Factors Associated with Refractory Status Epilepticus Termination Following Ketamine Initiation: A Multivariable Analysis Model

Srinivas, Meghana; Parker, Dennis L.; Millis, Scott R.; Marawar, Rohit; Zutshi, Deepti; Basha, Maysaa

doi:10.1007/s12028-022-01578-0

Cited by 9 publications

(15 citation statements)

References 18 publications

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“…Side effects of ketamine include hallucinations, nausea, vomiting, blurry vision, psychiatric symptoms, infection, arrhythmia, sepsis, shock, acidosis, and renal failure 6 ; but to our knowledge, abdominal compartment syndrome (ACS) has not been described with ketamine in literature. ACS is seen in critically ill patients and results from a pathological elevation of pressure (>20mm Hg) within the abdominal cavity with associated organ dysfunction.…”

Section: Discussionmentioning

confidence: 98%

“…Srinivas et al recently elucidated the deleterious effect of fluid volume overload with ketamine use in line with our report. 6 The acute development of multiorgan failure was attributed to ACS due to the temporal relation of worsening renal function and acidosis with escalating ketamine dose with the equivalent IV fluids. Although the patient had signs of infection (persistent leukocytosis, positive respiratory culture), the acuity of decline was not proportional to the evidence of infection.…”

Section: Discussionmentioning

confidence: 99%

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Abdominal Compartment Syndrome with Super-K (Ketamine) for Super-R(efractory) Status Epilepticus: A Case Report

et al. 2022

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Refractory status epilepticus is commonly defined as status epilepticus that fails to respond to two or more appropriately dosed intravenous anti-seizure medications including at least one non-benzodiazepine drug. Super-refractory status epilepticus (SRSE) is when status epilepticus continues for ≥24 h despite anesthetic treatment or recurs on an attempted wean of the anesthetic drugs. There is little evidence to guide the management of SRSE. Of late, unconventional therapies have been described in the literature regarding the management of SRSE, with ketamine leading the pack. Studies have noted ketamine's therapeutic efficacy up to 91% in SRSE cessation. Common side effects of ketamine include nausea, vomiting, headache, and hallucinations; but to our knowledge, ketamine has not been implicated in the pathogenesis of abdominal compartment syndrome. We describe a 74-year-old male who developed severe abdominal compartment syndrome in the setting of ketamine infusion for new-onset SRSE to increase awareness about this potential complication.

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Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

Abdominal Compartment Syndrome with Super-K (Ketamine) for Super-R(efractory) Status Epilepticus: A Case Report

et al. 2022

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“…However, our study focused on SRSE where the pathomechanisms for maintaining SE might be different, which limits comparability. Moreover, the size of our cohort does not allow further subgroup analysis 23 …”

Section: Discussionmentioning

confidence: 99%

“…Moreover, the size of our cohort does not allow further subgroup analysis. 23 The median latency between the first administration of PB and the first EEG without SE was 9.5 days, which appears long. However, this measure is strongly limited by its dependency on routine EEG recordings due to the retrospective study design and the circumstance that continuous EEG recordings are regularly obtained in merely 50% of patients with SE in German NICUs and are often acquired at low resolution (less than eight channels in 60% of cases).…”

Section: Adjor 95% CI Pmentioning

confidence: 94%

Phenobarbital in super‐refractory status epilepticus (PIRATE): A retrospective, multicenter analysis

et al. 2023

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Objective Super‐refractory status epilepticus (SRSE) is an enduring or recurring SE after 24 h or more of general anesthesia. This study aimed to evaluate the efficacy and safety of phenobarbital (PB) for the treatment of SRSE. Methods This retrospective, multicenter study included neurointensive care unit (NICU) patients with SRSE treated with PB between September 2015 and September 2020 from six participating centers of the Initiative of German NeuroIntensive Trial Engagement (IGNITE) to evaluate the efficacy and safety of PB treatment for SRSE. The primary outcome measure was seizure termination. In addition, we evaluated maximum reached serum levels, treatment duration, and clinical complications using a multivariate generalized linear model. Results Ninety‐one patients were included (45.1% female). Seizure termination was achieved in 54 patients (59.3%). Increasing serum levels of PB were associated with successful seizure control (per μg/mL: adjusted odds ratio [adj.OR] = 1.1, 95% confidence interval [CI] 1.0–1.2, p < .01). The median length of treatment in the NICU was 33.7 [23.2–56.6] days across groups. Clinical complications occurred in 89% (n = 81) of patients and included ICU‐acquired infections, hypotension requiring catecholamine therapy, and anaphylactic shock. There was no association between clinical complications and treatment outcome or in‐hospital mortality. The overall average modified Rankin scale (mRS) at discharge from the NICU was 5 ± 1. Six patients (6.6%) reached mRS ≤3, of whom five were successfully treated with PB. In‐hospital mortality was significantly higher in patients in whom seizure control could not be achieved. Significance We observed a high rate in attainment of seizure control in patients treated with PB. Success of treatment correlated with higher dosing and serum levels. However, as one would expect in a cohort of critically ill patients with prolonged NICU treatment, the rate of favorable clinical outcome at discharge from the NICU remained extremely low. Further prospective studies evaluating long‐term clinical outcome of PB treatment as well as an earlier use of PB at higher doses would be of value.

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“…Only descriptive statistics were used to analyze type of EEG use and treatment goals because a large proportion of studies had unclear/ unknown or mixed monitoring and treatment goals, which precluded meaningful statistical analyses (Table 2). The rate of continuous EEG (CEEG) monitoring was higher in publications after 2010 (pre-2010: continuous 8,18,25,27,28,[34][35][36]40,[53][54][55] : 76%, 244 of 321 patients; intermittent 4,19,23,37,56 : 24%, 77 of 321 patients; and 2010 onward: continuous 3,6,7,[11][12][13][20][21][22]29,32,33,41,42,45,49,51,[62][63][64][65][66]68 : 89%, 493 of 555 patients; intermittent 5,10,50,61 : 11%, 62 of 555 patients). The type of EEG monitoring was unknown/unclear for 45% of patients.…”

Section: Treatment and Monitoring Characteristicsmentioning

confidence: 99%

Treatment of Refractory Status Epilepticus With Continuous Intravenous Anesthetic Drugs

Au,

Kananeh,

Rahangdale

et al. 2024

JAMA Neurol

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ImportanceMultiple continuous intravenous anesthetic drugs (CIVADs) are available for the treatment of refractory status epilepticus (RSE). There is a paucity of data comparing the different types of CIVADs used for RSE.ObjectiveTo systematically review and compare outcome measures associated with the initial CIVAD choice in RSE in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Evidence ReviewData sources included English and non-English articles using Embase, MEDLINE, PubMed, and Web of Science (January 1994-June 2023) as well as manual search. Study selection included peer-reviewed studies of 5 or more patients and at least 1 patient older than 12 years with status epilepticus refractory to a benzodiazepine and at least 1 standard antiseizure medication, treated with continuously infused midazolam, ketamine, propofol, pentobarbital, or thiopental. Independent extraction of articles was performed using prespecified data items. The association between outcome variables and CIVAD was examined with an analysis of variance or χ2 test where appropriate. Binary logistic regressions were used to examine the association between outcome variables and CIVAD with etiology, change in mortality over time, electroencephalography (EEG) monitoring (continuous vs intermittent), and treatment goal (seizure vs burst suppression) included as covariates. Risk of bias was addressed by listing the population and type of each study.FindingsA total of 66 studies with 1637 patients were included. Significant differences among CIVAD groups in short-term failure, hypotension, and CIVAD substitution during treatment were observed. Non–epilepsy-related RSE (vs epilepsy-related RSE) was associated with a higher rate of CIVAD substitution (60 of 120 [50.0%] vs 11 of 43 [25.6%]; odds ratio [OR], 3.11; 95% CI, 1.44-7.11; P = .006) and mortality (98 of 227 [43.2%] vs 7 of 63 [11.1%]; OR, 17.0; 95% CI, 4.71-109.35; P &lt; .001). Seizure suppression was associated with mortality (OR, 7.72; 95% CI, 1.77-39.23; P = .005), but only a small subgroup was available for analysis (seizure suppression: 17 of 22 [77.3%] from 3 publications vs burst suppression: 25 of 98 [25.5%] from 12 publications). CIVAD choice and EEG type were not predictors of mortality. Earlier publication year was associated with mortality, although the observation was no longer statistically significant after adjusting SEs for clustering.Conclusions and RelevanceEpilepsy-related RSE was associated with lower mortality compared with other RSE etiologies. A trend of decreasing mortality over time was observed, which may suggest an effect of advances in neurocritical care. The overall data are heterogeneous, which limits definitive conclusions on the choice of optimal initial CIVAD in RSE treatment.

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Factors Associated with Refractory Status Epilepticus Termination Following Ketamine Initiation: A Multivariable Analysis Model

Cited by 9 publications

References 18 publications

Abdominal Compartment Syndrome with Super-K (Ketamine) for Super-R(efractory) Status Epilepticus: A Case Report

Abdominal Compartment Syndrome with Super-K (Ketamine) for Super-R(efractory) Status Epilepticus: A Case Report

Phenobarbital in super‐refractory status epilepticus (PIRATE): A retrospective, multicenter analysis

Treatment of Refractory Status Epilepticus With Continuous Intravenous Anesthetic Drugs

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