Do you keep patients nil per os (NPO) after having 2 seizures in 1 day?

Management of NPO Status in Patients with Multiple Seizures

Patients who have had 2 seizures in 1 day should remain NPO (nil per os) until a proper swallowing assessment has been completed to ensure patient safety. 1

Rationale for NPO Status

• Patients who have experienced seizures should remain NPO until swallowing screening is completed to prevent aspiration, which is a significant safety concern 1
• Swallowing assessment should ideally be done within 24 hours of hospital arrival, but should not delay urgent treatment decisions 1
• Multiple seizures can temporarily affect a patient's swallowing ability, increasing the risk of aspiration if oral intake is permitted too early 1

Risk Assessment After Multiple Seizures

• The risk of seizure recurrence increases substantially after 2 or 3 unprovoked seizures, from approximately one-third to about three-quarters of patients within 5 years 1, 2
• Early seizure recurrence is common, with a mean time to first recurrence of 121 minutes (median 90 minutes) and 85% of early recurrences happening within 360 minutes (6 hours) 1
• Risk factors for early seizure recurrence include:
  • Age ≥40 years 1
  • Alcoholism 1
  • Hyperglycemia 1
  • Glasgow Coma Scale score <15 1

NPO Management Algorithm

1. Initial Assessment:

   • Keep patient NPO immediately after multiple seizures 1
   • Assess for return to clinical baseline 1
   • Monitor for changes in neurological status 1

2. Swallowing Assessment:

   • Perform swallowing screening using a validated tool as soon as possible 1
   • Screening should be performed by a healthcare provider trained in swallowing assessment 1
   • If screening is abnormal, refer to a specialist with expertise in swallowing assessments 1

3. Medication Management During NPO Status:

   • Consider alternative routes for medication administration (intravenous, rectal) while patient is NPO 1, 3
   • Do not administer oral medications until swallowing has been assessed and found normal 1
   • Continuing the patient's home AED regimen via alternative routes when possible minimizes the risk of additional seizures during hospitalization 3

4. Duration of NPO Status:

   • Maintain NPO until swallowing assessment confirms safe oral intake 1
   • Continue close monitoring for changes in swallowing ability even after initial screening, as clinical status can change in the first hours following seizures 1

Special Considerations

• For patients who have had multiple seizures, the risk of additional seizures is significantly higher than after a single seizure 1, 2
• Patients with 2 unprovoked seizures have approximately a 73% risk of experiencing a third seizure, typically within one year 2
• Patients with provoked seizures (those with identifiable causes such as metabolic abnormalities, trauma, or toxins) may have different management needs and should have the underlying cause addressed 1

Common Pitfalls to Avoid

• Allowing oral intake too early before proper swallowing assessment can lead to aspiration pneumonia 1
• Changing a patient's established antiepileptic drug regimen during hospitalization is associated with increased odds of seizures during admission 3
• Failing to recognize that a patient's swallowing ability can change in the hours following seizures, requiring ongoing monitoring 1
• Overlooking alternative medication administration routes during NPO status, which can lead to subtherapeutic antiepileptic drug levels and breakthrough seizures 3