Treatment options in pediatric super-refractory status epilepticus

Arayakarnkul, Palita; Chomtho, Krisnachai

doi:10.1016/j.braindev.2018.11.011

Cited by 26 publications

(31 citation statements)

References 20 publications

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“…The reported application of a ketogenic diet for super-refractory status epilepticus in pediatric intensive care units has increased in recent years, including case reports and large series [ 4 , [6] , [7] , [8] , 10 , 12 , [46] , [47] , [48] , [49] , [50] , [51] , [52] , [53] , [54] , [55] , [56] , [57] , [58] , [59] , [60] , [61] ]. Park et al.…”

Section: A Ketogenic Diet For Super-refractory Status Epilepticusmentioning

confidence: 99%

“…reported that in patients with super-refractory status epilepticus, the number of patients who achieved a >50% reduction in seizure frequency after initiating a ketogenic diet was significantly higher in those with febrile infection-related epilepsy syndrome than in those without febrile infection-related epilepsy syndrome ( p < 0.05) [ 8 ]. Table 1 shows eight large series of children with super-refractory status epilepticus treated with a ketogenic diet in PICUs [ 4 , 8 , 10 , 12 , [46] , [47] , [48] , [49] ]. There was a trend of using a ketogenic diet in the acute stage (within 2 weeks of onset) of super-refractory status epilepticus in PICUs.…”

Section: A Ketogenic Diet For Super-refractory Status Epilepticusmentioning

confidence: 99%

“…first reported a 6-year-old boy who received a parenteral ketogenic diet in the acute stage (40 h after admission) in 2015 [ 9 ]. Table 2 shows an overview of case reports of ketogenic parenteral nutrition for pediatric patients with super-refractory status epilepticus in intensive care units [ 9 , 10 , 12 , 48 , 49 , 63 , 64 ]. The lag from the onset of status epilepticus to initiating a parenteral ketogenic diet was 2–31 days, and the duration of parenteral ketogenic diet therapy was 3–41 days.…”

Section: Parenteral Nutrition Of a Ketogenic Diet For Pediatric Reframentioning

confidence: 99%

“…Relatively less common side effects include hyperketosis (>6.5 mmol/L), hyperbilirubinemia, and altered liver function and pancreatic enzymes. The side effects observed during parenteral ketogenic diet therapy have been reported to be usually transient, and will recover after discontinuing the parenteral therapy or switching to an enteral ketogenic diet [ 9 , 10 , 12 , 13 , 48 , 49 , 63 , 64 ]. Therefore, surveillance of serum pancreatic enzymes and lipid profiles is very important when initiating parenteral ketogenic diet therapy in PICUs.…”

Section: Parenteral Nutrition Of a Ketogenic Diet For Pediatric Reframentioning

confidence: 99%

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Application of ketogenic diets for pediatric neurocritical care

Lin

Wang

2020

Biomedical Journal

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In this review, we summarize the general mechanisms of the ketogenic diet, and the application of a ketogenic diet in pediatric intensive care units for the neurological disorders of children and young infants. A ketogenic diet is a high-fat, low-carbohydrate, adequate-protein diet. It can alter the primary cerebral energy metabolism from glucose to ketone bodies, which involves multiple mechanisms of antiepileptic action, antiepileptogenic properties, neuro-protection, antioxidant and anti-inflammatory effects, and it is potentially a disease-modifying intervention. Although a ketogenic diet is typically used for the chronic stage of pharmacoresistant of epilepsy, recent studies have shown its efficacy in patients with the acute stage of refractory/super-refractory status epilepticus. The application of a ketogenic diet in pediatric intensive care units is a challenge because of the critical status of the patients, who are often in a coma or have a nothing by mouth order. Moreover, a ketogenic diet needs to be started early and sometimes through parenteral administration in patients with critical conditions such as refractory status epilepticus or febrile infection-related epilepsy syndrome. Animal models and some case reports have shown that the neuro-protective effects of a ketogenic diet can be extended to other emergent neurological diseases, such as traumatic brain injury and ischemic stroke.

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Section: A Ketogenic Diet For Super-refractory Status Epilepticusmentioning

confidence: 99%

Section: A Ketogenic Diet For Super-refractory Status Epilepticusmentioning

confidence: 99%

Section: Parenteral Nutrition Of a Ketogenic Diet For Pediatric Reframentioning

confidence: 99%

Section: Parenteral Nutrition Of a Ketogenic Diet For Pediatric Reframentioning

confidence: 99%

See 2 more Smart Citations

Application of ketogenic diets for pediatric neurocritical care

Lin

Wang

2020

Biomedical Journal

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“…When patients continue to have persistent seizure activity after second-line treatment, SE is often considered refractory, with reported mortality of 16-43.5% [45][46][47], though some recent case series also report lower mortality of 17% [48] in pediatric patients. Refractory SE (RSE) is seen in 23-44% of patients with CSE and there is no clear evidence to direct therapy in this phase [13,49].…”

Section: Third-line Therapy Phase (40-60 Min Refractory and Super-rementioning

confidence: 99%

Pharmacotherapy for Pediatric Convulsive Status Epilepticus

2019

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Convulsive status epilepticus (CSE) is one of the most common pediatric neurological emergencies. Ongoing seizure activity is a dynamic process and may be associated with progressive impairment of gamma-aminobutyric acid (GABA)-mediated inhibition due to rapid internalization of GABA A receptors. Further hyperexcitability may be caused by AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) and NMDA (N-methyl-d-aspartic acid) receptors moving from subsynaptic sites to the synaptic membrane. Receptor trafficking during prolonged seizures may contribute to difficulties treating seizures of longer duration and may provide some of the pathophysiological underpinnings of established and refractory SE (RSE). Simultaneously, a practice change toward more rapid initiation of first-line benzodiazepine (BZD) treatment and faster escalation to second-line non-BZD treatment for established SE is in progress. Early administration of the recommended BZD dose is suggested. For second-line treatment, non-BZD anti-seizure medications (ASMs) include valproate, fosphenytoin, or levetiracetam, among others, and at this point there is no clear evidence that any one of these options is better than the others. If seizures continue after second-line ASMs, RSE is manifested. RSE treatment consists of bolus doses and titration of continuous infusions under continuous electro-encephalography (EEG) guidance until electrographic seizure cessation or burst-suppression. Ultimately, etiological workup and related treatment of CSE, including broad spectrum immunotherapies as clinically indicated, is crucial. A potential therapeutic approach for future studies may entail consideration of interventions that may accelerate diagnosis and treatment of SE, as well as rational and early polytherapy based on synergism between ASMs by utilizing medications targeting different mechanisms of epileptogenesis and epileptogenicity.

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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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Treatment options in pediatric super-refractory status epilepticus

Cited by 26 publications

References 20 publications

Application of ketogenic diets for pediatric neurocritical care

Application of ketogenic diets for pediatric neurocritical care

Pharmacotherapy for Pediatric Convulsive Status Epilepticus

Treatment of Refractory Status Epilepticus With Continuous Intravenous Anesthetic Drugs

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