Intravenous anesthesia in treatment of nonconvulsive status epilepticus: Characteristics and outcomes

Abstract

Objective To determine factors associated with continuous anesthetic drug (IVAD) use in nonconvulsive status epilepticus (NCSE). Methods Retrospective cohort study of patients who met clinical and EEG criteria of NCSE from 2009 to 2014 at a tertiary academic medical center. Patients were categorized according to IVAD use. Outcome variables were response to treatment and in-hospital death. We used descriptive analyses for baseline characteristics and outcome variable differences among patients who did and did not receive IVAD. Results Forty-three patients had a total of 45 NCSE episodes. IVAD was used in 69% of the episodes. Patients treated with IVAD were younger (53.1±14.1 vs 64.1±13.3, p=0.019). The episodes treated with IVAD occurred more frequently in patients with an acute neurologic pathology (58% vs 21%, p=0.024) and those presenting in a coma (39% vs 7%, p=0.030). NCSE resolved in 74% of the patients who received IVAD. Duration of NCSE did not differ significantly by treatment group. There were total 13 in-hospital deaths: ten in IVAD users vs three in the no-IVAD group (p > 0.05). Only one in-hospital death appeared to be a direct consequence of IVAD use. Mortality was more common among episodes that were not treated according to the published status epilepticus treatment guidelines compared to the episodes where guidelines were followed. Conclusion Our findings showed that factors such as younger age, acute neurologic pathology and coma at presentation were associated with IVAD use in patients with NCSE. These factors should be controlled in the future outcome and effectiveness studies to determine the effect of IVAD use on outcome of NCSE.

Distinguishing in‐hospital and out‐of‐hospital status epilepticus: clinical implications from a 10‐year cohort study

“…In light of the limited evidence supporting the practice of therapeutic coma in refractory SE, the use of continuously administered anaesthetics has been questioned by a number of observational studies uncovering a large number of complications and an association of anaesthetics with increased mortality independent of many outcome predictors . However, there is an ongoing debate, as other studies could not reproduce these associations in specific SE subtypes such as new‐onset refractory SE and nonconvulsive SE . In a prospective multicentre observation, anaesthetics were not associated with death but with prolonged hospital stay .…”

Antiepileptic Drug Therapy for Status Epilepticus

“…IV anesthetic drugs are reportedly used to treat from 11% to 69% of patients with refractory NCSE. 49 53 54 74 It is noteworthy that the risk of IV anesthetic drug therapy is likely to be greater in patients with NCSE, especially in the case of focal NCSE with impaired consciousness without coma. 53 54 The outcome is likely to be better in NCSE without coma than in CSE or NCSE with coma.…”

A pragmatic approach to intravenous anaesthetics and electroencephalographic endpoints for the treatment of refractory and super-refractory status epilepticus in critical care

“…A recent survey suggests some agreement on the first-line anaesthetic agents; however, there is less consensus on which drug and when to introduce second-line anesthetics, and even less agreement on the third-line [51]. The first-line intravenous anesthetic agents most widely used to treat RSE are propofol, midazolam, and barbiturates are often added in association or used as second-line agent [9,51,52]; ketamine is less frequently used as first-line agent, more often added as third-line agent in association with midazolam or propofol [51,53].…”

“…Based on the clinical features and severity, SE is distinguished into "convulsive" or "non-convulsive", the former being the most common and harmful [9]. SE lasting longer than 120 min and not responding to firstand second-line treatments is defined as "refractory" (RSE) and requires general anaesthesia and intensive care unit admission.…”