Emergency Medicine Robert Wood Johnson University Hospital.
Pediatric Prehospital Seizure Management: Evidence Based Guidelines and State of Care in CO Kathleen Adelgais, MD MPH Pediatric Emergency Medicine Children’s.
How Do We Treat SE Patients When the Benzodiazepines Fail?
The ED Treatment of Seizure and SE Patients: What the 2004 ACEP Seizure Clinical Policy Doesn’t Tell You 1 Edward P. Sloan, MD, MPH, FACEP.
Edward P. Sloan, MD, MPH, FACEP Optimizing ED Seizure & SE Patient Management: A Useful SE Treatment Protocol.
Andy S. Jagoda, MD 1 Seizure and Status Epilepticus Therapeutics: A 2005 Update.
Benzodiazepines What are the Best Non-IV Parenteral Options for a Seizing Patient? William C. Dalsey, MD, FACEP, MBA Department of Emergency Medicine Robert.
Managing and Detecting Seizures in the ICU Special thanks to: Katherine Nickels, MD Assistant Professor of Neurology and Pediatrics Mayo Clinic.
P HARMACOTHERAPY IV S TATUS E PILEPTICUS Rowa’ Al Ramah 1.
ACEP Clinical Policy: ACEP Clinical Policy: Critical Issues for the Evaluation and Management of Adult Patients Presenting With Seizures William C. Dalsey,
Drug-Induced Seizures (in 15 minutes or Less) Robert S. Hoffman, MD Director, NYC Poison Center Associate Professor Emergency Medicine and Medicine NYU.
23 August 2015 Dr. Bandar Al-Jafen - Neurology Unit - Department of Medicine Management of Status Epilepticus Dr. Bandar Al-Jafen, MD Consultant Neurologist.
Status epilepticus. Status Epilepticus Traditionally, SE is defined as continuous or repetitive seizure activity persisting for at least 30 minutes without.
Pain Agitation & Delirium SCCM Pain assessment i. We recommend that pain be routinely monitored in all adult ICU patients (+1B). ii. The Behavioral.
Definition The epilepsies are a group of disorders characterized by chronic recurrent paroxysmal changes in neurologic function caused by abnormalities.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 52 Drug Therapy for Seizure Disorders and Spasticity.
The Nature of Disease.
Jason Haag Intern Conference. Case 34 y.o. with h/o seizure disorder presents to ED with increased seizure frequency. He states he’s had 4 tonic-clonic.
Mosby items and derived items © 2005, 2002 by Mosby, Inc. CHAPTER 13 Antiepileptic Agents.
Epilepsy Lecture Neuro Course 4th year. Objectives – To Review: What the term epilepsy means Basic mechanisms of epilepsy How seizures and epilepsies.
Mozhdehi panah.MD Neurologist  Definition  Etiology  Treatment  Complication.
Status Epilepticus Maria B. Weimer, MD LSUHSC Neurology.
Management. Goals of emergency management for status epilepticus Ensure adequate brain oxygenation and cardiorespiratory function Terminate clinical and.
Managing Seizure Patients in SE Following the Use of the Benzodiazepines.
Agents Used to Treat Seizures and Epilepsy Chapter 31.
Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 13 Antiepileptic Drugs.
Status epilepticus the paeds emerg perspective Stephen C. Porter MD MPH MSc Division Chief, Pediatric Emergency Medicine The Hospital for Sick Children.
First Line Therapy in Acute Seizure Management: Focusing on the Pediatric Patient William C. Dalsey, MD, FACEP, MBA Department of Emergency Medicine Robert.
Seizure Dr. Shreedhar Paudel May, Seizure….. A seizure is a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness.
The 30 minute definition It is a prolonged seizure that last more than 30 minutes, or Recurrent seizures during which the patient does not regain consciousness.
The term epilepsy refers to a group of disorders characterized by excessive excitability of neurons within the CNS. This abnormal activity can produce.
Status epilepticus PICU DIVISION.
Seizure Disorders Tiara Lintoco Batch 8. Seizure Disorders Seizures are symptoms of an abnormality in the nerve centers of the brain. Also known as convulsions,
Seizures LMH ER Rounds March 22, 2016 Prepared by Shane Barclay.
STATUS EPILEPTICUS STATUS EPILEPTICUS Time for a New Guideline for Management Prof Ashraf Abdou NEUROPSYCHIATRY DEPARTMENT FACULTY OF MEDICINE ALEXANDRIA.
Seizure / Epilepsy.
STATUS EPILEPTICUS (INVESTIGATION & MANAGEMENT)
Seizures in Childhood A seizure: is a transient occurrence of signs and/or symptoms resulting from abnormal excessive or synchronous neuronal activity.
Kaj Sep Nellie Mags STATUS EPILEPTICUS.
Neonatal Seizure.
Status epilepticus Dr Karen Goodfellow.
Status Epilepticus: Clinical Features, Pathophysiology, and Treatment
Prepared by Shane Barclay MD
TCA Poisoning.
Evaluation and Management of Pediatric Seizures
Presentation transcript:

General Anesthesia in Status Epilepticus Presented by R2 簡維宏 / VS 黃謙琳

Status Epilepticus continuous and rapidly repeating seizures medical emergency 102,000 to 152,000 cases per year in US and roughly 55,000 deaths associated with status epilepticus annually ~NEJM 1998; 338(14):

Definition (I) In 1962, Marseilles conference described status epilepticus as “enduring epileptic state”

Definition (II) In 1981, the International League against Epilepsy defined status epilepticus as a seizure that “persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur” ~Epilepsia 1981;22:

Definition (III) Status epilepticus as seizures that persist for 20 to 30 minutes, which is an estimate of the duration necessary to cause injury to central nervous system ~JAMA 1993;270:854-9

Definition (IV) Either continuous seizures lasting at least five minutes or two or more discrete seizures between which there is incomplete recovery of consciousness ~NEJM 1998; 338(14):

Clinical features (I) Loss of consciousness Clinically obvious seizures Duration Differential diagnosis with rigor due to sepsis, myoclonic jerking, generalized dystonia, and pseudostatus epilepticus ~NEJM 1998; 338(14):

Clinical features (II) Clinical manifestation often become subtle with time Electrographic status epilepticus: no observable, repetitive motor activity, and the detection of ongoing seizures requires electroencephalography Still at risk for CNS injury and require prompt treatment ~NEJM 1998; 338(14):

Etiology (I) Acute process 1. Electrolyte imbalance 2. Cerebrovascular accident 3. Cerebral trauma 4. Drug toxicity 5. Cerebral anoxic/hypoxic damage 6. CNS infection 7. Renal failure 8. Sepsis syndrome ~Anaestthesia 2001;56:

Etiology (II) Chronic process 1. Pre-existing epilepsy 2. Poor anticonvulsant drug compliance or change of anticonvulsant therapy 3. Chronic alcoholism 4. Cerebral tumors or other space- occupying lesion ~Anaestthesia 2001;56:

Pathophysiology (I) Failure of mechanism that normally abort an isolated seizure Arise from abnormally persistent, excessive excitation or ineffective recruitment of inhibition ??? ~NEJM 1998; 338(14):

Pathophysiology (II) Status epilepticus lasting for minutes can cause cerebral damage Glutamate-mediated excitotoxicity Superimposition of systemic stress exacerbating the degree of neuronal injury e.g. hyperthermia, hypotension, hypoxia ~Arch Neurol 1973; 29: 82-7

Management (I) Initial care includes standard measures applicable to any acute medical emergency See Figure1. ~NEJM 1998; 338(14):

Management (II) Treatment should proceed of four fronts 1. Termination of status epilepticus 2. Prevention of recurrence 3. Management of potential precipitating causes 4. Management of complications and underlying conditions ~Epilepsia 1999; 40(suppl.1): s59-63

Principles of Drug Treatment (I) Drug of choice: Lorazepam (0.1mg/kg) Other drugs: 1. Phenobarbital (15mg/kg) 2. Diazepam (0.15mg/kg) and Phenytoin (18mg/kg) 3. Phenytoin (18mg/kg) only ~NEJM 1998; 339(12):

Principles of Drug Treatment (II) Successful rate: Overt SESubtle SE Lorazepam64.9%17.9% Phenobarbital58.2%24.2% Diazepam and Phenytoin 55.8%8.3% Phenytoin only43.6%7.7% ~NEJM 1998; 339(12):

Principles of Drug Treatment (III) Patients who did not respond to first-line agents 1. Response rate to second-line agents: 7% 2. Response rate to third-line agents: 2.3% Status epilepticus that does not respond to a benzodiazepine, phenytoin, or Phenobarbital is considered refractory and required more aggressive treatment

Treatment of Refractory Status Epilepticus (I) Continuous intravenous infusions with anesthetic doses of midazolam, propofol, or barbiturates Inhalation anesthetic gases ~Anaesthesia, 2001; 56:

Treatment of Refractory Status Epilepticus (II) Continuous EEG monitor should be available Electrophysiological end-point 1. burst suppression 2. isoelectric patterns ~Quarterly Journal of Medicine 1996;89:

Treatment of Refractory Status Epilepticus (III) Long acting anti-epileptic drug therapy should be maintained at the upper limit of the normal range Anesthetized duration to 96 hours 2. Gradually tapering and if seizure recur, then re- anesthetized ~current treatment options in neurology 1999;1:359-69

IV General anesthesia (I) Propofol 1-2mg/kg bolus followed 2-10mg/kg/hr Barbiturate-like and benzodiazepine-like effect at the GABA receptor and a potent anticonvulsant action at clinical dose Rapid clearance Metabolic acidosis and lipidemia Avoid rapid discontinuation ~Anaesthesia, 2001; 56:

IV General Anesthesia (II) Midazolam 0.2mg/kg bolus followed µg/kg/min Rapid clearance and less hypotensive effect than barbiturates Tachyphylaxis ~Anaesthesia, 2001; 56:

IV General Anesthesia (III) Barbiturates (Thiopental) 3-5mg/kg bolus followed 3-5mg/kg/hr Potential cerebral protective effects Accumulates in lipoid tissues during prolong infusions, resulting in delay recovery Severe hypotension requiring vasopressor therapy Potently immunosuppressive and prolonged use increase the risk of nosocomial infection ~Anaesthesia, 2001; 56:

Inhalation Anesthetic Gases Drugs of choice : Isoflurane N 2 O: single use can’t achieve enough anesthetic level and long term use causing bone marrow suppression Enflurane: lowering seizure activity Halothane: High anesthetic gas concentration is need and resulting in hemodynamic unstable and potential organ toxicity

Isoflurane (I) An effective, rapidly titratable anticonvulsant Invasive monitors such as: A-line, CVP Usually necessitates hemodynamic support with fluids and/or vasopressors ~Anesthesiology, 1989; 71(5):

Isoflurane (II) A clinical series result (nine patient) 1.Isoflurane administrated for 1-55 hours 2.8 of 11 occasions, seizures resumed upon discontinuation of isoflurane 3.6 of 9 patients died ~Anesthesiology, 1989; 71(5):

Isoflurane (III) Effects on pathogenetic process 1. Can isoflurane “control” seizures permanently or alter a seizure focus? 2. Temporarily attenuate activity of epileptic neural generators 3. No evidence that adverse neuropathologic processes were stopped ~Anesthesiology 1989; 71(5): ~Anesthesiology 1987; 67: A390

Isoflurane (IV) Earlier use of isoflurane, within 60 minutes “therapeutic window” proposed by Delgado-Esceuta et al. Early role of isoflurane 1.Advantage: Titratablility and reversibility 2.Lack of prospective study ~NEJM 1982; 306:

Outcomes (I) Overall mortality: approximately 20~25% Higher mortality rate group: 1.age over 60 year-old 2.patient with ECG change 3.more severe underlying brain damage and underlying disease ~Epilepsia 1992; 33 (suppl.4):s15-25

Outcome (II) 90% of patients with status epilepticus secondary to anti-epileptic drug withdrawal, alcohol or trauma have good outcomes 33% 0f patients with status epilepticus secondary to stoke or hypoxia have good outcome

Outcome (III) Uncontrolled status epilepticus lasting more than 1 hour  mortality rate 34.8% Seizures were terminated within 30 minutes  mortality rate 3.7% It is not clear whether the success of treatment was the cause or the effect of the better prognosis, or a combination of both ~Epilepsia 1992; 33 (suppl.4):s15-25