Abstracts

Rationale: The ketogenic diet (KD) is a non-pharmacologic treatment for medically refractory epilepsy amongst other conditions. The exact mechanism of action of the KD as a therapeutic option to treat epilepsy remains unknown.

Medications utilize carbohydrates (CHO) as inactive ingredients regardless of product formulation. Because of the risk for breakthrough seizures with abrupt deviation from ketosis, it is important to review medications and minimize the amount CHO in product excipients. (Journal of Clinical Anesthesia 2016; 35, 170-5) Patients on KD often have concomitant medical issues, often requiring the use of general anesthesia (GA).

Many medications used in the ICU or OR either contain CHO or are diluted in fluids with dextrose or other sources of CHO. The use of these medications can shift patients out of ketosis and increase the risk of seizures. One case report in patients with GLUT1-Deficiency Syndrome (G1DS) recommends maintenance of normoglycemia and avoidance of glucose in the perioperative phase. (Am J Case Rep. 2019;20:647-650) A larger case series conducted by Boston Children’s hospital suggests children on KD can safely undergo GA for surgical procedures, and recommends continued monitoring of serum pH and bicarbonate during prolonged surgical procedures. (Epilepsia. 2002 May;43(5):525-9) There is limited literature regarding pharmacological modifications of intravenous (IV) medications admitted to intensive care units (ICU) and the operating rooms (OR) for acute conditions. To date there are no consensus guidelines on management of KD patients requiring GA.

The purpose of this study is to review the standard formulations of commonly used medications by anesthesia services at two large academic medical centers to assess potential risk of accidental CHO exposure.

Methods: Fifty medications were evaluated for potential risk for CHO exposure. Medications selected included commonly used medications in the perioperative period, organized as sedatives/hypnotics, analgesics, muscle relaxants, local anesthetics, cardiac medications, and antibiotics. Analysis consisted of descriptive statistical methods. Variables assessed included undiluted CHO content, dilution requirements, hospital standard dilution in dextrose, and additional drug stability in normal saline.

Results: An average of 40% of medications were made in dextrose as part of standard practice.

Conclusions: This study highlights a large number of medications utilized in the perioperative period contain carbohydrates, or may be made with dextrose as a standard diluent within pediatric institutions. Inadvertent use of these medications can shift patients out of ketosis and increase the risk of seizures, highlighting the importance of thorough clinical evaluation of medications to be used on KD patients expected to undergo medical procedures. Future efforts highlight the value of incorporating a neurology clinical pharmacy specialist with experience in management of KD to evaluate and prevent CHO administration, as well as the potential for the use of computerized physician order entry protocols specific to KD patients undergoing GA.

Funding: Please list any funding that was received in support of this abstract.: N/A.