REVIEW URRENT C OPINION

Patients’ safety in the epilepsy monitoring unit: time for revising practices Sylvain Rheims a,b and Philippe Ryvlin a,b

Purpose of review Long-term video-electroencephalography monitoring (LTM) in epilepsy monitoring units (EMUs) exposes patients to a variety of serious adverse events (SAEs) and safety issues, which have recently caught attention and are summarized in this review. Recent findings SAEs observed during LTM affect about 10% of patients and include secondary generalized tonic–clonic seizures, seizure clusters and status epilepticus, unusual for the patient; seizure-related falls, injuries, fractures, and aspiration; postictal psychosis; and cardiorespiratory distress, including sudden unexpected death in epilepsy (SUDEP) and near-SUDEP, which were encountered by more than 10% of European and Australian EMUs. Accordingly, 3% of US-based EMUs suffer a death within a 1-year duration census. Many of these SAEs might be promoted by antiepileptic drugs (AEDs) withdrawal, for which no specific guideline is currently available. Current recommendations regarding optimal organization of EMUs, and in particular continuous supervision by a dedicated staff, are not followed by respectively 20 and 26% of European and US-based EMUs. Summary SAEs during LTM are a significant concern and might be aggravated by suboptimal EMU organization and staff education. Lack of high-level evidence stands out as the main limiting factor to the development and dissemination of appropriate guidelines. Keywords adverse events, epilepsy monitoring unit, long-term monitoring, presurgical evaluation, safety

INTRODUCTION The utility of long-term video-electroencephalography (EEG) monitoring (LTM) in patients with epilepsy has been repeatedly demonstrated. Two clinical situations and diagnostic issues require performing LTM: seizures of uncertain origin, for which LTM will help to differentiate epileptic seizures from various types of nonepileptic seizures, primarily psychogenic nonepileptic seizures (PNES); and drug-resistant partial epilepsies, for which LTM aims at delineating the brain region giving rise to seizure, with the view to assessing the possibility of a curative surgical treatment. During the past 20 years, guidelines regarding the requirements for LTM in epilepsy have been released by several learned societies, including the International League against Epilepsy, the American Clinical Neurophysiology Society, and the National Association of Epilepsy Centers (NAEC) [1–3]. These guidelines primarily defined the clinical indications for LTM as well as their essential services, personnel, and facilities,

with a specific emphasis on the equipment and technical procedures required to capture seizures effectively. In contrast, the procedures needed to ensure patients’ safety during LTM were much less thoroughly evaluated, a situation reflecting the lack of high-quality evidence on the risks and risk factors of adverse events in epilepsy monitoring units (EMUs). More recently, however, management of safety issues during LTM has progressively emerged as one of the key elements that should be taken into account

a

Department of Functional Neurology and Epileptology and Institute for Epilepsies (IDEE), Hospices Civils de Lyon and bINSERM U1028/CNRS UMR5292, Lyon Neuroscience Research Center, Lyon, France Correspondence to Professor Philippe Ryvlin, Unite´ 301, Hoˆpital Neurologique, 59 boulevard Pinel, 69677 Bron cedex, France. Tel: +33472357044; e-mail: [email protected] Curr Opin Neurol 2014, 27:213–218 DOI:10.1097/WCO.0000000000000076

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KEY POINTS

27 EMUs in the United Kingdom over a period of 2 months, translating into evaluation of 272 seizures [14 ]. The largest retrospective study with the longest follow-up included 507 patients within a 6-year period [6], whereas the number of patients included in the other studies varied from 18 to 230 within a 6-month to 3-year period [4,7,16,17 ,18, 20,21,23,24]. Another study, which included 1116 patients over a period of 4 years, investigated seizurerelated falls only [9]. Patients’ characteristics also varied across studies. Two studies reported safety outcomes in patients with epileptic seizures or PNES [6,16], whereas nonepileptic seizures were excluded from the others. Patients with intractable partial epilepsy referred for presurgical evaluation were excluded from one series [18], whereas another study focused on this specific population [17 ]. A single study was specifically devoted to pediatric EMUs [11 ]. Although a large variability of adverse events rate was observed across studies, these rates provided some clues about the risk of adverse events during LTM, and specifically about the risk of occurrence of the more severe events, such as status epilepticus, seizure-related fractures, postictal psychosis, and cardiac events and/or respiratory complications. &&

 Management of safety issues during LTM has progressively emerged as one of the key elements that should be taken into account for EMU organization.  More than half of EMUs in the United States and in Europe have experienced severe adverse events every year, and SUDEP and near-SUDEP were encountered by more than 10% of EMUs in Europe and Australia.  Management of AEDs withdrawal might represent a key factor for occurrence of SAEs, especially in at-risk patients.  More than 20% of US and European EMUs report nonoptimal organization with intermittent supervision.  Evidence-based data on the impact of EMU organization and safety protocols on the occurrence of adverse events are required.

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for EMU organization [4–10,11 ,12 ,13 ,14 ]. The aim of the present review was to summarize the recent safety data and adverse events reported during LTM.

WHAT ARE THE RISKS? Two surveys of epilepsy professionals about safety issues during LTM have recently been conducted in the United States by the American Epilepsy Society (AES) [10] and in Europe by the European Epilepsy Monitoring Unit Association [15]. Despite methodological variations between these two studies, both shared similar conclusions about the need for EMUs to identify and address the potential safety risks. More than half of the 70 EMUs that responded to the AES survey reported having observed falls or postictal psychosis in the preceding 12 months, and several centers reported fall with concussion or death [10]. In addition, 7% of centers have encountered a cardiac arrest, and 3% a death, within the past 12 months [10]. The European survey included 48 EMUs, located in 18 countries [15]. All responding EMUs experienced a wide range of seizurerelated adverse events, although their incidence varied among the EMUs. Specifically, falls/traumatic injuries as well as status epilepticus were reported in up to 10% of recordings [15]. Apart from these two surveys, several studies evaluated the safety issues in EMU in detail [4,6–8, 11 ,14 ,16,17 ,18–21]. All but one [14 ] were retrospective monocentric studies. As detailed in Table 1 [4,6–9,11 ,13 ,14 ,17 ,18,21–24], both the sample size and the duration of census varied across them. The single prospective study collected data from &

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Status epilepticus Status epilepticus was reported in 0–3.5% of patients admitted to EMUs [6–8,11 ,17 ,18,22,24]. Most of the patients suffered from nonconvulsive status epilepticus whereas convulsive status epilepticus remained rare [6,7,18], with the exception of children in whom the rate of convulsive status epilepticus might be higher [11 ]. &

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Seizure-related falls and injuries Seizure-related falls represented a frequent seizurerelated adverse event in EMUs, reported in 1–20% of patients [4,6,7,9,16,18]. The overall incidence of fall in this population was about 6–8 per 1000 inpatient-days [6,19], translating into 218–291 per 100 patient-years as compared with 3 per 100 patient-years in patients attending an outpatient referral clinic [25]. Most falls in EMU led to minor injuries [4,9,18], but some serious traumas were also reported [6,7]. Dobesberger et al. [6] reported a patient who sustained a severe head injury with an acute epidural hematoma requiring immediate emergency surgery, whereas two other patients suffered from compression fractures of lumbar vertebrae. Similarly, Noe and Drazkowski [7] reported four patients (2.7%) who had vertebral Volume 27  Number 2  April 2014

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NA

NA

# Clusters  3 seizures/24 h

# Clusters  3 seizures/4 h

0

0

10

NA

NA

17

4

15

15

5

1999–2005

5090

507

Retros

Dobesberger et al. 2011 [6]

0

1

2

14

35

2

4

4

NA

5.7

2005–2006

752

149

Retros

Noe et al. 2009 [7]

0

2

6

NA

NA

3

1

3

NA

5.79

2009–2012

1709

175

Retros

Ley et al., 2013 [8]

NA, data not available; Prosp, prospective study; Retros, retrospective study.

0

0

# Postictal psychosis

# Death

0

# Fractures

1

1

# Injuries

0

9

# Falls

# Cardio-respiratory arrest

NA

Mean duration of LTM (days)

# Status epilepticus

2008–2009

286

# Seizures

Duration of census

44

Retros

# Patients

Design

Study reference

Atkinson et al. 2012 [4]

NA

NA

NA

NA

NA

NA

NA

2

26

NA

2006–2010

NA

1116

Retros

Pati et al., 2013 [9]

0

0

13

NA

NA

1

0

0

1

3.29

2008–2010

NA

454

Retros

Arrington et al., & 2013 [11 ]

15

22

NA

NA

NA

NA

NA

NA

NA

9

1968–2009

NA

133788

Retros

Ryvlin et al., && 2013 [13 ]

0

3

2

NA

NA

NA

NA

NA

8

NA

November and December 2011

272

NA

Prosp

Kandler et al., && 2013 [14 ]

Table 1. Characteristics and results of studies reporting safety data during long-term video-EEG monitoring

0

0

0

6

21

NA

0

3

NA

6

2010

190

54

Retros

Di Gennaro & 2012 [17 ]

0

0

0

NA

NA

NA

1

1

NA

4.4

2002–2005

227

100

Retros

Hui et al. 2007 [18]

0

0

0

0

0

2

0

0

0

4

2002–2011

NA

18

Retros

Da Conceicao et al., 2012 [21]

0

0

5

30

82

NA

NA

NA

NA

NA

2000

728

169

Retros

Rose et al. 2003 [22]

0

0

0

NA

11

NA

0

0

0

2

2006–2007

NA

129

Retros

Lee et al., 2009 [23]

0

0

0

0

0

0

0

0

1

4.4

2006–2008

NA

50

Retros

Moien-Afshari et al., 2009 [24]

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fracture after a seizure-related fall. Cervical spine injury and thoracic spine compression have also been reported. All serious injuries were associated with generalized tonic–clonic seizures (GTCS) [6,7].

Psychiatric complications Psychiatric adverse events in EMUs were reported in 5% of patients, a greater risk than that reported for injuries or status epilepticus [6]. Postictal psychoses were the most frequent psychiatric manifestations [6,7]. Half of patients with postictal psychiatric symptoms required hospitalization in a psychiatry department [6].

Cardiac events and/or respiratory complications One EMU safety study reported serious peri-ictal cardiac abnormality in three out of 109 patients (2.75%), including one ictal asystole that was subsequently treated with a cardiac pacemaker, one brief ventricular tachycardia that resolved spontaneously, and one acute ST-segment depression that rapidly resolved without specific intervention [7]. Other studies, with lower sample size, did not report any cardiac event [17 ,18]. These data are in line with larger series concentrating on ictal asystole, which showed that this event is observed in 0.27–0.4% of patients during LTM [26–28]. Aspiration of food, oral secretion, or emesis can also complicate seizures. It has been reported that 0.2% of GTCS led to aspiration pneumonia in institutionalized patients [29]. A recent study reported that 5.6% of seizures during LTM occurred while patients were eating or drinking, with the patient having food in the mouth at seizure onset in 2.4% [30]. However, there was only one suspected aspiration, which did not result in subsequent complication. Importantly, it should be noted that oral suctioning was provided in 85% of patients at risk of aspiration [30]. Apart from the risk of aspiration during and/or immediately after seizure, serious concerns have been raised about the risk of respiratory failure directly related to ictal activity. Bateman et al. [31] reported that about one-third of seizures was associated with oxygen desaturation less than 90%, and about 10% with oxygen desaturation less than 80%. Similar findings were reported in children [32]. Finally, seizures in EMU can lead to cardiorespiratory arrest and death, including sudden unexpected death in epilepsy (SUDEP). The International Mortality in EMUs (MORTEMUS) study aimed at quantifying this risk over all EMUs identified in Europe, Israel, Australia, and New Zealand [13 ]. &

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MORTEMUS findings showed that the incidence of SUDEP in adults in EMUs was 5.1 per 1000 patientyears [95% confidence interval (CI) 2.6–9.2] [13 ], a figure comparable to that observed in a similar population out of hospital (on average 4/1000 patient-years [33]). Although rare, SUDEP and near-SUDEP were encountered by more than 10% of all EMUs surveyed in MORTEMUS. &&

WHAT FACTORS MIGHT CONTRIBUTE TO THE OCCURRENCE OF ADVERSE EVENTS IN EPILEPSY MONITORING UNITS? According to available data, three main factors might have to be considered for the evaluation of the risk of adverse events during LTM: patients’ characteristics; management of antiepileptic drugs (AEDs) withdrawal; and EMU organization.

Patients’ characteristics Although there was no significant relation between risk of status epilepticus in the EMU and average seizure frequency per month, age at seizure onset or localization of the epileptogenic zone [34], patients’ history should be taken into account to better evaluate the risk of adverse events at the individual patient level. Injuries were thus more frequent in patients with a history of injuries (20%; 95% CI 7.5–42.2) than in those without (3%; 95% CI 1.6–5.2) [6]. Furthermore, all patients who experienced vertebral fractures suffered from osteopenia that required calcium and vitamin D supplementation [7]. One of the main risk factors for developing psychiatric complications during LTM was a history of psychiatric comorbidity. Dobesberger et al. [6] reported that 17% of patients (95% CI 10.9–26.5) with history of psychiatric disorders developed psychiatric complications during LTM, in comparison with only 1% (95% CI 0.4–3.4) of patients without such history. Similarly, the occurrence of status epilepticus during LTM was observed in 10% of patients with previous history of status epilepticus against 2% of those without [6], confirming a previous report [34].

Management of antiepileptic drug withdrawal Tapering off antiepileptic drugs is routinely performed in EMUs with the aims to promote the occurrence of seizures, decrease the length of hospital stay, and reduce its cost. However, this approach might also increase the risk of seizure clusters, defined as the occurrence of three or more seizures within a specific time frame (usually 4 or 24 h), with recovery to Volume 27  Number 2  April 2014

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Patients’ safety in the epilepsy monitoring unit Rheims and Ryvlin

clinical baseline between seizures [35]. Seizure clustering has been individualized as a significant risk factor for convulsive status epilepticus [35]. Similarly, postictal psychosis typically follows a cluster of seizures, often generalized [36,37]. In fact, AEDs withdrawal might also promote the occurrence of secondary GTCS in patients who usually do not suffer from this seizure type. Importantly, all observed SUDEP collected in MORTEMUS occurred following a GTCS, most often in patients with more than 50–100% AEDs withdrawal [13 ]. Many of these patients did not suffer a GTCS in the last 3 months (some never had a GTCS), strongly suggesting that AED withdrawal was directly responsible for the occurrence of the fatal GTCS [13 ]. Most EMUs that reported safety data did not use a standardized protocol of AEDs withdrawal, and rather tapered AEDs on a case-by-case basis [4,6,7,16,17 ,18,19]. Although the NAEC recommends that medication reduction should be avoided in the outpatient setting prior to LTM and that a specific protocol should be available within EMUs, no such protocol has yet been recommended [3]. Considering the multiplicity of physicians involved in AEDs management in EMUs, their different levels of expertise (resident, fellow and senior epileptologist), the turnover of the youngest physicians (residents and fellows), the great variability in patients’ profiles (seizure type(s) and frequency, history of seizure clusters, status epilepticus, and postictal psychosis, number, dosage, and type of AEDs), and the lack of available guideline, one can appreciate the level of empiricism and heterogeneity of practice currently at stake, and their potential impact on safety. However, whether or not the modalities of AED tapering (i.e., more or less rapid or marked) impact the risk of seizure clusters and status epilepticus remains to be established. It has been suggested that the risk of occurrence of seizure clusters decreases when a specific protocol is used to manage drugs tapering [17 ,22]. It might be speculated that a standardized withdrawal protocol might result in more progressive drug tapering as well as its modulation in patients with previous history of seizure clusters or status epilepticus. As a matter of fact, no status epilepticus was reported in a recent study that used a specific drug withdrawal protocol in which AEDs were not tapered in patients with history of status epilepticus [17 ]. &&

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Epilepsy monitoring unit organization Implementation of strict safety processes in the EMU, including dedicated staff education, improvement of patients’ supervision by nurses and EEG

technicians, and immediate review of adverse events, is expected to produce significant improvement of patient safety [12 ]. In contrast, the recent survey from the AES underscored that the level of knowledge about safety issues in EMU remains low [5]. In this context, developing a culture of safety in EMUs, which would rely both on better education of personnel and on consensus statements about the essential protocols for preventing seizure-related adverse events, might be of primary importance to decrease the rate of adverse events during LTM. Although most of the safety data reported in the present review were obtained from EMUs with 24/24 and 7/7 continuous nurse and/or technician supervision, as advised by the NAEC [3], the AES survey reported that 26% of EMUs did not benefit from such permanent supervision [5]. Similarly, 20% of responding European EMUs reported intermittent or only daytime supervision [15]. It might be speculated that the rate of adverse events might be greater in EMUs not benefiting from continuous supervision. As a matter of fact, more than half of SUDEP and fatal near SUDEP cases reported in the MORTEMUS study occurred under a similar level of supervision to that of a standard neurological ward wherein the patient’s clinical status is checked a few times per night [13 ]. In the other cases, constant nocturnal supervision was organized but with reduced staff compared with daytime monitoring, possibly accounting for the delayed interventions [13 ]. In line with this hypothesis, the UK prospective multicenter study showed that nursing staff did not attend the patients in 44% of seizures, and attendance was delayed beyond 30 s in a further 29% [14 ]. In this study, the most important factor shown to improve timely attendance of patients during seizures was the presence of a nurse dedicated to the telemetry beds [14 ]. Furthermore, it has been shown that safety signals, and particularly telemetry alarms, are not fully effective. A recent study evaluating the efficacy of telemetry alarms and push button alarms in the EMU reported that 15 of the 150 recorded events were missed, including four GTCS [38]. Missed events were mostly related to lack of hospital staff response to alarms, whereas the mean response time was about 40 s [38]. &

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CONCLUSION The issue of patients’ safety during LTM has long been neglected. Although the situation has recently improved, prevention of adverse events remains nonoptimized in a significant number of EMUs, and many issues remain to be addressed. The surveys launched by the American Epilepsy Society, the European Epilepsy Monitoring Unit Association,

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and their counterpart in Asia provide a useful description of the current situation and limitations encountered in EMUs [5,15]. Published data support the implementation of new safety protocols and harmonization of EMU organization and management of LTM, but the impact of these procedures on patients’ safety requires prospective multicentric evaluation and is currently lacking high-level evidence. This is particularly true for AEDs tapering, for which a standardized protocol is expected to reduce LTM-associated serious side-effects. A large national cluster-randomized study has been recently granted in France with the view to tackle this issue. It will prospectively include 1440 patients over 3 years and 20 adult and pediatric centers and should inform on both medical and medico-economic endpoints. Indeed, both these endpoints need to be considered to build harmonized international consensus that could be endorsed by regional/national regulatory authorities and overcome the economic factors that currently limit optimal care in EMUs. Acknowledgements None. Conflicts of interest There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. American Clinical Neurophysiology Society. Guideline twelve: guidelines for long-term monitoring for epilepsy. J Clin Neurophysiol 2008; 25:170– 180. 2. Velis D, Plouin P, Gotman J, da Silva FL. Recommendations regarding the requirements and applications for long-term recordings in epilepsy. Epilepsia 2007; 48:379–384. 3. The National Association of Epilepsy Centers. Guidelines for essential services, personnel, and facilities in specialized epilepsy centers. 2010; http:// www.naec-epilepsy.org/spec_care/documents/NAEC-FinalGuidelineswithru ralcenterrevision.pdf. [Accessed on 3 January 2014] 4. Atkinson M, Hari K, Schaefer K, Shah A. Improving safety outcomes in the epilepsy monitoring unit. Seizure 2012; 21:124–127. 5. Buelow JM, Privitera M, Levisohn P, Barkley GL. A description of current practice in epilepsy monitoring units. Epilepsy Behav 2009; 15:308–313. 6. Dobesberger J, Walser G, Unterberger I, et al. Video-EEG monitoring: safety and adverse events in 507 consecutive patients. Epilepsia 2011; 52:443– 452. 7. Noe KH, Drazkowski JF. Safety of long-term video-electroencephalographic monitoring for evaluation of epilepsy. Mayo Clin Proc 2009; 84:495– 500. 8. Ley M, Vivanco R, Massot A, et al. Safety study of long-term video-electroencephalogram monitoring. Neurologia 2014; 29:21–26. 9. Pati S, Kumaraswamy VM, Deep A, et al. Characteristics of falls in the epilepsy monitoring unit: a retrospective study. Epilepsy Behav 2013; 29:1–3. 10. Shafer PO, Buelow J, Ficker DM, et al. Risk of adverse events on epilepsy monitoring units: a survey of epilepsy professionals. Epilepsy Behav 2011; 20:502–505.

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11. Arrington DK, Ng YT, Troester MM, et al. Utility and safety of prolonged videoEEG monitoring in a tertiary pediatric epilepsy monitoring unit. Epilepsy Behav 2013; 27:346–350. The only study specifically devoted to pediatric EMUs. 12. Spanaki MV, McCloskey C, Remedio V, et al. Developing a culture of safety in & the epilepsy monitoring unit: a retrospective study of safety outcomes. Epilepsy Behav 2012; 25:185–188. The only retrospective study evaluating the impact on patients’ safety of developing specific trainings and protocols in the EMUs. 13. Ryvlin P, Nashef L, Lhatoo SD, et al. Incidence and mechanisms of cardior&& espiratory arrests in epilepsy monitoring units (MORTEMUS): a retrospective study. Lancet Neurol 2013; 12:966–977. This large international study provided the first evaluation of risk of occurrence and precipitating factors of death, SUDEP, and near-SUDEP in EMUs. 14. Kandler R, Lai M, Ponnusamy A, et al. The safety of UK video telemetry units: && results of a national service evaluation. Seizure 2013; 22:872–876. The only prospective study of safety issues in the EMU, with a specific emphasis on the impact of EMU organization. 15. Rubboli, G, S Beniczky, MP Canevini et al. Safety in the Epilepsy Monitoring Unit (EMU). A survey of the ‘Safety in the EMU’ Task Force in Europe. 67th Annual Meeting of the American Epilepsy Society, 6–10 December 2013, Washington, DC. American Epilepsy Society; 2013. 16. Atkinson M, Shah A, Hari K, et al. Safety considerations in the epilepsy monitoring unit for psychogenic nonepileptic seizures. Epilepsy Behav 2012; 25:176–180. 17. Di Gennaro G, Picardi A, Sparano A, et al. Seizure clusters and adverse & events during presurgical video-EEG monitoring with a slow antiepileptic drug (AED) taper. Clin Neurophysiol 2012; 123:486–488. The only study evaluating the impact of a standardized protocol of AEDs withdrawal during LTM. 18. Hui AC, Kwan P, Leung TW, et al. Diagnostic value and safety of long-term video-EEG monitoring. Hong Kong Med J 2007; 13:228–230. 19. Sanders PT, Cysyk BJ, Bare MA. Safety in long-term EEG/video monitoring. J Neurosci Nurs 1996; 28:305–313. 20. Liu J, Meng F, Liu Z. Seizure-related adverse events during video-electroencephalography monitoring. Epileptic Disord 2012; 14:51–56. 21. da Conceicao PO, de Araujo Filho GM, Mazetto L, et al. Safety of video-EEG monitoring and surgical outcome in patients with mesial temporal sclerosis and psychosis of epilepsy. Seizure 2012; 21:583–587. 22. Rose AB, McCabe PH, Gilliam FG, et al. Occurrence of seizure clusters and status epilepticus during inpatient video-EEG monitoring. Neurology 2003; 60:975–978. 23. Lee YY, Lee MY, Chen IA, et al. Long-term video-EEG monitoring for paroxysmal events. Chang Gung Med J 2009; 32:305–312. 24. Moien-Afshari F, Griebel R, Sadanand V, et al. Safety and yield of early cessation of AEDs in video-EEG telemetry and outcomes. Can J Neurol Sci 2009; 36:587–592. 25. Neufeld MY, Vishne T, Chistik V, Korczyn AD. Life-long history of injuries related to seizures. Epilepsy Res 1999; 34:123–127. 26. Rocamora R, Kurthen M, Lickfett L, et al. Cardiac asystole in epilepsy: clinical and neurophysiologic features. Epilepsia 2003; 44:179–185. 27. Schuele SU, Bermeo AC, Alexopoulos AV, et al. Video-electrographic and clinical features in patients with ictal asystole. Neurology 2007; 69:434–441. 28. Scott CA, Fish DR. Cardiac asystole in partial seizures. Epileptic Disord 2000; 2:89–92. 29. DeToledo JC, Lowe MR, Gonzalez J, Haddad H. Risk of aspiration pneumonia after an epileptic seizure: a retrospective analysis of 1634 adult patients. Epilepsy Behav 2004; 5:593–595. 30. Noe KH, Tapsell LM, Drazkowski JF. Risk of choking and aspiration during inpatient video-EEG monitoring. Epilepsy Res 2011; 93:84–86. 31. Bateman LM, Li CS, Seyal M. Ictal hypoxemia in localization-related epilepsy: analysis of incidence, severity and risk factors. Brain 2008; 131:3239–3245. 32. Moseley BD, Nickels K, Britton J, Wirrell E. How common is ictal hypoxemia and bradycardia in children with partial complex and generalized convulsive seizures? Epilepsia 2010; 51:1219–1224. 33. Tomson T, Nashef L, Ryvlin P. Sudden unexpected death in epilepsy: current knowledge and future directions. Lancet Neurol 2008; 7:1021–1031. 34. Haut SR, Swick C, Freeman K, Spencer S. Seizure clustering during epilepsy monitoring. Epilepsia 2002; 43:711–715. 35. Haut SR, Shinnar S, Moshe SL, et al. The association between seizure clustering and convulsive status epilepticus in patients with intractable complex partial seizures. Epilepsia 1999; 40:1832–1834. 36. Kanner AM, Trimble M, Schmitz B. Postictal affective episodes. Epilepsy Behav 2010; 19:156–158. 37. Trimble M, Kanner A, Schmitz B. Postictal psychosis. Epilepsy Behav 2010; 19:159–161. 38. Shin HW, Pennell PB, Lee JW, et al. Efficacy of safety signals in the epilepsy monitoring unit (EMU): should we worry? Epilepsy Behav 2012; 23:458– 461. &

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Patients' safety in the epilepsy monitoring unit: time for revising practices.

Long-term video-electroencephalography monitoring (LTM) in epilepsy monitoring units (EMUs) exposes patients to a variety of serious adverse events (S...
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