levetiracetam and Bradycardia

Among the most common autonomic signs visible in preterm neonates, apnea can represent the first sign of several neurologic and non-neurologic disorders, and seizure is a relatively infrequent cause. Herein authors present a case of neonatal autonomic apnea, discussing the polygraphic video-EEG features of this pathological entity and the differential diagnosis with central apnea and autonomic apnea.. A female preterm Caucasian infant (29 + 4 weeks' gestational age (GA)), first twin of a twin pregnancy, at birth was intubated and surfactant administration was performed. She was ventilated via invasive ventilation for three days, with subsequent weaning with non-invasive ventilation for other two days, when she stopped requiring any ventilator support. After one week the ventilation weaning, the child presented episodes of cyanosis associated with sudden oxygen desaturation, skin pallor, apnea, and bradycardia. Therefore, the child underwent a continuous video-eeg recording with polygraphic study. The exam showed the presence of apneic episodes with an abrupt and clear start, associated with oxygen desaturation at 70%, with minimal thoracic effort at onset, and then evolving into central apnea. Central apnea lasted about 16 s and presented clear start- and end-points. These episodes were also associated with suppression of the EEG trace in frequency and amplitude, and after about 10 s of central apnea an abrupt decrease of the child's heart rate (more than 50% variation, from 160 bpm to 65 bpm) was recorded. In the suspect of epileptic apneas of autonomic origin, a therapy with oral Levetiracetam, at a starting dose of 10 mg/Kg/day, then increased up to 40 mg/Kg/day, was initiated, and after about 48 h the first administration of the anticonvulsant therapy, no new episodes of cyanosis or electrical apneas were recorded.. Herein the authors suggest to consider the diagnosis of autonomic seizures in those neonates with apneic events associated with EEG suppression. Considering that apnea events are not only present in preterm infants but also in term neonates, it is mandatory to diagnose in this context neonatal seizures for a correct diagnosis and a proper therapeutic choice.

Topics: Anticonvulsants; Apnea; Autonomic Nervous System Diseases; Bradycardia; Cyanosis; Diagnosis, Differential; Diseases in Twins; Electroencephalography; Female; Gestational Age; Humans; Hypoxia; Infant, Newborn; Infant, Premature; Infant, Premature, Diseases; Levetiracetam; Seizures; Sleep Apnea, Central; Video Recording

Topics: Acetamides; Adult; Anticonvulsants; Bradycardia; Humans; Infusions, Intravenous; Lacosamide; Levetiracetam; Prospective Studies; Retrospective Studies

Medication administration via intravenous push presents multiple potential advantages; however, there may be an increased risk of adverse drug reactions. In 2020, Brigham and Women's Hospital changed levetiracetam intravenous administration to intravenous push (IVP).. The purpose of this analysis was to compare the safety profile of IVP to intravenous piggyback (IVPB) levetiracetam administration.. This institutional review board-approved, single-center, pre-post analysis was performed between 1 November, 2019 and 30 May, 2020. The electronic health record was used to identify all administrations of intravenous levetiracetam greater than 1000 mg in patients ≥ 18 years old. The major safety outcomes included hypotension, bradycardia, drug-induced sedation, and intravenous site reactions such as phlebitis and infiltration. The major efficiency outcome was the time from pharmacy order verification to first-dose administration.. A total of 498 administrations in 162 patients were included in the analysis: 252 administrations in 84 patients in the IVP group and 246 administrations in 78 patients in the IVPB group. The incidence of bradycardia was 7 vs 3 (3.2% vs 1.5%, p = 0.34); hypotension 10 vs 6 (5.2% vs 3.5%, p = 0.44); sedation 21 vs 36 (19.3% vs 27.9%, p = 0.12); and peripheral IV site reactions 0 vs 1 (0% vs 0.6%, p = 0.39) in the IVP vs IVPB groups, respectively. The median time between order verification and first-dose administration was significantly reduced in the IVP vs IVPB group (23.5 vs 55 min, p < 0.001).. Intravenous push levetiracetam administration of doses up to 4000 mg was associated with a similar incidence of cardiovascular, sedation, and infusion site-related adverse events compared to IVPB and resulted in a significant reduction in time to first-dose administration. Intravenous push levetiracetam in doses as high as 4000 mg may be considered safe with appropriate monitoring.

Topics: Academic Medical Centers; Administration, Intravenous; Adolescent; Bradycardia; Female; Humans; Hypotension; Infusions, Intravenous; Levetiracetam; Retrospective Studies

We report two cases of adults presenting with transient loss of consciousness (TLoC) followed by a rapid recovery. Careful history taking revealed a stereotyped prodrome of déjà vu, raising the possibility of these events being focal seizures rather than syncope. The patients were commenced on antiepileptic drugs (AEDs) at the same time as having cardiac monitoring organised. This confirmed asystole during the seizure symptoms, resulting in TLoC. It was assumed that the cardiac arrhythmia explained the entire picture, a permanent pacemaker (PPM) was inserted, and the AEDs were withdrawn in one patient and not commenced in the other. However, they both subsequently presented with worsening seizures, including generalised tonic-clonic seizures, despite a functioning pacemaker. The seizures improved on restarting AEDs. The cases illustrate the diagnostic and management difficulties of patients presenting with ictal asystole, a condition that requires input from various medical specialities. There is no strong evidence base for the management of ictal asystole, but we favour a combined approach of AEDs and PPM insertion.

Topics: Anticonvulsants; Bradycardia; Carbamazepine; Deja Vu; Epilepsy; Female; Heart Arrest; Humans; Lamotrigine; Levetiracetam; Male; Middle Aged; Pacemaker, Artificial; Unconsciousness

To describe the cardiovascular toxicity and pharmacokinetics of levetiracetam in overdose.. A 43-year-old female presented 8 h post ingestion of 60-80 g of levetiracetam with mild central nervous system depression, bradycardia, hypotension and oliguria. Her cardiovascular toxicity transiently responded to atropine and intravenous fluids. A bedside echocardiogram demonstrated normal left and right ventricular contractility. Despite her cardiovascular toxicity and oliguria, she had normal serial venous lactates and renal function; and made a complete recovery over 48 h. Her levetiracetam concentration was 463 mcg/ml 8 h post ingestion (therapeutic range 10-40 mcg/ml) and her concentration-time data best fitted a one-compartment model with first-order input and an elimination half-life of 10.4 h.. Levetiracetam in large ingestions appears to cause bradycardia and hypotension that is potentially responsive to atropine and intravenous fluids. Based on a normal echocardiogram, the mechanism for this effect may be levetiracetam acting at muscarinic receptors at high concentration. The pharmacokinetics of levetiracetam in overdose appeared to be similar to therapeutic levetiracetam dosing.

Topics: Adult; Atropine; Bradycardia; Cardiovascular System; Drug Overdose; Female; Humans; Hypotension; Levetiracetam; Oliguria; Piracetam

Ictal asystole (IA) is uncommonly diagnosed and has been implicated as a potential cause of sudden unexpected death in epilepsy. Sudden unexpected death in epilepsy is an increasingly recognizable condition and is more likely to occur in patients with medically intractable epilepsy and those suffering from convulsive epilepsy. We report 2 cases of recent onset of prolonged syncope and unrevealing cardiac work up. The inpatient video-EEG monitoring recorded left temporal ictal discharges followed by IA. Although the role of cardiac pacing is controversial in these patients, both patients had favorable outcome following cardiac pacemaker insertion. This report demonstrates the variability in IA pathophysiology and clinical manifestations. It also advocates that cardiac pacing might have a role in the management of IA.

Topics: Aged; Anticonvulsants; Bradycardia; Electroencephalography; Epilepsy, Temporal Lobe; Female; Heart Arrest; Humans; Inpatients; Levetiracetam; Middle Aged; Monitoring, Physiologic; Pacemaker, Artificial; Phenytoin; Piracetam; Syncope; Video Recording

Topics: Anticonvulsants; Benzodiazepines; Bradycardia; Brain Diseases; Cerebral Cortex; Clobazam; Drug Resistance; Electroencephalography; Heart Arrest; Humans; Lamotrigine; Levetiracetam; Magnetic Resonance Imaging; Male; Middle Aged; Piracetam; Seizures; Triazines