Anesthetic management of a patient with Lennox-Gastaut syndrome with intractable epilepsy -a case report-
The patient was a 34-month-old girl with a height of 90 cm and weight of 12.5 kg who was diagnosed with Lennox-Gastaut syndrome who was scheduled for surgical treatment of a lower lid epiblepharon. She was born by normal spontaneous vaginal delivery with a weight 3.52 kg at 38 weeks 6 days and there were no specific abnormalities in the antenatal exam. At the age of 40 days, she began to show signs of generalized tonic-clonic seizures. At that time, there were no abnormalities in her EEG and magnetic resonance imaging (MRI), but video-electroencephalographic monitoring showed lateralized to midline central, regionalized to central. Repeated EEG and MRI were normal and an epilepsy monitoring unit showed hypermotor seizures in the left frontotemporal and central regions.\nShe displayed developmental delay when compared to toddlers in the same age group. Because of the ataxia and muscle atrophy, she had been bedridden. Although she took antiepileptic drugs (AEDs), the tonic seizures persisted. As an additional treatment, she had given a ketogenic diet for 2 months. However, it also had no effect and was stopped. The frequency of the seizure was about three to ten times per day. Her preoperative vital signs, chest X-ray and laboratory data were normal ().\nThe patient took phenobarbital (30 mg), vigabatrin (300 mg), carbamazepine (250-200-100 mg), levetiracetam (250 mg), leucovorin (5 mg), pyridoxine (12.5 mg), lamotrigine (chewable, 12.5 mg) until the morning of the day of operation. Midazolam (1.2 mg, 0.1 mg /kg) was administered intravenously for sedation upon entering the operating room. Before anesthesia, the blood pressure was 94/60 mmHg, heart rate was 89 beats/min and oxygen saturation was 100%. Anesthesia was induced with thiopental sodium (50 mg, 5 mg/kg) intravenously and mask ventilation was started with 5 vol% isoflurane and 100% oxygen. After checking that the mask ventilation was operating properly, rocuronium bromide (10 mg, 1 mg/kg) was administered. After a minute, proper muscle relaxation was verified and the glottis was exposed using a Machintosh laryngoscope number 2. The trachea was intubated with an endobronchial tube with a 4.5 mm envelope. Mechanical ventilation was started with pressurecontrolled ventilation at a pressure 14 cmH2O (a tidal volume 90-100 ml) and a respiratory rate of 18-20 beats/min. Anesthesia was maintained with isoflurane (1.0-1.2 vol %) in oxygen (40%). Monitors included electrocardiography, pulse oxymetry and capnography, and inspired and the end-tidal concentrations of isoflurane were measured. During the operation, the blood pressure was 85-100/40-50 mmHg, heart rate was 85-110 beats/min, oxygen saturation was 100% and body temperature was 36.1-36.7℃. The blood sugar level was 149 mg/dl during the middle of the operation. The operation lasted a total of about 2 hours and 150 ml Ringer's lactate solution was supplied. At the end of surgery, anesthetics were discontinued. She recovered spontaneous respiration and glycopyrrolate (0.1 mg, 0.01 mg/kg) and pyridostigmine (2.5 mg, 0.2 mg /kg) were intravenously injected. After extubation was performed, her respiratory and circulatory conditions were stable and she was transferred to the postanesthetic care unit (PACU). Forty minutes later, during her stay with her mother in the PACU, she had a tonic seizure attack with mild eyeball deviation. The duration of the seizure was thirty seconds and there was no saturation change during the convulsion. According to her mother, the seizure was similar to her usual symptoms. She was discharged from the hospital the following day without complications.