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Post-op Patient Care FAQ's | Seizures in Pets

Post-op Patient Care FAQ's

Urination and bowel movements

Q.) How often should I take my dog out to go to the bathroom?

A.) Your dog should be taken outside 3-4 times a day while you are home.

Q.) What if my dog hasn't had a bowel movement in a few days?

A.) You can try adding canned pumpkin to their food (amount according to the size of your dog). You should see results in 12-24hrs. DO NOT give more than twice. If this does not help, please notify us or your general veterinarian.

Medications

Q.) Can I give all my pets medications at the same time?

A.) Yes, you can give all the prescribed medications together. If you have any other medications that were prescribed by your referring vet, please consult with a Technician or Dr. Chauvet.

Q.) Should I give my pet his medications with food?

A.) Yes, while your pet was here with us, we used a multitude of “treats” to get them to take their pills. Pill pockets are a favorite among dogs and cats, you may also use lunch meats, and cheese. If your pet is taking doxycycline do not give this pill with any dairy products

At Home Care

Q.) How do I safely pick up and hold my pet after surgery?

A.) When picking up your pet you want to keep the back horizontal, while supporting both the front and back. The same applies when putting her down.

Q.) What type of confinement would be best for my pet while on cage rest?

A.) Depending on the activity of your dog or cat; generally a small room, playpen, or a confined space is sufficient. If these options do not work for your pet then a crate would better suit them. The cage or area you use should be big enough for your pet to turn around in comfortably.

Q.) Do I really have to keep my dog locked up for two weeks?

A.) Strict cage rest is possibly the single most important aspect of your pet's recovery. You may sit with your pet on your lap or beside you for short periods. Be sure that you have a harness on them and control of them at all times. Remember to never leave him/her alone for even a second. They are on cage rest for a reason: we do not want them to re-injure themselves which could require more procedures or surgery. The medications they take often make them feel like they are 100% before they are 100%.

Q.) Can my pet interact with other pets in the home?

A.) While on cage rest (generally the first two weeks) it is best for your pet to remain confined and quiet. No long walks or playing with other animals in the home.

Q.) Can my dog have a bath?

A.) Bathing is not advised until the sutures are removed. Until then you can use baby wipes, damp cloths to clean them, or waterless shampoo. Avoid the incision.

Q.) How do I know if my pet is in pain, or if he is crying for other reasons?

A.) For the first few days after surgery your pet will be taking a pain reliever, usually when these are gone your pet should no longer be painful. Sometimes they can become frustrated due to the confinement. They also pant more if they are taking Prednisone, which makes them seem restless. If you feel that after finishing the pain reliever, your pet is still uncomfortable you can always contact us.

Seizures in Pets

What is Epilepsy? | Why do seizures occur? | How do we diagnose seizures? | Treating Seizures | Diet


What is a Seizure? back to top

A seizure is a disruption of the brain cells (neurons) that leads to the spontaneous discharge of those cells. The following may occur: loss of consciousness (glassy eyes), excess or loss of muscle tone, urination, defecation, salivation, other psychic manifestations, alteration of sensation and/or hallucinations of special senses (fly biting, shadow chasing, tail chasing)

There are usually 3 parts to a seizure: The aura, the ictus, and the post ictus. The aura is a subjective sensation that precedes seizure. It only lasts a few minutes and usually is expressed by anxiety. In humans, the events occurring can help localize the area or focus of the seizure in the brain but in the dog or cat, the aura is often missed or too brief. The ictus is the actual seizure event. It can vary in duration, and severity. The post ictus is the period after the seizure that lasts from minutes to days. Wide range of behaviors and neurological aberrations are seen. Blindness, depression, panting, pacing, lethargy are commonly seen. Occasionally, aggression is noted.

We are most familiar with the general motor seizure, better known as grand mal seizures. This type of seizure is expressed by the entire body. The whole brain is involved. The convulsions are symmetric. Salivation, urination, defecation and loss of consciousness are usually observed. Paddling of the limbs and chomping of jaws occur. The cause of these seizures can be acquired (congenital malformation, birth trauma, neonatal or post-natal hypoxia, trauma, encephalitis, neoplasm (cancer), etc. In such cases, the seizures may not appear for weeks, months or years after the causative lesion. This type of seizure can also be inherited from generation to generation.

Partial motor seizures are also known as focal motor seizure. Only one area of the body is affected. Only a certain part of the brain is involved in the seizure in this case. This category of seizures is considered to be of acquired cause. It is witnessed in all species. It can be simple (isolated muscle groups) and the consciousness is preserved, or it can be complex (change in behavior, fly biting, tail chasing, chewing, licking, vocalization, ECT) where the consciousness is not preserved. Psychomotor seizure is a term often used to refer to this form of seizure activity. This term has been dropped due to its allusion to psychiatric problems. In this form of seizure the patient is “unresponsive” that is, does not respond to sound or visual cues. Amnesia is often described in humans. The behavior seen is automatic and lasts 30 seconds to 2 minutes or more.

Two other forms of seizures are notable. Myoclonic seizure represent a sudden brief shock-like muscle contraction, this activity is general to face, trunk, or one or more limbs. Lapse attack is better known as the petite mal seizure, or absence seizure. Here, no muscle activity is seen. There is a brief loss in consciousness, a staring into space sort of look. These are rarely seen in pets.

Epilepsy is when seizures recur and are due to disease or injury to the brain directly. This excludes metabolic (liver disease, hypoglycemia, etc) and toxic causes. One seizure alone does not represent epilepsy. Epilepsy can be inherited or acquired and the seizures can be partial or grand-mal.

Status epilepticus is a condition in which seizures rapidly repeat, with no intervening stage of consciousness. It is a neurological emergency. If uncontrolled, it may lead to severe brain damage and death. High fevers, hypotension, lack of oxygen are often seen.

The neuron is the principal cell in the brain, that if damaged can lead to seizures. There are neurotransmitters (substance that influence the neuron function) that can excite the neurons (glutamate) or “sedate”/inhibit the neurons (GABA). For a seizure to occur there can be direct damage to the neuron cell membrane and thus the cell is unstable and discharged on its own. There can be an excess of excitatory neurotransmitter or lack of inhibitory neurotransmitter. And of course anything in between is fair game.

The more a patient seizure, the more it is likely to seizure again. Why? The sick neuron can eventually affect neighboring neurons and lead to a bigger seizure area and more convulsions. This is called kindling. Once this stage of kindling has been achieved, the susceptibility to seizures is essentially permanent. It is also possible, via its connections to other neurons that another site of seizures is started elsewhere in the brain. Now there are two sites that can lead to seizures on their own or together. This is called secondary epileptogenesis. Repeated bombardment of normal neurons by an epileptogenic focus may perhaps cause the development of kindling or secondary epileptogenesis in the recipient neurons. This mechanism may play a role in the gradual worsening of some epileptics. Thus, treatment of seizures may be indicated even in cases where clinical seizures may be considered too infrequent to bother treating.

The history is very important. The breed, sex, age, history of vaccines, diet, geographical location, history of seizures in the lineage, past trauma, medical history are all crucial. The type of seizure witnessed also helps narrow down the cause. Inherited epilepsy has been confirmed in only 6 breeds: Beagle, German Shepherd Dog, Tervuren Shepherd, Horaks's dogs (research dogs), Golden Retrievers, and Dachshunds. A number of breeds are suspected to have familial epilepsy buy extensive research is still required to confirm inheritance. The work required demonstrating inheritance and the mode of inheritance is extensive and large number of dogs and breeding are necessary. Males seem to be about 5 times more often affected than females.

A good physical examination is important. The description of the seizure is crucial to the clinician. In the age of camcorders, a video is defiantly worth a thousand words. Because many seizures are due to metabolic problems, blood count is very important. The blood glucose/ sugar should be checked at the time of seizure. Sometimes, titers (levels of antibodies in the blood) are required to check for infections such as viruses, fungal diseases, or parasites. For example, a puppy with normal blood work and seizures should be tested for canine distemper virus.

An electroencephalogram (EEG) is useful but not readily accessible in veterinary medicine. It is difficult to run and requires the expertise of a well trained neurologist to interpret it. The test takes about an hour to run and necessitates patient's cooperation for movement will interfere with the recording.

Magnetic Resonance Imaging (MRI) or Computer Aided Tomography (CAT) scans are often available to image the brain and rule out some of the causes of epilepsy such as cancer, and more. In addition, spinal fluid may need to be collected and analyzed.

When to start treatment? Remember that: DIAGNOSIS = PROPER TREATMENT and NO DRUG IS EFFECTIVE IN ALL CASES.

The principle of good anticonvulsant therapy depends on a thorough workup, knowledge of the drugs used, regular measurement of drug levels in the blood to ensure proper dosage and effect, multiple drug usage effects, other illnesses, and if the patient is older or pregnant which can decrease the blood protein and affect the drug activity. The more rapidly serum drug concentration is reached, the better the success. Thus it is best to start with higher dosages or a loading dose.

The problems with anticonvulsant therapy arise if the medication is changed too quickly, before therapeutic range is reached. Therefore change therapy only after the highest possible level is reached. As well, one drug is better than many in most cases. Good record keeping by the owner and the veterinarian is crucial. Beware of drug interactions: Know that antibiotics, antacids, cardiac drugs, steroids, anti-asthma drugs and others can affect the anticonvulsant drug effects on the dog or cat. Liver or kidney diseases always complicate therapy.

Phenobarbital is the most commonly used drug for controlling seizures. It makes the GABA neurotransmitter work better and the neuron is less likely to discharge spontaneously. The drug takes about two to three weeks to stabilize in the blood and thus this is a good time to get a blood level done. Because the drug is processed by the liver, liver enzymes and function should also be checked at that time. Phenobarbital can also lead to liver disease in some cases. Antacids and certain antibiotics can make Phenobarbital more toxic. The drug can be slowly decreased over weeks only if the patient does not seizure for one year of if there is evidence of liver disease. Otherwise, Phenobarbital is usually a lifetime commitment.

Primidone acts in a similar fashion as Phenobarbital. Actually, Primidone is metabolized / broken down by the liver to Phenobarbital. However, it takes 5 times more Primidone to do what Phenobarbital does to control seizures. Primidone is toxic to the liver in many cases and is more expensive. Most people do not use it anymore. It is not recommended.

• Mechanism of action: PB binds to GABA receptor at a specific barbituate binding site. In the presence of GABA, the chloride channels are open for longer period of time and hyperpolarization occurs (the inside of the cell becomes more negative).PB also decreased the effects of glutamate, an excitatory neurotransmitter, and blocks the response to NMDA.
  
• The dose is 3-5 mg/kg bid in dogs and 2-3 mg/kg bid in cats. Steady state of the drug is reached in about 10 to 14 days.
  
• The therapeutic range in the dog is 15-45 ug/ml. The dose is adjusted based on the serum levels. There exists a linear correlation between the dose and the level.
  
• The major side effects are sedation, drinking too much (polydypsia), urinating excessively (polyuria), and eating too much (polyphagia). PB is suspected to be hepatotoxic. Even though elevations of liver enzymes are frequent, hepatotoxicity is not yet proven. To monitor the drug therapy, serum levels of PB and chemistry panel are performed 2 weeks after every dose adjustment and once a year once maintenance is achieved. Libido is reported to be affected in humans. Drug interactions can be encountered. Some drugs potentiate the effects of PB (chloramphenicol, cimetidine...)
  
• Therapy is terminated once the patient has had no seizure within 6-12 months. Decreasing the drug by 20% every 2-4 weeks is recommended.
  
  Potassium Bromide
  
  

  The mechanism of action depends on the small size of bromide (Br-) compared to chloride (Cl). The bromide ion replaces the chloride and enters the cell faster, making the inside of the cell more negative and less likely to discharge. The half life is 25 days in the dog. Hence, levels are not stable for about 4 to 5 months. But because toxic levels can be reached sooner, the first check should be performed 6 weeks after initiating therapy.

  
  

  The dose is 20-30 mg/kg/day and can be divided into twice a day dosing. If seizure control is needed rapidly, a total oral loading dose of 75 -600 mg/dg and then maintenance dose of 45 mg/kg/d. Levels can be done 4 weeks into therapy and about 4 months into therapy. The therapeutic range of bromide in the serum is 1-2 mg/ml. This range is greater when the patient is also on PB 2-3 mg/ml or more.

  
  

  Side effects are rare. But sedation and wobbliness are noted. In people, GI signs, rashes, and emotional disturbances are noted. 25% of dogs also show hyperphasia. Whether or not KBr toxicity or potentiation of PB exists is uncertain but some patients on both drugs have shown more severe side effects. The idiosyncratic psychosis reported in human is difficult to document in animals. Avoid in pregnant animals.

  
  

  KBr was the first anticonvulsant used but went out of style with new drugs coming in the market. Recently, it has been used more and more for refractory seizures in children. In dogs, it is most commonly used as a combination therapy, added on to the PB. Currently, studies are undergoing to evaluate the effect of KBr in dogs as a sole anticonvulsant.

  
  Impress stable diet to not vary the salt content in the diet.
  The use of KBr in cats is contraindicated in cats due to secondary eosinophilic bronchoalveolitis.
  
  
  Benzodiazepines
  
  

  Mechanism of action is the same for all. They bind to specific benzodiazepine receptors on the GABA receptor complex.
  The half life in dogs is very short and thus the drug is of little use for maintenance therapy.
  Diazepam (Valium) is however the first choice for status epilepticus treatment because it acts so fast (very lipid soluble). Diazepam is now being investigated for rectal use which would be an excellent method of administration for the owner. Newer benzodiazepines are available on the market.

  
  

  In cats the dose is 2-5 mg/kg bid or tid.
  Clobazam is 8-10 times less sedative than other benzodiazepines but this drug is not as potent as diazepam. It is used mostly for clonic seizures in humans.
  Clorazepate (Tranxene) may be useful in dogs because they do not develop tolerance to the drug.

  
  Clonazepam appears to act longer in dogs and is not as sedative as Diazepam.
  Side effects include tolerance and sedation.
  
  
  Gabapentin
  
  
  
  
  • Maximum blood levels are reached in one hour and half life is 3-4 hours in dogs. The recommended dose is 10-20 mg/kg PO TID.
    
  • Metabolized by the liver and excreted 100% by kidneys. 60% of the drug is unchanged.
    
  • Often used as a third anticonvulsant. Reduces frenquency and severity of seizures in 50% of the dogs
    
  • Not used in cats
  
  
  Levetiracetam (Keppra)
  
  
  
  
  • Not metabolized by liver and is excreted renally. No drug to drug interactions = safe
    
  • 10-20 mg/kg PO TID – very costly – in cats 5-30 mg/kg BID to TID.
    
  • Intravenous use may be good for status epilepticus.
    
  • Few side effects and minimal hepatic toxicity but extremely short elimination half life in the cat.
  
  
  Zonisamide
  
  
  
  
  • Metabolized by hepatic microsomal enzymes – half life is 15 hours.
    
  • 10 mg/kg BID PO.
    
  • Decreased seizure frequency 50%
    
  • Mild side effects include sedation, ataxia, vomiting in some dogs.
  
  
  Topiramate
  
  
  
  
  • Not extensively metabolized.
    
  • Ataxia, lethargy are side effects
    
  • Avoid in renally impaired patients.
    
  • 2.5-5 mg/kg PO TID
  
  
  Pregabalin
  
  
  
  
  • Similar to gabapentin
    
  • No drug to drug interaction and renally excreted.
  
  
  Ketogenic diet back to top
  
  

  This diet was first described in 1921 by wilder. The recommendations were high fat and low carbohydrate diet. This leads to ketosis and acidosis. The basic principles of this diet were to imitate the effects of starvation which were known to suppress seizures. The mechanism of the diet remains unknown. A transient acidosis (increase acid) within the cell is suspected. This decreased normal excitability. This diet has not been tried in dogs.

  
  
  

  This diet is mostly used in children for refractory seizures, absence seizures, and myoclonic seizures, akinetic and atonic attacks. Here are some of the guidelines.

  
  
  
  
  
  • 1 gram/Kg of protein and the rest in fat only small amounts of carbohydrate
    
  • Fat to carbohydrate ratio should be 3:1. This is called the ketogenic potential to antiketogenic potential ratio.
    
    0.9 (gram fat) + 0.46 (gram protein)
    
  • (gram carbohydrate) + 0.1 (gram fat) + 0.58 (gram protein)
  
  
  The Ketogenic diet: 87% of the calories come from fat, 6% from carbohydrates, 7% from protein.
  The Medium Chain Triglyceride diet is more palatable and does not increase cholesterol. This diet requires 60% medium chain triglycerides, 11% other fats, 19% carbohydrates, and 10% proteins.
  
  Other Diet anecdotes
  
  

  Although unconfirmed scientifically, hypoallergenic diets have been useful in the management of seizures. Allergies can lead to seizures or worsen the control of seizures. Diets such as venison/potato, catfish/rice and so on, have been useful but require owner commitment.

  
  

  Antioxidants help prevent damage secondary to seizures:
  Vitamin E, Selenium, vitamin B compels, Vitamin C; Olive oil daily on the food helps and so does omega 3 fatty acids.

  
  Hypothyroidism, hyperadrenocorticism, etc. can affect the control of seizures. Yearly bloodwork will help detect such problems.