Factors affecting mortality of refractory status epilepticus

Tatlidil, Isil; Türe, Hatice; Akhan, Galip

doi:10.1111/ane.13173

Cited by 10 publications

(15 citation statements)

References 25 publications

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“…If persisting despite two adequate treatment lines, it is defined as refractory (RSE), with 1 or without 2 need of anesthetics, while if continuing for 24 h despite general anesthesia as super refractory (SRSE) 1 . These entities bear an increasing mortality risk, up to 40%, depending on underlying patient characteristics, SE etiologies, history of seizures, and treatment regimen 3‐5 . High mortality has been reported when SE results from acute brain injury, such as stroke, infection, 6 or inflammatory conditions, 7 and severe, progressive entities, such as malignant brain tumors.…”

Section: Introductionmentioning

confidence: 99%

“…1 These entities bear an increasing mortality risk, up to 40%, depending on underlying patient characteristics, SE etiologies, history of seizures, and treatment regimen. [3][4][5] High mortality has been reported when SE results from acute brain injury, such as stroke, infection, 6 or inflammatory conditions, 7 and severe, progressive entities, such as malignant brain tumors.In animal models, ongoing SE induce internalization of postsynaptic gamma-amino-butyric-acid (GABA A ) receptors, 8 which could explain efficacy loss of benzodiazepines, while N-methyl-D-aspartate (NMDA) receptors are increased at cells surface. 8 Ketamine (KET), an NMDA antagonist, has shown in animal SE models promising findings.…”

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confidence: 99%

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confidence: 99%

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Ketamine in adult super‐refractory status epilepticus: Efficacy analysis on a prospective registry

Caranzano

Nový

Rossetti

2022

Acta Neuro Scandinavica

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Background Status epilepticus (SE) persisting despite two anti‐seizures medications (ASM) and anesthetics is labeled super refractory (SRSE), correlating with important morbidity and mortality. Its treatment relies on expert opinions. Due to its pharmacological properties, ketamine (KET) has received increasing attention, but data are essentially retrospective. Aims To describe an unselected cohort of adults receiving KET for SRSE. Methods Analysis of a prospective registry of consecutive SE episodes, identifying SRSE patients receiving ketamine (KET). Comparison with recent adult series including more than 10 patients. Results Eleven patients received KET after a median of 4 days (range: 2–20); median dose was 5 mg/kg/h (range: 2.5–15). KET provided permanent SE control in three (27%). Previous series, using KET administration delays and doses similar to our cohort, report KET efficacy in 28–96% of cases. Conclusions We found a lower SE control rate than existing literature, whose data are, however, often retrospective, potentially selecting patients with less severe SE forms or responding to KET. This might explain outcome differences, as KET administration modalities were comparable with our cohort. Since randomized controlled studies are lacking on this subject, the analysis of this prospective, unselected cohort, if confirmed, suggests a current overestimation of KET efficacy in SRSE.

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Section: Introductionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Ketamine in adult super‐refractory status epilepticus: Efficacy analysis on a prospective registry

Caranzano

Nový

Rossetti

2022

Acta Neuro Scandinavica

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“…RSE is a neurological emergency and a serious illness with a high risk of mortality and morbidity, especially in elderly patients and those with cardiac comorbidities. 8 Anesthetics have been introduced to terminate seizure rapidly in RSE and super-RSE; however, hypotension is a critical side effect when treating SE using a higher dosage of benzodiazepines and other GABA A , which often require vasopressor agents. Among anesthetics, NMDA receptor antagonists, such as ketamine, could be efficient in prolonged RSE, while maintaining stable blood pressure by increasing the blood pressure.…”

Section: Discussionmentioning

confidence: 99%

Early Combination Therapy of Ketamine and Midazolam in Patients with Refractory Status Epilepticus in Hemodynamic Unstable State

Choi¹,

Shin²

2021

J Epilepsy Res

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The use of anesthetics is inevitable to suppress seizure activity in refractory status epilepticus (RSE). Hypotension, which is a critical side effect observed when treating RSE using a higher dosage of anesthetics that enhance γ-aminobutyric acid (GABA) activity, often requires vasopressor agents. Concomitant treatment with N-methyl-D-aspartate (NMDA) receptor antagonists, such as ketamine, could be effective in prolonged refractory SE, while maintaining stable blood pressure owing to the blockage of catecholamine reuptake in the systemic circulation. We report two cases of patients who had RSE with hemodynamic instability treated promptly with an early combination of ketamine and low-dose midazolam. The combination treatment effectively suppressed epileptic discharge with less hemodynamic side effects; moreover, a low dose of midazolam was required when combined with ketamine therapy. The initial combination of a third-line therapy that blocks NMDA receptors with enhanced GABAergic activity could be useful in RSE. Further studies are necessary in many variable etiologies of SE.

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“…The results of this study have been replicated to a large degree by multiple groups. [3][4][5] Given the plausible biological mechanisms for detrimental effects of IVAD, this would suggest that at the very least, there is a delicate, dangerous balance between risk and benefit in the use of these IVADs in the management of refractory SE.…”

Section: Commentarymentioning

confidence: 99%

Only a Fine Line Separates Genius, Insanity, and Anesthetic Medication for Coma Induction in Status Epilepticus

Lee¹

2021

Epilepsy Curr

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This study aims to explore safety and efficacy of artificial coma induction to treat status epilepticus (SE) immediately after first-line antiseizure treatment instead of following the recommended approach of first using second-line drugs. Methods: Clinical and electrophysiologic data of all adult patients treated for SE from 2017 to 2018 in the Swiss academic medical care centers from Basel and Geneva were retrospectively assessed. Primary outcomes were return to premorbid neurologic function and in-hospital death. Secondary outcomes were the emergence of complications during SE, duration of SE, and ICU and hospital stay. Results: Of 230 patients, 205 received treatment escalation after first-line medication. Of those, 27.3% were directly treated with artificial coma and 72.7% with second-line non-anesthetic antiseizure drugs. Of the latter, 16.6% were subsequently put on artificial coma after failure of second-line treatment. Multivariable analyses revealed increasing odds for coma induction after first-line treatment with younger age, the presence of convulsions, and with an increased SE severity as quantified by the Status Epilepticus Severity Score. While outcomes and complications did not differ compared to patients with treatment escalation according to the guidelines, coma induction after first-line treatment was associated with shorter SE duration, ICU, and hospital stay. Conclusions: Early induction of artificial coma is performed in more than every fourth patient and especially in younger patients presenting with convulsions and more severe SE. Our data demonstrate that this aggressive treatment escalation was not associated with an increase in complications but with shorter duration of SE, ICU, and hospital stays. Classification of Evidence: This study provides Class III evidence that early induction of artificial coma after unsuccessful first-line treatment for SE is associated with shorter duration of SE, ICU, and hospital stays than the use of a second-line nonanesthetic antiseizure drug instead or prior to anesthetics, without an associated increase in complications.

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Factors affecting mortality of refractory status epilepticus

Cited by 10 publications

References 25 publications

Ketamine in adult super‐refractory status epilepticus: Efficacy analysis on a prospective registry

Ketamine in adult super‐refractory status epilepticus: Efficacy analysis on a prospective registry

Early Combination Therapy of Ketamine and Midazolam in Patients with Refractory Status Epilepticus in Hemodynamic Unstable State

Only a Fine Line Separates Genius, Insanity, and Anesthetic Medication for Coma Induction in Status Epilepticus

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