Mortality and recovery from refractory status epilepticus in the intensive care unit: A 7‐year observational study

Abstract

40-4.12; p = 0.001 and RR 2.81, 95%CI 1.59-4.96; p < 0.0001). The estimated hazard ratio of death was 3.1 (95% CI1.6-6.0; p = 0.001) for patients with HE and 1.1 (95% CI 0.5-2.3; p = 0.745) for patients with brain tumors. RSE duration and nonconvulsive status epilepticus in coma were independently associated with death (for every hour RR 1.001; 95%CI 1.00-1.002; p = 0.011 and RR 3.62; 95%CI 1.34-9.77; p = 0.005). Significance: Brain tumors and HE had high relative risks for death and were independently associated with mortality in our cohort of critically ill RSE patients. Other clinical characteristics, as well as the use of intravenous anesthetic drugs and mechanical ventilation, may not be strongly related to outcome and should therefore be used cautiously for informed decision making regarding treatment. KEY WORDS: Refractory status epilepticus, Mortality, Hypoxic encephalopathy, Brain tumor, Neurocritical care.Refractory status epilepticus (RSE) is one of the most life-threatening neurologic emergencies and is characterized by high morbidity and mortality. This severe condition heralds a worse prognosis than treatment-responsive status epilepticus (SE) (Holtkamp et al., 2005;Rossetti et al., 2005), and serious outcome is considered to be mainly related to its etiology. Most studies propose the definition of RSE as a persistent SE after failure of a first-line (intravenous benzodiazepines) and one second-line antiepileptic drug (AED) (mostly phenytoin, valproate, levetiracetam, or phenobarbital), whereas others suggest a SE duration of >60 min (Hanley and Kross, 1998;Mayer et al., 2002). Despite the clinical and socioeconomic impact of RSE, current knowledge relies almost exclusively on retrospective assessments, its management on small case series, and expert opinions (Mayer et al., 2002;Holtkamp et al., 2005;Leppert et al., 2005;Rossetti et al., 2005;Holtkamp, 2011;Rossetti & Lowenstein, 2011). These reports suggest a frequency of RSE of up to 43% of all SE episodes, with nearly all subjects needing critical care and pharmacologic coma induction. Beyond these series one recent prospective study assessed frequency and clinical predictors of RSE emergence, and reported a 40% mortality in a tertiary clinical setting. However, the small sample size of 29 RSE episodes hinders inferences regarding the individual impact of different comorbidities (Novy et al., 2010). In order to respond to the discrepancy of important clinical and socioeconomic impact on the one hand and lack of larger and quantifying studies on the other hand, the Innsbruck Colloquium on SE held in April 2009, underscored the urgent need for more investigations in this field.

Anesthetic drugs in status epilepticus: Risk or rescue? A 6-year cohort study

“…In what is seemingly the same patient cohort, the authors previously reported that "the use of IV anesthetic drugs and mechanical ventilation may not be strongly related to outcome and should therefore be used cautiously for informed decision-making regarding treatment." 3 We support this interpretation and stress that while anesthesia presents clear risks to the patient, this must be balanced against the risks of prolonged seizure activity. The true value of the article by Sutter et al 1 is the message to take caution before initiating anesthetics.…”

“…Underlying etiology may be the most important outcome predictor. 3 In a previous study, we reported that the use of IVAD was not strongly related to outcome. 3 Albeit deriving from the same center, this cohort differed regarding inclusion criteria and study period.…”

“…3 In a previous study, we reported that the use of IVAD was not strongly related to outcome. 3 Albeit deriving from the same center, this cohort differed regarding inclusion criteria and study period. This study and our previous findings indicate that the association of IVAD is not significant after adjustment for refractory SE, which is explained by the strong correlation of treatment-refractoriness and IVADs, possibly not reflecting the true association.…”

Status Epilepticus in Adults: A Review of Diagnosis and Treatment

“…[35][36][37][38] In a recent study, 38 researchers found higher rates of infection and death in patients receiving anesthetic agents, even when corrected for critical medical conditions and for the refractoriness of the status epilepticus. It remains unclear whether the anesthetic agents themselves or a selection bias led to this worsened mortality.…”

Therapeutic coma for status epilepticus

“…Observational SE studies have reported different rates of CIVAD prescription: 5% in Germany, 18 8% in Italy, 19 10.7% 12 in Switzerland, 22% in France, 20 and up to 31% 21 or 36% in the United States. 22 The same is true when describing treatment of refractory SE: CIVADs were used in 30% 23 and 43% 24 of patients in Switzerland, as opposed to 87.3% in the United States. 25 Three recent studies performed in the United States and Switzerland [10][11][12] have questioned the risk/benefit ratio of TC, with observational data showing an independent association with worse outcome after correction for major confounders.…”