Increasing Ketamine Use for Refractory Status Epilepticus in US Pediatric Hospitals

Abstract

Ketamine is an emerging therapy for pediatric refractory status epilepticus. The circumstances of its use, however, are understudied. The authors described pediatric refractory status epilepticus treated with ketamine from 2010 to 2014 at 45 centers using the Pediatric Hospital Inpatient System database. For comparison, they described children treated with pentobarbital. The authors estimated that 48 children received ketamine and pentobarbital for refractory status epilepticus, and 630 pentobarbital without ketamine. Those receiving only pentobarbital were median age 3 [interquartile range 0-10], and spent 30 [18-52] days in-hospital, including 17 [9-28] intensive care unit (ICU) days; 17% died. Median cost was $148 000 [81 000-241 000]. The pentobarbital-ketamine group was older (7 [2-11]) with longer hospital stays (51 [30-93]) and more ICU days (29 [20-56]); 29% died. Median cost was $298 000 [176 000-607 000]. For 71%, ketamine was given ≥1 day after pentobarbital. Ketamine cases per half-year increased from 2 to 9 ( P < .05). Ketamine is increasingly used for severe pediatric refractory status epilepticus, typically after pentobarbital. Research on its effectiveness is indicated.

Treatment of Refractory Convulsive Status Epilepticus: A Comprehensive Review by the American Epilepsy Society Treatments Committee

“…While some case reports did not find a response, [44][45][46][47] and while some larger series are not sufficiently granular to determine specific KET treatment outcome in RSE, 48 others report a response in most of the episodes, [49][50][51] or partial response in their series. [52][53][54][55] In a large multicenter class IV study of 58 children and adults (which included NCSE cases), KET was started after a median of 9 days, yet it controlled RSE "likely" in 12% and "possibly" in additional 20%.…”

Potential Consequences of High-Dose Infusion of Ketamine for Refractory Status Epilepticus: Case Reports and Systematic Literature Review

“…While ketamine has neuroprotective effects in adults, paediatric patients, with developing brains undergoing continuous neurogenesis, are thought to be particularly susceptible to neurotoxicity 29,30,34,35 . Paradoxically, the incidence of ketamine use in paediatric patients with RSE is steadily increasing despite two sets of recently published recommendations on RSE management; one listing ketamine a fifth-line agent and the second, an international survey of RSE experts, not mentioning ketamine at all [36][37][38] . Given the appreciable differences in incidence of use, dosing strategies, and potential adverse events between adult and paediatric patients, we separated our analysis of adult and paediatric studies.…”

“…SE is the most common neurological emergency in paediatrics and affects between 17 to 23 per 100,000 children each year, of whom 25% to 45% progress to RSE 37,54 . The literature on ketamine in paediatric RSE includes two case reports, four case series, one cohort study, and one systematic review as shown in Table 2 36,48,49,51,[55][56][57][58] . Of these eight studies, one (12.5%) reported complete control of seizure activity in all patients, four (50%) described moderate control, one (12.5%) reported mild control and two studies (25%) reported poor seizure control (none reported failure of treatment response).…”

Status Epilepticus—Work-Up and Management in Children

“…36 Ketamine is an alternative treatment for RSE, increasingly popular in children. 114 Current literature describes midazolam as the first choice for anesthetic treatment in pediatric RSE, followed by pentobarbital. 107,115 In a study of 51 children, midazolam infusion controlled SE in all patients except one.…”