RevBrasAnestesiol.2016;66(4):426---429
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Psychogenic
non-epileptic
seizures
in
the
post-anesthesia
recovery
unit
Juan
A.
Ramos
∗,
Sorin
J.
Brull
DepartmentofAnesthesiology,MayoClinic,Jacksonville,FL,UnitedStates
Received22August2013;accepted17October2013 Availableonline11November2013
KEYWORDS
Convulsion; Non-epileptic; Complications; Anestheticanesthesia recoveryperiod; Recoveryroom pseudoseizures; Postoperative
Abstract
Introduction:Psychogenic non-epileptic seizures (PNES or ‘‘pseudoseizures’’) remain an obscure topic in the peri-operative setting. They are sudden and time-limited motor and cognitivedisturbances,whichmimicepilepticseizures,butarepsychogenicallymediated. Pseu-doseizuresoccurmorefrequentlythanepilepsyintheperi-operativesetting.Early diagnosis andmanagementmaypreventiatrogenicinjury.
Case:48year-oldfemalewithahistoryofdepressionand‘‘seizures’’presentedforgynecologic surgery.Shedescribedherseizurehistoryas‘‘controlled’’withoutanticonvulsanttherapy.The patientunderwentuneventfulgeneralanesthesiaandrecoveredneurologicallyintact.During thefirsttwopostoperativehours,thepatientexperienced3episodesofseizure-likeactivity withgeneralizedshakingofextremitiesandpelvicthrusting;hereyeswerefirmlyclosed.No tonguebitingorincontinencewasnoted.Theepisodeslastedapproximately3mineach,oneof whichresolvedspontaneouslyandtheothertwofollowingintravenouslorazepam.Duringthese episodes,thepatienthadstablehemodynamicsandadequateventilationsuchthat endotra-chealintubationwasdeemedunwarranted.Post-ictally,thepatientwasneurologicallyintact. Computedaxialtomographyofthehead,metabolicassay,andelectroencephalogramshowed noabnormalities.ApresumptivediagnosisofPNESwasmade.
Discussion: Psychogenicnon-epilepticseizuresmimicshivering,andshouldbeconsideredearly inthedifferentialdiagnosisofpostoperativeshaking,astheymaybemorelikelythanepilepsy inthissetting.Pseudoseizurepatternsincludeasynchronousconvulsiveepisodeslastingmore than90s,forcedeye closurewith resistanceto opening, andretained pupillaryresponses. Autonomicmanifestationssuchastachycardia,cyanosisandincontinenceareusuallyabsent.
∗Correspondingauthor.
E-mail:juanramos66@hotmail.com(J.A.Ramos).
http://dx.doi.org/10.1016/j.bjane.2013.10.005
Psychogenicnon-epilepticseizuresinthepost-anesthesiarecoveryunit 427
A psychiatric backgroundiscommon.Knowledge andcorrect diagnosis ofpseudoseizures is ofgreatimportanceforanesthesiologiststopreventmorbidityandiatrogenicinjurysuch as respiratory arrestcausedbyanticonvulsant therapy,inadditiontotherisks associatedwith endotrachealintubationandprolongedhospitalstays.Thediagnosisofpseudoseizuresmustbe thoroughlydocumentedandrelayedintransferofcaretoavoid misdiagnosisandiatrogenic complications. Treatmentrecommendationsareanecdotal;psychiatricinterventionsarethe hallmarkoftreatment.Anestheticrecommendationsincludetechniquesinvolvingtheminimum requiredshort-actingagents,alongwithhighlevelsofperi-operativepsychologicalsupportand reassurance.
©2013SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense(
http://creativecommons.org/licenses/by-nc-nd/4.0/).
PALAVRAS-CHAVE
Convulsões; Sintomas
Comportamentais; Períodode Recuperac¸ãoda Anestesia; Complicac¸ões Pós-Operatórias
Convulsõesnãoepilépticaspsicogênicasemsaladerecuperac¸ãopós-anestésica
Resumo
Introduc¸ão: Asconvulsõesnão epilépticas psicogênicas(CNEP ou‘‘pseudoconvulsões’’) per-manecem como tema obscuro no cenário perioperatório. Trata-se de distúrbios motores e cognitivossúbitos,masportempolimitado,queimitamasconvulsõesepilépticas,masquesão psicogenicamentemediados.Pseudoconvulsõesocorremcommaisfrequênciaqueepilepsiaem cenárioperioperatório.Odiagnósticoetratamentoprecocespodemevitarlesõesiatrogênicas.
Caso: Pacientedosexofeminino,48anosdeidade,comhistóriadedepressãoe‘‘convulsões’’, apresentou-se para cirurgia ginecológica. A paciente descreveu sua história de convulsões ‘‘controladas’’semousodeterapiaanticonvulsivante.Apacientefoisubmetidaàanestesia geralsemintercorrênciaserecuperou-seneurologicamenteintacta.Duranteasduasprimeiras horasdepós-operatório,apacienteapresentoutrêsepisódiossemelhantesàconvulsão,com tremoresgeneralizadosdasextremidadeseimpulsopélvico;seusolhosestavambemfechados. Nãoobservamosmordeduradalínguaouincontinência.Osepisódiosduraramcercade3min cada; umdosepisódios resolveuespontaneamente eosoutrosdoisapósaadministrac¸ãode lorazepam porviaintravenosa.Duranteosepisódios,acondic¸ãohemodinâmicadapaciente eraestáveleaventilac¸ãoadequada,demodoqueaintubac¸ãotraquealfoiconsiderada injus-tificável.Apósaconvulsão,apacienteestavaneurologicamenteintacta.Tomografiaaxialda cabec¸a,testemetabólicoeeletroencefalogramanãomostraramalterac¸ões.Odiagnósticode provávelCNEPfoifeito.
Discussão: Asconvulsões nãoepilépticas psicogênicas imitamotremor edevem ser inicial-menteconsideradasnodiagnósticodiferencialdetremorpós-operatório,poispodemsermais prováveis quea epilepsianesse cenário. Ospadrões dapseudoconvulsãoincluem episódios convulsivosassíncronos quedurammaisde90s,olhosforc¸adamentefechadoscom resistên-ciaàaberturaerespostaspupilaresmantidas.Manifestac¸õesautonômicas,comotaquicardia, cianose eincontinência, normalmenteestão ausentes. Uma históriapsiquiátrica é comum. O conhecimento e o diagnóstico correto de pseudoconvulsões são muito importantes para os anestesiologistas para aprevenc¸ão de morbidade e lesões iatrogênicas, como a parada respiratóriacausadaporterapiaanticonvulsivante,alémdosriscosassociadosàintubac¸ão oro-traquealeinternac¸ãoprolongada.Odiagnósticodepseudoconvulsõesdevesercuidadosamente documentadoeretransmitidonastrocasdeequipesmédicasparaevitarerrosdediagnóstico ecomplicac¸õesiatrogênicas.Asrecomendac¸õesdetratamentosãoanedóticas;intervenc¸ões psiquiátricassãoopilardotratamento.Asrecomendac¸ões anestésicasincluemtécnicasque envolvem ousode agentesdeac¸ãocurta,juntamentecomaltos níveis deapoioe amparo psicológiconoperíodoperioperatório.
© 2013 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. Este é um artigo Open Access sob a licença de CC BY-NC-ND (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Introduction
Psychogenic non-epileptic seizures (PNES), also known as pseudoseizures, are a well-known entity in the neurolog-ical literature; however, theyremain an obscure topicin
428 J.A.Ramos,S.J.Brull
psychogenically mediated.1,2 They should be considered earlyinthedifferentialdiagnosisofpostoperativeshaking, aspostoperativeseizuresarerareevents3,4;thismakesPNES more likelythan epilepsyin this setting.3 Early diagnosis andmanagementmaypreventmorbidityfrominappropriate treatmentandresourcemisuseinthesepatients.
We present a case of seizure activity in the post-anesthesiacareunit(PACU)diagnosedsubsequentlyasPNES.
Case
report
A48year-oldfemalewithapastmedicalhistorysignificant for urinary incontinence, depression, chronic migraines, asthma,kidneycancer(s/pnephrectomy)andaremote his-toryof‘‘seizures’’presentedforaurinaryslingimplantation procedure. On further questioning, the patient described herseizurehistoryas‘‘resolved’’andnotwarranting anti-convulsanttherapy;thelastepisodewasmorethan3years before.Thepatientunderwentuneventfulgeneral anesthe-siathatwasinducedwithpropofol,fentanylandmidazolam (aspremedication)andwasmaintainedwithsevoflurane.An uneventfulsurgery wasfollowed by successfulemergence andtrachealextubation,afterwhichthepatientwas trans-ferredtothePACUwithoutcomplicationsandneurologically intact.
Duringthesubsequent2hinthePACU,thepatient experi-enced3episodesofseizure-likeactivity.Thesespellsstarted asgeneralizedshakingofallextremities,thepatient’shead andpelvicthrusting,witheyesfirmlyclosed.Notongue bit-ingand/or bowelor bladderincontinencewasnoted.The episodes lasted approximately 3min each, one of which resolvedspontaneouslyandtheothertwoafterthe admin-istration of 2mg of intravenous lorazepam. During the entire PACU stay, the patient had stable hemodynamics and adequate ventilation/oxygenation such that endotra-chealintubationwasdeemedunwarranted.Post-ictally,the patient’sneurologicstatusimprovedslowlyandreturnedto baseline.Aneurologist wasconsulted,whorecommended computedaxialtomography ofthehead, metabolicassay, and electroencephalogram (EEG); all tests were negative andshowednoabnormalities. A thoroughchartreview of thepatientrevealed prior EEGtesting withnormal brain-wave activity in the setting of 4 ‘‘seizure spells.’’ The patienthadalsobeen worked-upinthe pastfor transient neurologicdeficitsofunknownetiology,suggesting somato-formdisorder.Afterdiscussionwiththeneurologyteamas wellasthepatient’sownneurologist,thediagnosisofPNES wasmade.The remainderof thepatient’shospitalcourse wasuneventfulandshewasdischargedhomethefollowing day.
Discussion
Generalized shaking in the post-operative period is most commonlydue toshivering,and mayor maynot be ther-moregulatoryin origin.5Non-thermoregulatoryshiveringis thoughttobesecondarytotheeffectsofvolatile anesthet-ics,painorboth.6Postoperativeseizuresarerareeventsand thusareaninfrequentcauseofgeneralizedpost-operative shaking.Whentheydooccur,theyaregenerallyattributable to an identifiable drug reaction, metabolic disorder, or
neurologicalevent,havingthehighestincidenceinthe neu-rosurgicalpopulation.3
PNES(alsoreferredtoas‘‘pseudoseizures’’)mimic shiv-ering,andtheyshouldbeconsideredearlyinthedifferential diagnosis of postoperative shaking, as they may be more likelytooccurthanepilepsyinthepostoperativesetting.3 First described in the PACU by Parry and Hirsch,7 these attacksresemblegrandmalspellsbutlackabnormal elec-tricaldischargesonEEG.TheprevalenceofPNEShasbeen estimated to bebetween 2 and 33 per 100,000.8 In fact, among patients referred to outpatient epilepsy centers, between 5 and25 percentare likelytohave PNES,while 25---40 percentof patients evaluatedin inpatientepilepsy monitoringunitsforintractableseizuresareultimately diag-nosedwithPNES.1
Ingeneral,PNEStendtofollowcertainpatterns, which include: extravagant convulsive episodes that last longer than 90s withasynchronous limb movement, side-to-side headmovement,forcedeyeclosurewithresistancetoeye opening, and retained pupillary responses.1,3 Autonomic manifestations such as tachycardia, cyanosis and inconti-nenceareusuallyabsent.Recallofeventsduringtheictus, ictalstuttering,vocalizationsandlacrimationarerelatively uncommoninepilepticseizures,andsuggestPNES.A back-groundofpsychiatricdisordersiscommonandmayinclude depression,anxiety,somatoformdisorder, borderline, nar-cissistic and histrionic personality disorders, aswell as a historyofsexualand/orphysical abuse.1 Inonestudy,the occurrenceofanepisodeinthedoctor’swaitingor exami-nationroomwasestimatedtohavea75percentpredictive value for PNES.9 The diagnosis of PNES is one of exclu-sion, andthe gold standard diagnostic toolappears tobe simultaneousrecording ofseizures onvideo tapeandEEG recording.10
KnowledgeofPNESisofgreatrelevancefor anesthesiol-ogiststopreventmorbidityandiatrogenicinjury.Onestudy thatfollowed13PNESpatientsforover4yearsdocumented eightepisodesofrespiratory arrestcausedby intravenous anticonvulsant therapy administered on the presumptive diagnosisofseizures.11Additionally,othermorbiditymaybe encountered from endotracheal intubation and prolonged hospital stays. The diagnosis of PNES must bethoroughly documentedand relayedin transferof care toavoid sub-sequentcomplications.MultiplePNESepisodesthatfollow general anesthesiawarrant further evaluation and exclu-sionofotherdiagnoses.Inambiguouscases,apre-operative neurologicalevaluationmaywellbeindicated.
TreatmentrecommendationsforPNESaremostlybased upon anecdotal experienceor small case series;however, psychiatric interventions are the hallmark of treatment. Theseshouldbeindividualizedaccordingtotheunderlying psychiatricdisorder; a commonintervention is traditional psychotherapy.12 Anesthetic recommendations arescarce, butincludetechniquesinvolvingonlytheminimumrequired quantitiesofpreferablyshort-actingagents,alongwithhigh levels of peri-operative psychological support, and most importantly,constantreassuranceforthesepatients.3
Conflicts
of
interest
Psychogenicnon-epilepticseizuresinthepost-anesthesiarecoveryunit 429
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