Prolonged mechanical ventilation in patients with terminated status epilepticus and outcome: An observational cohort study

Abstract

Objective: Classical clinical characteristics associated with successful or unsuccessful extubation are unreliable in neurocritically ill patients, and attempts to predict successful extubation in this context have failed. We aimed to investigate the frequency of mechanical ventilation (MV) in adult patients in status epilepticus (SE) and its clinical associations, to identify predictors at SE onset of prolonged postictal MV, and to determine the associated outcomes with prolonged MV. Methods:From 2012 to 2018, SE patients treated in intensive care units at a Swiss academic care center were included. Multivariable Poisson regression adjusting for potential confounders, such as continuously administered anesthetics, was performed to identify risks for postictal MV for >24 h after SE and its association with no return to neurologic function and death. Linear regression was performed to identify correlations between the durations of administered specific anesthetics and postictal MV.Results: Of 262 patients, 42% were ventilated, with 24% being on ventilators for >24 h after SE. Patients with prolonged postictal MV were extubated at a median of 7 days, with 56% not being extubated on the day of successful weaning from MV because of altered consciousness and/or lack of airway-protective reflexes.After extubation, noninvasive ventilation and reintubation were rarely needed.Prolonged postictal MV was associated with increased risk for death independent of potential confounders, including fatal etiology of SE, age, SE severity, and use of anesthetics (relative risk for every additional day = 2.7, p = .024). At SE onset, decreased consciousness and presumed fatal etiology predicted prolonged postictal MV. Anesthetics were associated with prolonged MV, but linear regression could not identify significant correlations.

Early timing of anesthesia in status epilepticus is associated with complete recovery: A 7‐year retrospective two‐center study

“…Moreover, a shorter duration of mechanical ventilation is associated with a lower rate of ventilator‐associated pneumonia. A congruent result has also been shown in a prior SE cohort study 12 …”

“…A congruent result has also been shown in a prior SE cohort study. 12 As especially in patients with potentially fatal etiologies, anesthesia can be started early for other reasons than controlling SE, such as for airway protection, our result of decreased odds for return to premorbid function with delayed anesthesia could be confounded by the underlying etiologies of SE. Our multivariable analyses, however, revealed decreasing odds for return to premorbid function with every additional nonanesthetic antiseizure drug given prior to anesthesia (i.e., with increasing delay of anesthesia) independent of confounders, including potentially fatal etiologies, increasing age, the types and severity of SE, and the Charlson Comorbidity Index.…”

“…As previously described in our studies, 5,12,21 and according to the recent guidelines, 2 convulsive SE was defined as evidence of epileptic seizures lasting ≥5 min clinically, and all other types of SE as evidence of clinical symptoms or as detected by electroencephalography (EEG) lasting at least 10 min. Types of SE were assessed from the digital EEG databases.…”

“…[2][3][4] When SE is refractory to first-and second-line antiseizure drugs, treatment escalation with the induction of an artificial coma by continuously administered intravenous anesthetic drugs is recommended for 24-48 h with the aim of terminating seizures. [2][3][4] Although, at first glance, these recommendations seem justified, high-quality studies regarding the efficacy and tolerability of anesthesia at different stages of SE are scarce 5 and the induction of artificial coma has been associated with adverse effects, [6][7][8][9][10] complications during the course of SE 10,11 and the postictal phase, 12 and unfavorable outcomes in some studies. 10,11,13,14 This comes along with a large proportion of patients with SE in whom neither treatment start (with underdosing of benzodiazepines) nor escalation [15][16][17] adheres to the guidelines.…”

Comparing Patients With Isolated Seizures and Status Epilepticus in Intensive Care Units

“…Definition, Duration, and Severity of SE SE was diagnosed and defined according to the ILAE 19 and specific specifical types of SE were categorized as focal nonconvulsive without coma (with or without altered consciousness), with motor symptoms including myoclonic and convulsive types, and nonconvulsive SE with coma. As outlined in our previous studies, 13,16,[20][21][22] the duration of SE was defined as the time between clinical and/or EEG evidence of start of seizures and seizure termination as verified by EEG. SE duration in our studies represents an approximation of 12 hours at most, as during the study period our monitoring unit used 2 types of EEG (continuous EEG monitoring or spot video-EEGs ≥30 minutes at least twice every 24 hours) in patients with nonrefractory SE and continuous video-EEG in all patients with treatment-refractory SE.…”