Third-line antiepileptic therapy and outcome in status epilepticus

Kowalski, Robert G.; Ziai, Wendy; Rees, Richard N; Werner, J. Kent; Kim, Grace; Goodwin, Haley; Geocadin, Romergryko G.

doi:10.1097/ccm.0b013e3182591ff1

Cited by 129 publications

(49 citation statements)

References 40 publications

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“…The majority of them were treated with hypothermia. In our study, the mortality rate was lower than in other studies [28–30]. This might be explained by differences in the source population.…”

Section: Discussioncontrasting

confidence: 86%

(S)-Ketamine in Refractory and Super-Refractory Status Epilepticus: A Retrospective Study

et al. 2016

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ObjectiveThe aim was to describe the safety and efficacy of (S)-ketamine [(S)-KET] in a series of patients with refractory and super-refractory status epilepticus (RSE and SRSE) in a specialized neurological intensive care unit (NICU).MethodsWe retrospectively analyzed the data of patients with RSE and SRSE treated with (S)-KET in the NICU, Salzburg, Austria, from 2011 to 2015. Data collection included demographic features, clinical presentation, diagnosis, electroencephalogram (EEG) data, anticonvulsant treatment, timing, and duration of treatment with (S)-KET. Outcomes were seizure control and death.ResultsA total of 42 patients (14 women) with RSE and SRSE were treated with (S)-KET. The median duration of status epilepticus (SE) was 10 days [first quartile (Q1) 5.0, Q3 21.0]; the median latency from SE onset to the first administration of (S)-KET was 3 days (Q1 2.0, Q3 6.8). Prior to (S)-KET administration, patients had received a median of two (Q1 2.0, Q3 3.0) anesthetics and three (Q1 2.0, Q3 4.0) antiepileptic drugs. Forty percent of patients (17/42) received propofol: 65 % prior to (S)-KET; 35 % at the same time with (S)-KET. Seven patients received a median bolus of (S)-KET of 200 mg (Q1 200, Q3 250) followed by a continuous infusion, while 35 started with a continuous infusion (maximum rate median 2.55 mg/kg/h; Q1 2.09, Q3 3.22). In 64 % of patients (27/42), (S)-KET was the last drug before SE cessation; in five patients, it was given with propofol at the same time. Median duration of administration was 4 days (Q1 2.0, Q3 6.8). Overall (S)-KET treatment was well tolerated, adverse effects were not observed, and overall mortality was 45.2 %.ConclusionsTreatment of SRSE in adult patients with (S)-KET led to resolution of status in 64 %. No adverse events were found, indicating a favorable safety profile.

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Section: Discussioncontrasting

confidence: 86%

(S)-Ketamine in Refractory and Super-Refractory Status Epilepticus: A Retrospective Study

et al. 2016

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“…However, favorable outcomes were possible, and treatment-associated morbidity was manageable in the ICU setting. Our cohort is unique as it focused only on SRSE patients, whereas previously published cohorts have been mostly a mix of patients RSE and SRSE [1,4,12,16,17]. …”

Section: Discussionmentioning

confidence: 99%

Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study

et al. 2014

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IntroductionSeizures refractory to third-line therapy are also labeled super-refractory status epilepticus (SRSE). These seizures are extremely difficult to control and associated with poor outcome. We aimed to characterize efficacy and side-effects of continuous infusions of pentobarbital (cIV-PTB) treating SRSE.MethodsWe retrospectively reviewed continuous electroencephalography (cEEG) reports for all adults with RSE treated with cIV-PTB between May 1997 and April 2010 at our institution. Patients with post-anoxic SE and those receiving cIV-PTB for reasons other than RSE were excluded. We collected baseline information, cEEG findings, side-effects and functional outcome at discharge and one year.ResultsThirty one SRSE patients treated with cIV-PTB for RSE were identified. Mean age was 48 years old (interquartile range (IQR) 28,63), 26% (N = 8) had a history of epilepsy. Median SE duration was 6.5 days (IQR 4,11) and the mean duration of cIV-PTB was 6 days (IQR 3,14). 74% (N = 23) presented with convulsive SE. Underlying etiology was acute symptomatic seizures in 52% (N = 16; 12/16 with encephalitis), remote 30% (N = 10), and unknown 16% (N = 5). cIV-PTB controlled seizures in 90% (N = 28) of patients but seizures recurred in 48% (N = 15) while weaning cIV-PTB, despite the fact that suppression-burst was attained in 90% (N = 28) of patients and persisted >72 hours in 56% (N = 17). Weaning was successful after adding phenobarbital in 80% (12/15 of the patients with withdrawal seizures). Complications during or after cIV-PTB included pneumonia (32%, N = 10), hypotension requiring pressors (29%, N = 9), urinary tract infection (13%, N = 4), and one patient each with propylene glycol toxicity and cardiac arrest. One-third (35%, N = 11) had no identified new complication after starting cIV-PTB. At one year after discharge, 74% (N = 23) were dead or in a state of unresponsive wakefulness, 16% (N = 5) severely disabled, and 10% (N = 3) had no or minimal disability. Death or unresponsive wakefulness was associated with catastrophic etiology (p = 0.03), but none of the other collected variables.ConclusionscIV-PTB effectively aborts SRSE and complications are infrequent; outcome in this highly refractory cohort of patients with devastating underlying etiologies remains poor. Phenobarbital may be particularly helpful when weaning cIV-PTB.

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“…Notably, some studies suggest that the use of intravenous anesthetic drugs (IVADs) is associated with negative outcomes 75, 76. Especially pentobarbital has been linked to the development of hypotension requiring prolonged duration of mechanical ventilation and vasopressor therapies,76 which have in turn been associated with poor long‐term outcome 54.…”

Section: Factors Affecting Outcomementioning

confidence: 99%

“…Especially pentobarbital has been linked to the development of hypotension requiring prolonged duration of mechanical ventilation and vasopressor therapies,76 which have in turn been associated with poor long‐term outcome 54. Continuous infusion of thiopental was also associated with more frequent adverse events and worse outcome at 6 months compared to continuous infusions of midazolam 77.…”

Section: Factors Affecting Outcomementioning

confidence: 99%

Long‐term outcomes of status epilepticus: A critical assessment

et al. 2018

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SummaryWe reviewed 37 studies reporting long‐term outcomes after a status epilepticus (SE) episode in pediatric and adult populations. Study design, length of follow‐up, outcome measures, domains investigated (mortality, SE recurrence, subsequent epilepsy, cognitive outcome, functional outcome, or quality of life), and predictors of long‐term outcomes are summarized. Despite heterogeneity in the design of prior studies, overall risk of poor long‐term outcome after SE is high in both children and adults. Etiology is the main determinant of outcome, and the effect of age or SE duration is often difficult to distinguish from the underlying cause. The effect of the treatment on long‐term outcome after SE is still unknown.

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Third-line antiepileptic therapy and outcome in status epilepticus

Cited by 129 publications

References 40 publications

(S)-Ketamine in Refractory and Super-Refractory Status Epilepticus: A Retrospective Study

(S)-Ketamine in Refractory and Super-Refractory Status Epilepticus: A Retrospective Study

Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study

Long‐term outcomes of status epilepticus: A critical assessment

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