1. Not So Grand: A Postoperative Seizure
From the Publishers of
Consult Guys
Not So Grand:
A Postoperative Seizure
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3. PMHx: BPH, no seizure history Meds: tramadol 1 tab, Q6hrs PSHx: none
Dear Howard and Geno,
I need some quick advice about a patient that I was asked to see this morning. I am with him right now in the ICU. He had a grand mal seizure 24 hours following knee surgery and I am not sure what the next step is. Here goes.
The patient is a 58-year-old man with right knee degenerative arthritis secondary past traumatic injury. He has significant pain with weight bearing which has limited his functional status and work as stone mason. He has been in relatively good health.
PMHx: BPH, no seizure history
Meds: tramadol 1 tab, Q6hrs
PSHx: none
SHx: non-smoker, has 4 to 5 drinks (scotch) 3 to 4 days per week which has helped with his knee pain. He has never been intoxicated.
FHx: negative
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4. Preoperative Physical Exam
BP 122/70, P 78, R 12, Wt 72kg, BMI 28, POx 98%
Patient is a 58-year-old, well nourished, white, male
Lungs are clear
Heart regular rhythm, S1 and S2 normal, no murmurs
Abdomen soft , active bowel sounds, no organomegaly
Right knee with effusion and painful on ROM
Pulses + 2 bilaterally
Neuro without focal signs
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5. Postoperative Course
10/12/16, hours: Total knee arthroplasty. No complications. Vital signs stable during surgery and during the postop period.
10/13/16, hours: Patient complained of nausea and feeling nervous. The orthopedic resident evaluated the patient.
BP 160/90, P 110/min, R 18, T 98.6, POx 94%
Patient was noted to be tremulous, diaphoretic.
No cardiac murmurs, clear lungs, no focal neurologic signs but mild tremor, very anxious
Right leg ACE wrapped
Wearing bilateral IPC sleeves and apixaban ordered 2.5 mg, BID to start at 0800 hours
CXR normal, ECG: sinus tachycardia(110)- otherwise normal
CBC Hg 12.8/ Hct 37, WBC 7, Troponins normal, glucose 90, Magnesium, electrolytes normal, Cr 0.9, BUN 20
CTA Chest negative for PE
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6. The Case
10/13/16, 0800 hours: Patient has grand mal seizure. An RRT is called and the patient is transferred to the Neuro-ICU.
He is started on levetiracetam 500mg, IV, Q12hours
Head CT negative, EEG scheduled. BP 168/100, P 110, R 18, T 99.8, POx 96
Patient not oriented, agitated and placed in restraints
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7. First Seizure in Adults
Stroke
Traumatic brain injury
Meningitis
Anoxic encephalopathy
Massive pulmonary embolism
Seizure associated in less than 1% of cases
Metabolic
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8. First Seizure in Adults
Metabolic causes of seizure in the postoperative period
Hypoglycemia – not present
Non-ketotic hyperosmolar coma – he is not diabetic
Hyponatremia – not present
Hypocalcemia- consider following thyroid or parathyroid surgery
Hypomagnesemia – not present
Acute renal failure – not present
Withdrawal syndromes
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9. CAGE Criteria
1. Have you ever felt you should Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt bad or Guilty about your drinking?
4. Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?
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10. AUDIT-C screening results could be used to identify patients at risk
for increased postoperative health care use who might benefit from
preoperative alcohol interventions.
Highest AUDIT-C scores 9 to 12
1. Longer postop hospital LOS 5.8 vs 5.0 days
2. More ICU days 4.5 vs 2.8 days
3. Increase return to the operating room 10% vs 5% in the 30 days after surgery
Rubinsky AD, Sun H, Blough DK, Maynard C, Bryson CL, Harris AH, et al. AUDIT-C alcohol screening results and postoperative inpatient health care use. J Am Coll Surg. 2012;214: e1. [PMID: ] doi: /j.jamcollsurg

11. Results: AUDIT-C score;
Scores ≥5 were associated increased risk of complication(s)
Scores ≥9 with increased hospital LOS and ICU days.
Rubinsky AD, Bishop MJ, Maynard C, Henderson WG, Hawn MT, Harris AH, et al. Postoperative risks associated with alcohol screening depend on
documented drinking at the time of surgery. Drug Alcohol Depend. 2013;132: [PMID: ] doi: /j.drugalcdep

12. The Case
Postop Approx 17 hours.: Nausea + Vomiting, Tachycardia, Hypertension, Tachypnea
Postop 24 hours: Seizure, Hypertension, Tachycardia, Tachypnea, Agitated, confused, hallucinations
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13. Summary Recommendations
Patients with unhealthy alcohol use face multiple risks in the perioperative period.
Patients frequent heavy alcohol use have additional risk of physiologic dependence and withdrawal.
All preoperative patients should be assessed for quantity, frequency, and last dose of alcohol use and screening with AUDIT-C.
Patients who screen positive for unhealthy alcohol use should have CBC, LFTS, PT and PTT completed.
Perioperative monitoring for alcohol withdrawal.
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14. Summary Recommendations
We suggest that patients whose need for surgery is not urgent be treated for unhealthy alcohol use prior to rather than subsequent to surgery [Grade 2B].
For patients with known or suspected frequent heavy drinking who do not cease or reduce alcohol use and have not yet experienced withdrawal symptoms, prophylactic benzodiazepine to prevent withdrawal.
Rx with multivitamins and thiamine to prevent stress-induced Wernicke-Korsakoff syndrome.
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15. Our Case
Patients with heavy alcohol abuse need to have a thorough history (AUDIT C)
Postpone surgery if patients is positive for AUDIT C history
If patient goes to surgery with little or no history, should be treated with benzodiazepine, thiamine and multivitamins
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