04105 Guidelines for Anesthesia and Surgery in People with Epilepsy

Guidelines For Anesthesia and Procedures in People with Epilepsy

For people with epilepsy, skipping or even delaying a single dose of anti-seizure medications can result in seizures. Avoiding or minimizing skipped doses is important for people with epilepsy.
 

•    Seizure medications should be taken the night before and early in the morning before a colonoscopy. Patients are typically given instructions for a “bowel prep” starting the night before their colonoscopy, which involves frequent intake of laxatives the night before and morning of your colonoscopy, often starting at about 6 pm.

•    Seizure medications should be taken early in the morning before surgery. Patients are usually instructed not to eat or drink after a certain time so their stomach will be empty during surgery. Tell your doctor or surgery team that you take seizure medications. Your doctor will probably advise you to take your seizure medications with a very small amount of water (1 ounce). The timing of medication administration is more complicated for patients who much take medications with applesauce or similar solids. In this case, the medication can be given 6 hours (or as early as possible) before surgery; however, the next dose must still be given as close to on-time as possible. Thus, the risk of seizures if the medication is not given must be weighed against the risk of aspiration if pills are given close to surgery. Discuss the timing of taking your seizure medications with your surgeon and anesthesiologist.

•    If you have missed doses of seizure medications, seizures may happen when anesthesia wears off. There is little risk of seizures during general anesthesia because anesthetic medications reduce the hyperactive brain activity causing seizures. Sevoflurane—a type of anesthesia—is typically avoided as it can sometimes cause seizures. There is no increased risk of having a seizure when waking up from anesthesia if your seizure medications have been taken.

•    If even a single dose of seizure medication cannot be given orally then the medication should be given by another route. This may occur because you are under anesthesia during prolonged surgery or you are unable to swallow in the post-operative period. Seizure medications that are available in intravenous (IV) form include phenytoin (Dilantin^®), levetiracetam (Keppra^®), lacosamide (Vimpat^®), valproate (Depakote^®), and phenobarbital. Seizure medications that are not available in IV formulation include carbamazepine (Tegretol^®), oxcarbazepine (Trileptal^®), topiramate (Topamax^®), and lamotrigine (Lamictal^®).

•    Lorazepam (Ativan^®) or another similar drug called a “benzodiazepine” is usually administered on a standing basis if a person with epilepsy can’t be given their usual seizure medications by the IV route. It must be administered at the time their usual AED would be given or at the end of general anesthesia. IV doses of benzodiazepines should not be delayed until seizures occur because it is then too late to prevent the seizure.

•    There are times when patients cannot take their seizure medications for prolonged periods, e.g., in the ICU or after stomach surgery.  Switching to a seizure medication that is available in IV form is the simplest solution. For some epilepsy patients, only their unique combination of seizure medications will prevent their seizures. For these people, it is important that their medications be given. If they miss more than 2 doses of their usual medications, then an IV medication must be given. If their usual medications are not available in IV form, then alternative methods of administration include through an NG tube or giving oral formulations per rectum.