Psychogenic non-epileptic seizures in the post-anesthesia recovery unit

Abstract

Psychogenic non-epileptic seizures mimic shivering, and should be considered early in the differential diagnosis of postoperative shaking, as they may be more likely than epilepsy in this setting. Pseudoseizure patterns include asynchronous convulsive episodes lasting more than 90s, forced eye closure with resistance to opening, and retained pupillary responses. Autonomic manifestations such as tachycardia, cyanosis and incontinence are usually absent. A psychiatric background is common. Knowledge and correct diagnosis of pseudoseizures is of great importance for anesthesiologists to prevent morbidity and iatrogenic injury such as respiratory arrest caused by anticonvulsant therapy, in addition to the risks associated with endotracheal intubation and prolonged hospital stays. The diagnosis of pseudoseizures must be thoroughly documented and relayed in transfer of care to avoid misdiagnosis and iatrogenic complications. Treatment recommendations are anecdotal; psychiatric interventions are the hallmark of treatment. Anesthetic recommendations include techniques involving the minimum required short-acting agents, along with high levels of peri-operative psychological support and reassurance.

Seizure following general anesthesia for cystoscopy and urethral dilatation: A case report

“…Ramos et al . [ 9 ] mentioned that psychogenic non-epileptic seizures (PNES or “pseudo-seizures”) remain an obscure topic in the peri-operative setting. A sudden and time-limited motor and cognitive disturbances, which mimic epileptic seizures, are psychogenically mediated.…”

Post-operative functional neurological symptom disorder after anesthesia

“…Our search strategy identified 38 previously reported cases of PNES, psychogenic coma, or conversion paralysis in the immediate post-anesthesia period [6,8,. The largest case series was published by Reuber et al in 2000 that described six cases of post-operative PNES that had been misdiagnosed previously with epilepsy and treated chronically with anticonvulsants [10].…”

“…Symptoms include abnormal body movements that are waxing and waning typically for a prolonged duration, closed eyes with resistance to eye-opening, positive response to noxious stimuli, and gradual onset of symptoms with abrupt recovery [5]. Releasing the patient' s arm over the face will typically show purposeful arm movement by the patient to protect the face [6]. There is resistance to anti-epileptic medication and after organic causes for seizures have been excluded, treatment is primarily psychiatric care including cognitive behavioral therapy (CBT) and potentially adjunctive medications.…”

“…These atypical post-anesthetic manifestations remain an obscure topic in the peri-operative setting, and early diagnosis may help prevent iatrogenic injury [6]. The use of hypnotics and anticonvulsants may hinder diagnosis, prolong anesthetic recovery, and importantly introduce potential side effects from unnecessary medications [10].…”