Discharging epilepsy patients

[iBS1972]

A patient with recurrent epilepsy is admitted. He is compliant with medications and has been seeing a great outpatient epitologist. Yet, he still gets on average 1 partial complex seizure a month over the past couple years (this is an improvement); he also had had one GTC seizure about half a year ago. He is now admitted because of status epilepticus. (He is currently in process of being worked up for surgical intervention with implantable device).

When do you discharge him? Do you Change his meds? (or let OP follow up appointment manage it)? Do you do anything else besides monitoring him IP? How would you feel if you were to get this patient, and how would you feel discharging him (going with the assumption that you defer med changes to OP)?

I wish I had asked these questions when I had the patient on my service, but questions often come to me after (sometimes long after) the situation has passed. I would appreciate any input. Note: I'm asking because I'm considering neurology, and since seizure is one of the most common diagnosis for admission and it is also often incurable, I was hoping to see how neurologists approach these kinds of patients.

Thanks!

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[oopsy]

A patient with recurrent epilepsy is admitted. He is compliant with medications and has been seeing a great outpatient epitologist. Yet, he still gets on average 1 partial complex seizure a month over the past couple years (this is an improvement); he also had had one GTC seizure about half a year ago. He is now admitted because of status epilepticus. (He is currently in process of being worked up for surgical intervention with implantable device).

When do you discharge him? Do you Change his meds? (or let OP follow up appointment manage it)? Do you do anything else besides monitoring him IP? How would you feel if you were to get this patient, and how would you feel discharging him (going with the assumption that you defer med changes to OP)?

I wish I had asked these questions when I had the patient on my service, but questions often come to me after (sometimes long after) the situation has passed. I would appreciate any input. Note: I'm asking because I'm considering neurology, and since seizure is one of the most common diagnosis for admission and it is also often incurable, I was hoping to see how neurologists approach these kinds of patients.

Thanks!

Seizure is definitely not incurable, at least if you mean lack of control. Epilepsy patients generally do extremely well. There are patients with refractory seizures that are tough, moreso in the pediatric world, but nevertheless, challenging patients abound in all specialties. There are many parts of neurology to pick on regarding limited therapeutic potential. Epilepsy is not one of them. I say this with exactly zero interest in epilepsy.

You would definitely changes his medications if he/she is status. Those drugs would be hard to pull off once you got control, and would be done slowly and carefully. I would discharge him when he is medically stable, not seizing, tolerating AEDs well, and moving in the right direction. In complicated epilepsy patients, its best practice to speak with the primary neurologist first since they've probably tried quite a bit with them, and they know more about them than you do. In the absence thereof, you're the doctor, you make the prescribing decision. Finally, unless the patient is refractory to medications, I wouldn't accept 1 partial complex seizure a month. In most states, that means they can't drive. Most people would push harder until they've proven to themselves they can't get better control than this without totally zonking him out.

 

[Neurologo]

When do you discharge him? Do you Change his meds? (or let OP follow up appointment manage it)? Do you do anything else besides monitoring him IP? How would you feel if you were to get this patient, and how would you feel discharging him (going with the assumption that you defer med changes to OP)?

You can read a latest review article on management of status epilepticus. Epileptologists here would be the best to answer but here is what I typically do:
- Home AED should be continued and increased in dosage rather than switching cold turkey. But this should be discussed with his/her neurologist.
- Try benzos first before IV AED loading.
- Intubation usually occurs when addition of 2 IV AEDs loading fail or when vitals unstable.
- Depending on the severity and duration of the status, you add upto total of 3 AEDs in tandem and 1-2 IV anesthetics. Having 4 AEDs has no proven benefit. Anesthetic use should be the last resort due to some association with increased mortality.
- Find out the cause of the status (noncompliance, infections, etc.).
- for refractory status, you may need to induce "burst-suppression" or "suppression" state.
- Slowly wean IV anesthetics (about 10% per hour) once seizure free state achieved on continuous EEG for 24-48 hrs.
- Discharge on 2-3 AEDs which would be continued for at least 3-6 months before attempting to wean further.