04105--Guidelines for Anesthesia and Surgery in People with Epilepsy

Guidelines For Anesthesia and Surgery in People with Epilepsy

Antiepileptic drugs (AEDs) cause unique considerations for people with epilepsy because skipping, or even delaying, a single dose can result in seizures. Strategies for avoiding or minimizing skipped doses is important for people diagnosed with epilepsy.

•   AEDs should be taken early in the morning before surgery. For surgical procedures, it is important that your stomach be so you may be instructed to not eat or drink after midnight. However, tell your doctor that you take seizure medications. Your doctor will probably advise you to take your AEDs 2 hours before surgery with a very small amount of water (1 ounce). The timing when to take your medication can be more complicated for patients who must take medications with applesauce or similar solids. In this case, the medication can be administered 6 hours (or as early as possible) before surgery. In this case, later medication doses still should be given as close to on-time as possible. Discuss the timing of taking your AEDs with your surgeon and anesthesiologist.

•   If you have missed doses of AEDs then seizures may emerge when anesthesia wears off. There is little risk of seizures during general anesthesia because anesthetic medications reduces 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 seizures when waking up form anesthesia if your AEDs have been taken.

•   If even a single AED dose cannot be given orally then the AED 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. AEDs that are available in intravenous (IV) form include phenytoin (Dilantin^®), levetiracetam (Keppra^®), lacosamide (Vimpat^®), valproate (Depakote^®), and phenobarbital. AEDs 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 AEDs 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 AEDs for prolonged periods, e.g., in the ICU or after stomach surgery.  Switching to an AED that is available in IV form is the simplest solution. For some epilepsy patients, only their unique combination of AEDs will prevent their seizures. For these people, their AEDs must be given if they will miss more than 2 doses of their usual AEDs. If their usual AEDs are not available in IV form, then alternative methods of administration include through an NG tube or giving oral formulations per rectum.