The Real-World Boards: Question #41
A 79-year-old woman has her first seizure(s) in the ICU
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A 79-year-old woman nursing home resident with chronic kidney disease and chronic back pain on long-term oxycodone is admitted to the ICU with septic shock from healthcare-associated pneumonia. She is intubated for hypoxemic respiratory failure and provided cefepime, vancomycin, hydrocortisone, and a fentanyl infusion.
On hospital day 3, fentanyl is discontinued for somnolence (RASS -3). Over the next 24 hours, she awakens but remains inattentive and does not follow commands. She has prolonged episodes of staring. An EEG during an episode shows epileptiform discharges >2.5/sec. She has no past seizure history. Lorazepam and levetiracetam are provided, and neurology consultation is requested.
Laboratory studies (including sodium, magnesium, calcium, pH, and glucose) are unremarkable except for creatinine 3.1 mg/dL, increased from 1.4 mg/dL at admission, with BUN 82 mg/dL. Urine output is 0.7 mL/kg/hr. CT head shows no acute abnormality.
