What is Specialized Care in Status Epilepticus and in Which ICU?

Abstract

Status epilepticus (SE) is a serious, potentially life-threatening condition. The outcome of SE is variable, while some patients may present neurological deficits, others recover without sequellae. The reasons for these different outcomes are not fully understood, but some prognostic factors have been identified, such as the age, the clinical type of SE, a previous history of epilepsy, the etiology, and the delay of treatment onset [1][2][3].Despite being an important stage in the treatment, there have been very few studies on the various management options when patients are admitted in intensive care.In this retrospective study, Valeras et al. compared the management and outcome of 168 cases of SE admitted to either a neurological intensive care unit (NICU) (27 %) or a medical intensive care unit (MICU) (73 %) in the same tertiary care hospital. The authors did not find a significant difference in terms of length of hospital stay, mortality, or outcome at discharge. This finding remained after adjustment for confounding factors. However, on admission, there were significant differences between the patient groups. Stroke accounted for 39 % and toxic and metabolic etiologies for 11 % of cases in the NICU group compared to 12 and 21 %, respectively, in the MICU group. The APACHE-II severity score at admission was higher in the MICU group than in the NICU group (17.5 vs. 13.4), as was consciousness impairment (48 vs. 22 %). There was no significant difference in terms of mortality, even if a trend to decreased mortality existed in NICU (4 % in the NICU group; 8 % in the MICU group) and no difference in outcome according to Rankin score. Regarding the management modalities, the only significant difference related to continuous EEG monitoring, performed in 85 % of cases in NICU compared to 30 % in MICU. The higher rate of intubation in MICU (72 %, compared to 48 % in NICU) was partially correlated with consciousness impairment.Should one therefore conclude from this study that there is no benefit to be gained from specialist intensive care in the management of SE, in contrast to what has been demonstrated in other acute neurological pathologies [4,5]?We are convinced that some SEs may benefit from a neurological ICU, even if the study of Varelas et al. failed

Neurocritical Care Outcomes, Research, and Technology

“…One study showed that, for status epilepticus, more continuous electroencephalograms (EEGs) were ordered in the neuroICU, and fewer patients were intubated, but more eventually received tracheostomies compared with medical ICU admission. No significant differences were found in mortality, LOS, and outcome at discharge; however, the heterogeneity of status epilepticus limits direct comparison, and more research to evaluate expected benefits of status epilepticus management in a neuroICU is justified . A benefit for neuroICU care may be shown for various other disease processes, such as cerebral venous sinus thrombosis: after institution of continuous neuroICU coverage, outcomes improved in a recent single-institution experience …”

Update in Neurocritical Care: a summary of the 2018 Paris international conference of the French Society of Intensive Care

“…Although SRSE has a poor prognosis, some patients may recover even in prolonged cases. Advice by and/or transfer to centres with specific neurology expertise are advisable [77].…”