Risk of adverse events on epilepsy monitoring units: a survey of epilepsy professionals.

In 2008 a workgroup of health care professionals from the American Epilepsy Society (AES) was convened to address the lack of consensus regarding patient care in epilepsy monitoring units (EMUs). The group developed a questionnaire designed to identify the extent to which selected adverse events occurred in EMUs, and it was sent via email to all members of the AES. We asked that only one representative from each center report. Seventy responses were received. The number of centers reporting the following adverse events included: falls by 69%, status epilepticus by 63%, and postictal psychosis by 54%. Infrequent events with serious consequences were also reported including pneumonia by 10%, cardiac arrest by 7%, fractures by 6%, and death by 3% (N=2). Of the 58 respondents who reported using intracranial electrodes, 37.9% (N=22) reported that patients pulled out or dislodged electrodes. This study highlights the need for EMUs to identify and address potential safety risks in their environment, patient population, and system of care.

Practice parameter update: management issues for women with epilepsy--focus on pregnancy (an evidence-based review): vitamin K, folic acid, blood levels, and breastfeeding: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society.

OBJECTIVE: To reassess the evidence for management issues related to the care of women with epilepsy (WWE) during pregnancy, including preconceptional folic acid use, prenatal vitamin K use, risk of hemorrhagic disease of the newborn, clinical implications of placental and breast milk transfer of antiepileptic drugs (AEDs), risks of breastfeeding, and change in AED levels during pregnancy. METHODS: A 20-member committee evaluated the available evidence based on a structured literature review and classification of relevant articles published between 1985 and October 2007. RESULTS: Preconceptional folic acid supplementation is possibly effective in preventing major congenital malformations in the newborns of WWE taking AEDs. There is inadequate evidence to determine if the newborns of WWE taking AEDs have a substantially increased risk of hemorrhagic complications. Primidone and levetiracetam probably transfer into breast milk in amounts that may be clinically important. Valproate, phenobarbital, phenytoin, and carbamazepine probably are not transferred into breast milk in clinically important amounts. Pregnancy probably causes an increase in the clearance and a decrease in the concentration of lamotrigine, phenytoin, and to a lesser extent carbamazepine, and possibly decreases the level of levetiracetam and the active oxcarbazepine metabolite, the monohydroxy derivative. RECOMMENDATIONS: Supplementing women with epilepsy with at least 0.4 mg of folic acid before they become pregnant may be considered (Level C). Monitoring of lamotrigine, carbamazepine, and phenytoin levels during pregnancy should be considered (Level B) and monitoring of levetiracetam and oxcarbazepine (as monohydroxy derivative) levels may be considered (Level C). A paucity of evidence limited the strength of many recommendations.

Health issues for women with epilepsy: a descriptive survey to assess knowledge and awareness among healthcare providers.

The American Academy of Neurology and the American College of Obstetricians and Gynecologists recently issued practice parameters for women with epilepsy. These parameters suggest optimal care practices. To assess knowledge of the issues covered in the parameters and to facilitate educational efforts to promote best care, the Epilepsy Foundation conducted a survey of healthcare professionals likely to provide care to women with epilepsy. The survey sampled 3535 healthcare professionals across a wide range of specialties. Most respondents did not know the specific effects of estrogen and progesterone on the seizure threshold, were not aware of menstrual-associated seizure patterns, and could not identify which antiepileptic drugs interfere with oral contraceptives. The majority of respondents did not know that women with epilepsy have higher rates of infertility, reproductive endocrine disorders, and sexual dysfunction. Most respondents did not know the frequency of birth defects in children born to women with epilepsy. Providers seeing the largest number of persons with epilepsy were more likely to have correct answers. By specialty, neurologists provided the highest number of correct responses, followed (in descending order) by endocrinologists, obstetricians/gynecologists, internal medicine physicians, family practice physicians, and pediatricians. These results suggest that women with epilepsy are not receiving adequate counseling and that care practices may not conform to those recommended.

New therapies in the management of acute or cluster seizures and seizure emergencies.

Acute repetitive seizures, also known as cluster or serial seizures, may present considerable health risks, including death, to patients with epilepsy and often are a cause of psychosocial stigma. Fortunately, new formulations and drug-delivery systems approved by the Food and Drug Administration (FDA) over the past 5 years offer patients and health care providers greater control over acute repetitive seizures and emergency situations. Drugs that can be given intravenously, such as diazepam, phenytoin and valproate sodium solution, typically have the most rapid onset but are limited to use in clinical settings by health care professionals authorized to use them. In contrast, diazepam rectal gel can be administered to patients by their caregivers or family members in the home or in other non-hospital settings. Studies have shown that rectal diazepam used in such settings can reduce the number of emergency room visits, costs associated with emergent care and stress on the patient and family. Health education is necessary to help patients and families understand new treatment options and use them successfully. Additionally, facilitating patient compliance with prescribed treatment regimens may reduce the frequency and consequences of seizure emergencies.

Epilepsy and seizures: advances in seizure assessment, treatment, and self-management.

The scope of providing care for people with epilepsy and seizures has expanded dramatically in recent years. The tremendous growth in our understanding, along with new and innovative treatment options has increased the likelihood of seizure control and improved quality of life for many people. The ability to more accurately diagnose seizures will be enhanced by new seizure assessment guidelines. A fuller appreciation of the patient's perspective will aid nurses in their support of self-management practices. The new millennium will challenge nurses to enhance self-management education in more diverse practice settings, geographical areas, and patient populations.

Counseling women with epilepsy.

All persons with epilepsy have a right to timely, accurate, culturally sensitive information that will help them manage their seizures and their lives successfully. The goals of counseling are to provide guidance for women with epilepsy in making informed choices, to promote self-management practices that will decrease health risks, and to provide comprehensive answers about relevant issues. Four broad areas that should be covered in counseling women with epilepsy include access to care, unique health needs of women with epilepsy, personal care and safety, and social and community relationships. These are described here in more detail.

Hormone-sensitive seizures in women with epilepsy.

Until the associations between seizures and hormones are better understood, finding appropriate therapies for hormone-sensitive seizures remains problematic. Most importantly, women with epilepsy need information about the complex interactions of brain function, hormones, seizures, and medications. Nurses can educate women concerning the hormonal aspects of epilepsy and methods of assessing seizures in relation to menstrual patterns. Nurses can also serve as patient advocates, ensuring that their patients are heard, and that they have access to appropriate care and are informed about therapeutic options that can improve seizure control and quality of life.

Nursing support of epilepsy self-management.

Self-management techniques for epilepsy can encompass any treatment or behavior that may enhance seizure control, minimize side effects and risks, promote adaptation, and enhance quality of life. Nursing support of self-management involves assessing a variety of factors, but, ultimately, nurses' promotion of responsibility and their offer of support and care may make the most difference in the success of any self-management approach.

When a parent has epilepsy.

I have just ended year one of being a parent. Though I have presented many difficulties of being a parent with epilepsy, there are many more joys. The most important thing for nurses to remember is that a person with epilepsy can become a parent, often without difficulty. For others, living with epilepsy will pose special concerns or problems that may complicate the parenting role.