Anesthetic Barbiturates in Refractory Status Epilepticus

Young, G. Bryan; Blume, Warren T.; Bolton, Charles F.; Warren, Kenneth G.

doi:10.1017/s0317167100022769

Cited by 48 publications

(24 citation statements)

References 7 publications

(7 reference statements)

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“…In previous studies, the efficacy of cIV-PTB in RSE ranged from 65% to 100%, but apart from a single series reporting 40 patients, the others included fewer than 18 patients [18-25]. Our results are consistent with a meta-analysis of patients with RSE treated with PTB in which 92% were seizure-free with PTB, compared to 80% with midazolam or 73% with propofol [11].…”

Section: Discussionsupporting

confidence: 85%

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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Section: Discussionsupporting

confidence: 85%

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

et al. 2014

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“…For these reasons, many different protocols are used in treating RSE (4). One of the most frequently used and the best studied protocol in the United States involves use of high-dose barbiturates (9)(10)(11)(12)(13)(14)(15)(16). High-dose barbiturate treatment is associated with significant mortality ranging from 10 to 75 depending on the study.…”

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confidence: 99%

Treatment of Refractory Status Epilepticus with Propofol: Clinical and Pharmacokinetic Findings

et al. 1998

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Summary: Purpose:We compared propofol with high-dose barbiturates in the treatment of refractory status epilepticus (RSE) and propose a protocol for the administration of propofol in RSE in adults, correlating propofol's effect with plasma levels.Methods: Sixteen patients with RSE were included; 8 were treated primarily with high-dose barbiturates and 8 were treated primarily with propofol.Results: Both groups of patients had multiple medical problems and a subsequent high mortality. A smaller but not statistically significant fraction of patients had their seizures controlled with propofol (63%) than with high-dose barbiturate therapy (82%). The time from initiation of high-dose barbiturate therapy to attainment of control of RSE was longer (123 min) than the time to attainment of seizure control in the group receiving propofol (2.6 min, p = 0.002). Plasma concentrations of propofol associated with control of SE were 14 pM +. 4 (2.5 p,g/ml). Recurrent seizures were common when propofol infusions were suddenly discontinued but not when the infusions were gradually tapered.Conclusions: If used appropriately, propofol infusions can effectively and quickly terminate many but not all episodes of RSE. Propofol is a promising agent for use in treating RSE, but more studies are required to determine its true value in comparison with other agents.

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“…Young et al also used pentobarbitone in four adults maintaining concentrations between 20 and 40 mg/l to produce a burst suppression pattern, again with preservation of the light reflex. 3 Tasker et al noted that two of their patients lost the pupillary response to light at thiopentone concentrations of 58 and 77 mg/l respectively.4 The first patient recovered but the second died. It was observed with this patient that once the thiopentone had been stopped, a further five days of support were required before all the drug had been eliminated.…”

Section: Discussionmentioning

confidence: 99%