Observed medical and surgical complications of prolonged barbiturate coma for refractory status epilepticus

Abstract

Background: Refractory status epilepticus is often treated with third-line therapy, such as pentobarbital coma. However, its use is limited by side effects. Recognizing and preventing major and minor adverse effects of prolonged pentobarbital coma may increase good outcomes. This study retrospectively reviewed direct and indirect medical and surgical pentobarbital coma. Methods: Retrospective chart review of all patients with refractory status epilepticus treated with pentobarbital over a 1 year period at a large tertiary care center. We collected baseline data, EEG data, and complications that were observed. Results: Overall, nine patients [median age 46.4 (IQR 21.7, 75.5) years] were induced with pentobarbital coma median 11 (IQR 3, 33) days after seizure onset for a median of 9 (IQR 3.5, 45.4) days. A total of four to eight concurrent antiepileptics were tried prior to the pentobarbital coma. Phenobarbital, due to recurrence of seizures on weaning pentobarbital coma, was required in seven patients. Observed complications included peripheral neuropathy (77.8%), cerebral atrophy (33.3%), volume overload (44.4%), renal/metabolic (77.8%), gastrointestinal (66.6%), endocrine (55.6%), cardiac/hemodynamic/vascular (77.8%), respiratory (100%), and infectious (77.8%). The number of complications trended with duration of induced coma but was nonsignificant. Median ICU length of stay was 40 (IQR 28, 97.5) days. Overall, five patients were able to follow commands after a median 37 (IQR 25.5, 90) days from coma onset. There were eight patients that were discharged from hospital with three remaining in a prolonged unresponsive state. There was one patient that died prior to discharge. Conclusions: This study highlights the high morbidity in patients with refractory status epilepticus requiring pentobarbital coma. Anticipating and addressing the indirect and direct complications in prolonged pentobarbital coma may improve survival and functional outcomes in patients with refractory status epilepticus.

Evolution of Cerebral Atrophy in a Patient with Super Refractory Status Epilepticus Treated with Barbiturate Coma

“…Recognizing complications, either directly or indirectly related, to barbiturate coma are important and may lead to improved outcomes [ 5 , 11 ]. Future studies should systematically evaluate the long-term functional outcomes in patients who present with super refractory status epilepticus in relation to the management and associated complications.…”

“…Multiple complications were observed in our patient during his medically induced coma. These complications may not be directly related to the medications themselves itself, but rather a reflection of the immobile, critically ill state [ 5 ].…”

“…However, global cerebral atrophy is less characterized. Global cerebral atrophy in refractory status epilepticus may be a result of prolonged critical illness, progression of underlying brain pathology causing seizures independent of the status epilepticus, or direct effect of high doses of antiepileptic agents used to treat the status epilepticus [ 4 , 5 ]. Elucidation of pathophysiology and triggers might help in emphasizing clinical paradigms of management that lead to better outcomes.…”

Weaning from antiseizure drugs after new onset status epilepticus

“…Successful weaning from ASDs in the inpatient setting has been shown, as well as in patients with epilepsy who have been seizure‐free for prolonged periods of time in the outpatient setting, but there is a paucity of data on the safety of discontinuing ASDs in NOSE after hospital discharge. There is a specific reluctance to wean patients off of barbiturate medications due to the possibility for seizure recurrence during withdrawal . This study describes the Mayo Clinic experience of weaning from ASDs following control of NOSE.…”

“…There is a specific reluctance to wean patients off of barbiturate medications due to the possibility for seizure recurrence during withdrawal. [10][11][12] This study describes the Mayo Clinic experience of weaning from ASDs following control of NOSE.…”