1
|
Dunn EJ, Willis DD. Ketamine for Super-Refractory Status Epilepticus in Palliative Care. A Case Report and Review of the Literature. Am J Hosp Palliat Care 2023:10499091231215491. [PMID: 37982530 DOI: 10.1177/10499091231215491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023] Open
Abstract
We report a case of super refractory status epilepticus uncontrolled by multiple anti-seizure medications in an individual with acute liver failure due to hepatic cirrhosis and an obstructive ileocecal mass plus multiple bilateral lung lesions presumed to be metastatic. A ketamine infusion was initiated late in his hospitalization which eliminated the convulsive seizures in less than an hour. The abatement of convulsive seizures allowed his grieving wife to return to her husband's bedside to witness the withdrawal of life sustaining treatment and be present during the final 24 hours of his life. We review the medical literature on the role of Intravenous (IV) Ketamine in the treatment of super refractory status epilepticus.
Collapse
Affiliation(s)
- Edward J Dunn
- U of L Health - Jewish Hospital Palliative Care, Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA
- U of L Health - Jewish Hospital, University of Louisville School of Medicine, Louisville, KY, USA
| | - David D Willis
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
2
|
The Role of Glutamate Receptors in Epilepsy. Biomedicines 2023; 11:biomedicines11030783. [PMID: 36979762 PMCID: PMC10045847 DOI: 10.3390/biomedicines11030783] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/26/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Glutamate is an essential excitatory neurotransmitter in the central nervous system, playing an indispensable role in neuronal development and memory formation. The dysregulation of glutamate receptors and the glutamatergic system is involved in numerous neurological and psychiatric disorders, especially epilepsy. There are two main classes of glutamate receptor, namely ionotropic and metabotropic (mGluRs) receptors. The former stimulate fast excitatory neurotransmission, are N-methyl-d-aspartate (NMDA), α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA), and kainate; while the latter are G-protein-coupled receptors that mediate glutamatergic activity via intracellular messenger systems. Glutamate, glutamate receptors, and regulation of astrocytes are significantly involved in the pathogenesis of acute seizure and chronic epilepsy. Some glutamate receptor antagonists have been shown to be effective for the treatment of epilepsy, and research and clinical trials are ongoing.
Collapse
|
3
|
Treatment of refractory status epilepticus with intravenous anesthetic agents: A systematic review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.1016/j.tacc.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
4
|
Roynard P, Bilderback A, Dewey CW. Intravenous Ketamine Bolus(es) for the Treatment of Status Epilepticus, Refractory Status Epilepticus, and Cluster Seizures: A Retrospective Study of 15 Dogs. Front Vet Sci 2021; 8:547279. [PMID: 33681317 PMCID: PMC7925624 DOI: 10.3389/fvets.2021.547279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 01/07/2021] [Indexed: 12/02/2022] Open
Abstract
Status epilepticus (SE) and cluster seizures (CS) are common occurrences in veterinary neurology and frequent reasons of admission to veterinary hospitals. With prolonged seizure activity, gamma amino-butyric acid (GABA) receptors (GABAa receptors) become inactive, leading to a state of pharmacoresistance to benzodiazepines and other GABAergic medications, which is called refractory status epilepticus (RSE). Prolonged seizure activity is also associated with overexpression of N-methyl-D-aspartic (NMDA) receptors. Rodent models have shown the efficacy of ketamine (KET) in treating RSE, and its use has been reported in one canine case of RSE. Boluses of KET 5 mg/kg IV have become the preferred treatment for RSE in our hospital. A retrospective study was performed to evaluate and report our experience with KET IV bolus to treat prolonged and/or repeated seizure activity in cases of canine CS, SE, and RSE. A total of 15 dogs were retrieved, for 20 hospitalizations and 28 KET IV injections over 3 years. KET IV boluses were used 12 times for RSE (9 generalized seizures, 3 focal seizures) and KET terminated the episode of RSE 12/12 times (100%); however, seizures recurred 4/12 times (33%) within ≤6 h of KET IV bolus. When used for CS apart from episodes of RSE, KET IV bolus was associated with termination of the CS episode only 4/14 times (29%). Only 4/28 (14%) KET IV boluses were associated with adverse effects imputable only to the use of KET. One dog experienced a short, self-limited seizure activity during administration of KET IV, which was most likely related to a pre-mature use of KET IV (i.e., before GABAergic resistance and NMDA receptor overexpression had taken place). This study indicates that KET 5 mg/kg IV bolus may be successful for the treatment of RSE in dogs.
Collapse
Affiliation(s)
- Patrick Roynard
- Long Island Veterinary Specialists, Department of Neurology/Neurosurgery, Plainview, NY, United States
| | - Ann Bilderback
- VCA Northwest Veterinary Specialists, Clackamas, OR, United States
| | | |
Collapse
|
5
|
Der-Nigoghossian C, Tesoro EP, Strein M, Brophy GM. Principles of Pharmacotherapy of Seizures and Status Epilepticus. Semin Neurol 2020; 40:681-695. [PMID: 33176370 DOI: 10.1055/s-0040-1718721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Status epilepticus is a neurological emergency with an outcome that is highly associated with the initial pharmacotherapy management that must be administered in a timely fashion. Beyond first-line therapy of status epilepticus, treatment is not guided by robust evidence. Optimal pharmacotherapy selection for individual patients is essential in the management of seizures and status epilepticus with careful evaluation of pharmacokinetic and pharmacodynamic factors. With the addition of newer antiseizure agents to the market, understanding their role in the management of status epilepticus is critical. Etiology-guided therapy should be considered in certain patients with drug-induced seizures, alcohol withdrawal, or autoimmune encephalitis. Some patient populations warrant special consideration, such as pediatric, pregnant, elderly, and the critically ill. Seizure prophylaxis is indicated in select patients with acute neurological injury and should be limited to the acute postinjury period.
Collapse
Affiliation(s)
- Caroline Der-Nigoghossian
- Department of Pharmacy, Neurosciences Intensive Care Unit, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Eljim P Tesoro
- Department of Pharmacy Practice (MC 886), College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Micheal Strein
- Pharmacotherapy and Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
| | - Gretchen M Brophy
- Pharmacotherapy and Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
| |
Collapse
|
6
|
Alkhachroum A, Der-Nigoghossian CA, Mathews E, Massad N, Letchinger R, Doyle K, Chiu WT, Kromm J, Rubinos C, Velazquez A, Roh D, Agarwal S, Park S, Connolly ES, Claassen J. Ketamine to treat super-refractory status epilepticus. Neurology 2020; 95:e2286-e2294. [PMID: 32873691 DOI: 10.1212/wnl.0000000000010611] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 05/14/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test ketamine infusion efficacy in the treatment of super-refractory status epilepticus (SRSE), we studied patients with SRSE who were treated with ketamine retrospectively. We also studied the effect of high doses of ketamine on brain physiology as reflected by invasive multimodality monitoring (MMM). METHODS We studied a consecutive series of 68 patients with SRSE who were admitted between 2009 and 2018, treated with ketamine, and monitored with scalp EEG. Eleven of these patients underwent MMM at the time of ketamine administration. We compared patients who had seizure cessation after ketamine initiation to those who did not. RESULTS Mean age was 53 ± 18 years and 46% of patients were female. Seizure burden decreased by at least 50% within 24 hours of starting ketamine in 55 (81%) patients, with complete cessation in 43 (63%). Average dose of ketamine infusion was 2.2 ± 1.8 mg/kg/h, with median duration of 2 (1-4) days. Average dose of midazolam was 1.0 ± 0.8 mg/kg/h at the time of ketamine initiation and was started at a median of 0.4 (0.1-1.0) days before ketamine. Using a generalized linear mixed effect model, ketamine was associated with stable mean arterial pressure (odds ratio 1.39, 95% confidence interval 1.38-1.40) and with decreased vasopressor requirements over time. We found no effect on intracranial pressure, cerebral blood flow, or cerebral perfusion pressure. CONCLUSION Ketamine treatment was associated with a decrease in seizure burden in patients with SRSE. Our data support the notion that high-dose ketamine infusions are associated with decreased vasopressor requirements without increased intracranial pressure. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that ketamine decreases seizures in patients with SRSE.
Collapse
Affiliation(s)
- Ayham Alkhachroum
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Caroline A Der-Nigoghossian
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Elizabeth Mathews
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Nina Massad
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Riva Letchinger
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Kevin Doyle
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Wei-Ting Chiu
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Julie Kromm
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Clio Rubinos
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Angela Velazquez
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - David Roh
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Sachin Agarwal
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Soojin Park
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - E Sander Connolly
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada
| | - Jan Claassen
- From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada.
| |
Collapse
|
7
|
Sabharwal V, Poongkunran M, Talahma M, Iwuchukwu IO, Ramsay E, Khan F, Menon U, Ciccotto G, Khandker N, McGrade H. Secondary hypothermia in patients with super-refractory status epilepticus managed with propofol and ketamine. Epilepsy Behav 2020; 105:106960. [PMID: 32092461 DOI: 10.1016/j.yebeh.2020.106960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 01/24/2020] [Accepted: 02/01/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Therapeutic hypothermia as a potent nonpharmacologic antiseizure therapy has been investigated experimentally in animal models and humans. Although induced hypothermia has been shown to be neuroprotective in acute convulsive status epilepticus, whether its use will translate into improved outcomes for patients with super-refractory nonconvulsive status epilepticus (SRNCSE) has been debated. No clinical data are available on the occurrence and prognostic impact of secondary hypothermia (s-HT) in patients with SRNCSE. With the possibility of core to periphery redistribution of heat with propofol and a centrally mediated dose-dependent fall in body temperature with ketamine, we aimed to investigate the incidence of s-HT events in patients with SRNCSE managed with propofol and ketamine and their impact on clinical outcomes. METHODS We performed a retrospective observational analysis of consecutive patients with SRNCSE managed with propofol and/or ketamine in a single-center neurological intensive care unit between December 1, 2012 and December 31, 2015. Patients were divided according to the occurrence of hypothermia (temperature < 35.0 °C) into an s-HT group and a nonhypothermia (n-HT) group. Patients who received targeted temperature management therapy were excluded. We compared the demographics, comorbidities, treatment characteristics, and outcomes between groups. RESULTS Ninety-nine consecutive patients with SRNCSE managed with propofol and/or ketamine were identified during the study period. Twenty patients who received targeted temperature management were excluded, leaving a total of 79 patients for analysis. Hypothermia was observed in 52% (41/79) of the study population. Ketamine was used in 63/79 patients (80%). Ketamine infusion rates were higher and of longer duration among patients who developed s-HT compared with those who did not (mean dosage: 57.35 ± 26.6 mcg/kg/min vs 37.17 ± 15 mcg/kg/min, P = 0.001; duration: 116.36 ± 81.9 h vs 88 ± 89.7 h, P = 0.048). Propofol was used in 78/79 patients (99%), with no significant differences in characteristics between groups (mean dosage: 46.44 ± 20.2 mcg/kg/min vs 36.9 ± 12.9 mcg/kg/min, P = 0.058; duration: 125.43 ± 96.4 h vs 102.3 ± 87.1 h, P = 0.215). No significant differences in demographics, comorbidities, status epilepticus duration and resolution rates, and outcomes were observed between groups. CONCLUSION In this single-center retrospective analysis of patients whose SRNCSE is being treated, higher doses and longer durations of ketamine were associated with the occurrence of s-HT. Further investigation is warranted to clarify the thermogenic effects of ketamine and its effect on status epilepticus outcomes.
Collapse
Affiliation(s)
- Vivek Sabharwal
- Department of Neuro Critical Care, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA, United States of America.
| | - Mugilan Poongkunran
- Department of Neurology, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA, United States of America
| | - Murad Talahma
- Department of Neuro Critical Care, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA, United States of America
| | - Ifeanyi O Iwuchukwu
- Department of Neuro Critical Care, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA, United States of America
| | - Eugene Ramsay
- The International Center for Epilepsy at Ochsner, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA, United States of America
| | - Fawad Khan
- The International Center for Epilepsy at Ochsner, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA, United States of America
| | - Uma Menon
- The International Center for Epilepsy at Ochsner, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA, United States of America
| | - Giuseppe Ciccotto
- Department of Neuro Critical Care, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA, United States of America
| | - Namir Khandker
- Department of Neuro Critical Care, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA, United States of America
| | - Harold McGrade
- Department of Neuro Critical Care, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA, United States of America
| |
Collapse
|
8
|
Kramer AH, Kromm J. Quantitative Continuous EEG: Bridging the Gap Between the ICU Bedside and the EEG Interpreter. Neurocrit Care 2020; 30:499-504. [PMID: 30788706 DOI: 10.1007/s12028-019-00694-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Andreas H Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada.
| | - Julie Kromm
- Departments of Critical Care Medicine and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| |
Collapse
|
9
|
Minicucci F, Ferlisi M, Brigo F, Mecarelli O, Meletti S, Aguglia U, Michelucci R, Mastrangelo M, Specchio N, Sartori S, Tinuper P. Management of status epilepticus in adults. Position paper of the Italian League against Epilepsy. Epilepsy Behav 2020; 102:106675. [PMID: 31766004 DOI: 10.1016/j.yebeh.2019.106675] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/30/2019] [Accepted: 10/30/2019] [Indexed: 01/15/2023]
Abstract
Since the publication of the Italian League Against Epilepsy guidelines for the treatment of status epilepticus in 2006, advances in the field have ushered in improvements in the therapeutic arsenal. The present position paper provides neurologists, epileptologists, neurointensive care specialists, and emergency physicians with updated recommendations for the treatment of adult patients with status epilepticus. The aim is to standardize treatment recommendations in the care of this patient population.
Collapse
Affiliation(s)
- Fabio Minicucci
- Epilepsy Center, Unit of Neurophysiology, Neurological Department, IRCCS San Raffaele Hospital, Milan, Italy.
| | - Monica Ferlisi
- Division of Neurology A, Azienda Ospedaliera Universitaria Integrata, Verona, Italy.
| | - Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy; Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy
| | - Oriano Mecarelli
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy.
| | - Stefano Meletti
- Department of Biomedical, Metabolic and Neural Sciences, Center for Neurosciences and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy.
| | - Umberto Aguglia
- Epilepsy Center, Department of Medical and Surgical Sciences Regional, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Roberto Michelucci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unit of Neurology, Bellaria Hospital, Bologna, Italy.
| | - Massimo Mastrangelo
- Pediatric Neurology Unit, "V. Buzzi" Children's Hospital, Pediatrics Department, ASST Fatebenefratelli Sacco, Milan, Italy.
| | - Nicola Specchio
- Department of Neuroscience, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.
| | - Paolo Tinuper
- IRCCS Istituto delle Scienze Neurologiche, Bellaria Hospital, Bologna, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy.
| |
Collapse
|
10
|
Meaden CW, Barnes S. Ketamine Implicated in New Onset Seizure. Clin Pract Cases Emerg Med 2019; 3:401-404. [PMID: 31763599 PMCID: PMC6861038 DOI: 10.5811/cpcem.2019.9.44271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/20/2019] [Accepted: 09/10/2019] [Indexed: 11/30/2022] Open
Abstract
Ketamine is used widely in emergency departments for a variety of purposes, including procedural sedation and pain management. A major benefit of using ketamine is the rapid onset and lack of respiratory depression. The known side effects include emergence reactions, hallucinations, hypertension, dizziness, nausea, and vomiting. Recent studies have shown the benefit of ketamine for refractory status epilepticus; however, this application of the drug is still being studied. We present a case where ketamine likely induced a seizure in a patient on whom it was used as a single agent in procedural sedation. Seizure is not a known side effect of ketamine in patients without a seizure history. Given the eagerness over additional uses for ketamine, this novel case of a seizure following procedural sedation with ketamine should be of interest to emergency providers.
Collapse
Affiliation(s)
- Christopher W Meaden
- St. Joseph's University Medical Center, Department of Emergency Medicine, Paterson, New Jersey
| | - Stacey Barnes
- St. Joseph's University Medical Center, Department of Emergency Medicine, Paterson, New Jersey
| |
Collapse
|
11
|
Status Epilepticus in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
12
|
Fujikawa DG. Starting ketamine for neuroprotection earlier than its current use as an anesthetic/antiepileptic drug late in refractory status epilepticus. Epilepsia 2019; 60:373-380. [PMID: 30785224 DOI: 10.1111/epi.14676] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 12/26/2022]
Abstract
Ketamine is currently being used as an anesthetic/antiepileptic drug in refractory status epilepticus. To validate its use, 2 clinical trials are recruiting patients. However, preclinical studies of its use in chemically induced status epilepticus in rodents have shown that it is remarkably neuroprotective, through N-methyl-d-aspartate-receptor blockade, even when given after the onset of status epilepticus. Human studies have shown that status epilepticus-induced brain damage can be caused by a glutamate analogue and that it occurs in the same brain regions as in the animal studies. We therefore propose that ketamine be started early in the course of human status epilepticus as a neuroprotectant and that it be continued until epileptic discharges are eliminated. Using it as an anesthetic/antiepileptic drug late in the course of refractory status epilepticus only ensures that it is given after widespread brain damage has occurred.
Collapse
Affiliation(s)
- Denson G Fujikawa
- Neurology Department, VA Greater Los Angeles Healthcare System, Sepulveda Ambulatory Care Center and Nursing Home, North Hills, California.,Department of Neurology and Brain Research Institute, David Geffen School of Medicine, Los Angeles, California
| |
Collapse
|
13
|
Golub D, Yanai A, Darzi K, Papadopoulos J, Kaufman B. Potential consequences of high-dose infusion of ketamine for refractory status epilepticus: case reports and systematic literature review. Anaesth Intensive Care 2018; 46:516-528. [PMID: 30189827 DOI: 10.1177/0310057x1804600514] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Our goal was to provide comprehensive data on the effectiveness of ketamine in refractory status epilepticus (RSE) and to describe the potential consequences of long-term ketamine infusion. Ketamine, an N-methyl D-aspartate (NMDA) receptor antagonist, blocks excitatory pathways contributing to ongoing seizure. While ketamine use is standard in anaesthetic induction, no definitive protocol exists for its use in RSE, and little is known about its adverse effects in long-term, high-dose administration. We present two cases of RSE that responded rapidly to ketamine infusion, both with fatal outcomes secondary to metabolic acidosis and cardiovascular collapse. We performed a systematic review of the application and consequences of ketamine use in RSE. PubMed, Ovid, MEDLINE and PMC were searched for articles describing ketamine treatment for RSE according to a predetermined search strategy and inclusion criteria. The systematic review revealed wide discrepancies in ketamine dosing (infusion maintenance dose range 0.0075-10.5 mg/kg/hour), but good outcomes in medically managed RSE (75% of studies reported moderate or complete seizure control in adults, 62.5% in paediatrics). Additionally, literature review elucidated a potentially causal relationship between prolonged ketamine infusion and both cardiovascular and metabolic dysregulation. Ketamine is effective in RSE by antagonising excitotoxic NMDA receptors. However, there is high variability in ketamine dosing and scarce data on its safety in long-term infusion. Metabolic acidosis and haemodynamic instability associated with the use of long-term, high-dose ketamine infusions must be of concern to clinicians administering ketamine to critically ill patients.
Collapse
Affiliation(s)
| | | | | | | | - B Kaufman
- Professor, Departments of Medicine, Anesthesiology, Neurology and Neurosurgery, NYU School of Medicine, New York, NY, USA
| |
Collapse
|
14
|
Abstract
BACKGROUND Ketamine is an emerging third-line medication for refractory status epilepticus, a medical and neurological emergency requiring prompt and appropriate treatment. Owing to its pharmacological properties, ketamine represents a practical alternative to conventional anaesthetics. OBJECTIVE The objective of this study was to assess the efficacy and safety of ketamine to treat refractory status epilepticus in paediatric and adult populations. METHODS We conducted a literature search using the PubMed database, Cochrane Database of Systematic Reviews and ClinicalTrials.gov website. RESULTS We found no results from randomised controlled trials. The literature included 27 case reports accounting for 30 individuals and 14 case series, six of which included children. Overall, 248 individuals (29 children) with a median age of 43.5 years (range 2 months to 67 years) were treated in 12 case series whose sample size ranged from 5 to 67 patients (median 11). Regardless of the status epilepticus type, ketamine was twice as effective if administered early, with an efficacy rate as high as 64% in refractory status epilepticus lasting 3 days and dropping to 32% when the mean refractory status epilepticus duration was 26.5 days. Ketamine doses were extremely heterogeneous and did not appear to be an independent prognostic factor. Endotracheal intubation, a negative prognostic factor for status epilepticus, was unnecessary in 12 individuals (10 children), seven of whom were treated with oral ketamine for non-convulsive status epilepticus. CONCLUSIONS Although ketamine has proven to be effective in treating refractory status epilepticus, available studies are hampered by methodological limitations that prevent any firm conclusion. Results from two ongoing studies (ClinicalTrials.gov identification number: NCT02431663 and NCT03115489) and further clinical trials will hopefully confirm the better efficacy and safety profile of ketamine compared with conventional anaesthetics as third-line therapy in refractory status epilepticus, both in paediatric and adult populations.
Collapse
Affiliation(s)
- Anna Rosati
- Neuroscience Department, Children's Hospital Anna Meyer, University of Florence, Viale Pieraccini 24, 50139, Florence, Italy
| | | | - Renzo Guerrini
- Neuroscience Department, Children's Hospital Anna Meyer, University of Florence, Viale Pieraccini 24, 50139, Florence, Italy.
| |
Collapse
|
15
|
Höfler J, Trinka E. Intravenous ketamine in status epilepticus. Epilepsia 2018; 59 Suppl 2:198-206. [DOI: 10.1111/epi.14480] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Julia Höfler
- Department of Neurology; Paracelsus Medical University Salzburg and Christian Doppler Medical Center; Salzburg Austria
| | - Eugen Trinka
- Department of Neurology; Paracelsus Medical University Salzburg and Christian Doppler Medical Center; Salzburg Austria
| |
Collapse
|
16
|
Poblete R, Sung G. Status Epilepticus and Beyond: A Clinical Review of Status Epilepticus and an Update on Current Management Strategies in Super-refractory Status Epilepticus. Korean J Crit Care Med 2017; 32:89-105. [PMID: 31723624 PMCID: PMC6786704 DOI: 10.4266/kjccm.2017.00252] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/05/2017] [Indexed: 12/03/2022] Open
Abstract
Status epilepticus and refractory status epilepticus represent some of the most complex conditions encountered in the neurological intensive care unit. Challenges in management are common as treatment options become limited and prolonged hospital courses are accompanied by complications and worsening patient outcomes. Antiepileptic drug treatments have become increasingly complex. Rational polytherapy should consider the pharmacodynamics and kinetics of medications. When seizures cannot be controlled with medical therapy, alternative treatments, including early surgical evaluation can be considered; however, evidence is limited. This review provides a brief overview of status epilepticus, and a recent update on the management of refractory status epilepticus based on evidence from the literature, evidence-based guidelines, and experiences at our institution.
Collapse
Affiliation(s)
- Roy Poblete
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Gene Sung
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
17
|
Continuous Infusion Antiepileptic Medications for Refractory Status Epilepticus: A Review for Nurses. Crit Care Nurs Q 2016; 40:67-85. [PMID: 27893511 DOI: 10.1097/cnq.0000000000000143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Status epilepticus requires treatment with emergent initial therapy with a benzodiazepine and urgent control therapy with an additional antiepileptic drug (AED) to terminate clinical and/or electrographic seizure activity. However, nearly one-third of patients will prove refractory to the aforementioned therapies and are prone to a higher degree of neuronal injury, resistance to pharmacotherapy, and death. Current guidelines for refractory status epilepticus (RSE) recommend initiating a continuous intravenous (CIV) anesthetic over bolus dosing with a different AED. Continuous intravenous agents most commonly used for this indication include midazolam, propofol, and pentobarbital, but ketamine is an alternative option. Comparative studies illustrating the optimal agent are lacking, and selection is often based on adverse effect profiles and patient-specific factors. In addition, dosing and titration are largely based on small studies and expert opinion with continuous electroencephalogram monitoring used to guide intensity and duration of treatment. Nonetheless, the doses required to halt seizure activity are likely to produce profound adverse effects that clinicians should anticipate and combat. The purpose of this review was to summarize the available RSE literature focusing on CIV midazolam, pentobarbital, propofol, and ketamine, and to serve as a primer for nurses providing care to these patients.
Collapse
|
18
|
25 years of advances in the definition, classification and treatment of status epilepticus. Seizure 2016; 44:65-73. [PMID: 27890484 DOI: 10.1016/j.seizure.2016.11.001] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 11/01/2016] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Status epilepticus (SE) requires not only urgent symptomatic treatment with antiepileptic drugs but also rapid identification and treatment of its cause. This narrative review summarizes the most important advances in classification and treatment of SE. METHOD Data sources included MEDLINE, EMBASE, ClinicalTrials.gov, and back tracking of references in pertinent studies, reviews, and books. RESULTS SE is now defined as "a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally, prolonged seizures (after time point t1). It is a condition, which can have long-term consequences (after time point t2), including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures." A new diagnostic classification system of SE introduces four axes: semiology, aetiology, EEG correlates, and age. For the acute treatment intravenous benzodiazepines (lorazepam, diazepam, clonazepam) and intramuscular midazolam appear as most effective treatments for early SE. In children, buccal or intranasal midazolam are useful alternatives. In established SE intravenous antiepileptic drugs (phenytoin, valproate, levetiracetam, phenobarbital, and lacosamide) are in use. Treatment options in refractory SE are intravenous anaesthetics; ketamine, magnesium, steroids and other drugs have been used in super-refractory SE with variable outcomes. CONCLUSION Over the past 25 years major advances in definition, classification and understanding of its mechanisms have been achieved. Despite this up to 40% of patients in early status cannot be controlled with first line drugs. The treatment of super-refractory status is still an almost evidence free zone.
Collapse
|
19
|
Abstract
OBJECTIVES We described the use of adjunctive ketamine to terminate seizure activity and decrease the dose and duration of pentobarbital coma in 2 patients with refractory status epilepticus (SE). CASES A 56-year-old woman (patient 1) developed SE after cardiac arrest, which was refractory to antiepileptic agents and escalating doses of continuous midazolam. Midazolam was replaced with pentobarbital infusion with no significant change in electroencephalography. A continuous ketamine infusion was initiated as an adjunct to pentobarbital. After initiation of ketamine, seizure frequency decreased and sustained burst suppression was achieved. After 48 hours of induced burst suppression, pentobarbital was discontinued followed by ketamine and the patient remained seizure on oral anticonvulsants alone. Meanwhile, a 57-year-old woman (patient 2) with autoimmune encephalitis developed SE, which was refractory to first-line medications. Pentobarbital infusion was initiated with attainment of burst suppression on electroencephalography. Multiple attempts at weaning pentobarbital failed because of recurrence of seizures. To minimize the dose of pentobarbital needed, a continuous ketamine infusion was initiated as an adjunct to pentobarbital with maintenance of burst suppression at much lower doses of pentobarbital than before. Ketamine was continued for 19 days with titration of other antiepileptic therapy, without return of SE. CONCLUSIONS These cases demonstrate that ketamine may show promise as an adjunct to induced pentobarbital coma for refractory SE. Adjunctive use of ketamine may reduce the dose and duration of pentobarbital required, hence preventing complications associated with barbiturate therapy. Future studies are needed to define the optimal dose, timing, and role of ketamine infusions in the management of refractory SE.
Collapse
|
20
|
Reznik ME, Berger K, Claassen J. Comparison of Intravenous Anesthetic Agents for the Treatment of Refractory Status Epilepticus. J Clin Med 2016; 5:jcm5050054. [PMID: 27213459 PMCID: PMC4882483 DOI: 10.3390/jcm5050054] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/08/2016] [Accepted: 05/16/2016] [Indexed: 11/16/2022] Open
Abstract
Status epilepticus that cannot be controlled with first- and second-line agents is called refractory status epilepticus (RSE), a condition that is associated with significant morbidity and mortality. Most experts agree that treatment of RSE necessitates the use of continuous infusion intravenous anesthetic drugs such as midazolam, propofol, pentobarbital, thiopental, and ketamine, each of which has its own unique characteristics. This review compares the various anesthetic agents while providing an approach to their use in adult patients, along with possible associated complications.
Collapse
Affiliation(s)
- Michael E Reznik
- Department of Critical Care Neurology, Columbia University Medical Center, New York, NY 10032, USA.
| | - Karen Berger
- Department of Pharmacy, Weill Cornell Medical Center, New York, NY 10065, USA.
| | - Jan Claassen
- Department of Critical Care Neurology, Columbia University Medical Center, New York, NY 10032, USA.
| |
Collapse
|
21
|
Bayrlee A, Ganeshalingam N, Kurczewski L, Brophy GM. Treatment of Super-Refractory Status Epilepticus. Curr Neurol Neurosci Rep 2016; 15:66. [PMID: 26299274 DOI: 10.1007/s11910-015-0589-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Super-refractory status epilepticus (SRSE) is a devastating neurological condition with limited treatment options. We conducted an extensive literature search to identify and summarize the therapeutic options for SRSE. The search mainly resulted in case reports of various pharmacologic and non-pharmacologic treatments. The success rate of each of the following agents, ketamine, inhaled anesthetics, intravenous immunoglobulin G (IVIG), IV steroids, ketogenic diet, hypothermia, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and vagal nerve stimulation (VNS), are discussed in greater detail. The choice of appropriate treatment options for a given patient is based on clinical presentation. This review focuses on evidence-based, pharmacotherapeutic strategies for patients in SRSE.
Collapse
Affiliation(s)
- Ahmad Bayrlee
- Department of Neurology, Virginia Commonwealth University, P.O. Box 980599, Richmond, VA, 23298, USA,
| | | | | | | |
Collapse
|
22
|
Abstract
Nonconvulsive status epilepticus (NCSE) is a state of continuous or repetitive seizures without convulsions. Owing to the nonspecific symptoms and considerable morbidity and mortality associated with NCSE, clinical research has focused on early diagnosis, risk stratification and seizure termination. The subtle symptoms and the necessity for electroencephalographic confirmation of seizures result in under-diagnosis with deleterious consequences. The introduction of continuous EEG to clinical practice, and the characterization of electrographic criteria have delineated a number of NCSE types that are associated with different prognoses in several clinical settings. Epidemiological studies have uncovered risk factors for NCSE; knowledge of these factors, together with particular clinical characteristics and EEG observations, enables tailored treatment. Despite these advances, NCSE can be refractory to antiepileptic drugs, necessitating further escalation of treatment. The presumptive escalation to anaesthetics, however, has recently been questioned owing to an association with increased mortality. This Review compiles epidemiological, clinical and diagnostic aspects of NCSE, and considers current treatment options and prognosis.
Collapse
|
23
|
Trinka E, Höfler J, Leitinger M, Rohracher A, Kalss G, Brigo F. Pharmacologic treatment of status epilepticus. Expert Opin Pharmacother 2016; 17:513-34. [DOI: 10.1517/14656566.2016.1127354] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
24
|
Lionel KR, Hrishi AP. Seizures - just the tip of the iceberg: Critical care management of super-refractory status epilepticus. Indian J Crit Care Med 2016; 20:587-592. [PMID: 27829714 PMCID: PMC5073773 DOI: 10.4103/0972-5229.192047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is defined as status epilepticus (SE) that continues or recurs 24 h or more after the onset of anesthetic therapy, including those cases where SE recurs on the reduction or withdrawal of anesthesia. Although SRSE is a rare clinical problem, it is associated with high mortality and morbidity rates. This article reviews the treatment approaches and the systemic complications commonly encountered in patients with SRSE. As evident in our search of literature, therapy for SRSE and its complications have been based on clinical reports and expert opinions since there is a lack of controlled and randomized trials. Even though this complex condition starts as a neurological disorder, because of the associated systemic complications, it can be considered as a multisystem disorder requiring scrupulous attention and deliberate efforts to prevent, detect, and treat these systemic effects. We have critically reviewed the intensive care management for SRSE per se as well as its associated systemic complications. We believe that a good recovery can occur even after prolonged and severe SRSE as long as the systemic complications are detected early and managed appropriately.
Collapse
Affiliation(s)
- Karen Ruby Lionel
- Department of Neuroanesthesia and Neurocritical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ajay Prasad Hrishi
- Department of Neuroanesthesia and Neurocritical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| |
Collapse
|
25
|
Höfler J, Rohracher A, Kalss G, Zimmermann G, Dobesberger J, Pilz G, Leitinger M, Kuchukhidze G, Butz K, Taylor A, Novak H, Trinka E. (S)-Ketamine in Refractory and Super-Refractory Status Epilepticus: A Retrospective Study. CNS Drugs 2016; 30:869-76. [PMID: 27465262 PMCID: PMC4996879 DOI: 10.1007/s40263-016-0371-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aim was to describe the safety and efficacy of (S)-ketamine [(S)-KET] in a series of patients with refractory and super-refractory status epilepticus (RSE and SRSE) in a specialized neurological intensive care unit (NICU). METHODS We retrospectively analyzed the data of patients with RSE and SRSE treated with (S)-KET in the NICU, Salzburg, Austria, from 2011 to 2015. Data collection included demographic features, clinical presentation, diagnosis, electroencephalogram (EEG) data, anticonvulsant treatment, timing, and duration of treatment with (S)-KET. Outcomes were seizure control and death. RESULTS A total of 42 patients (14 women) with RSE and SRSE were treated with (S)-KET. The median duration of status epilepticus (SE) was 10 days [first quartile (Q1) 5.0, Q3 21.0]; the median latency from SE onset to the first administration of (S)-KET was 3 days (Q1 2.0, Q3 6.8). Prior to (S)-KET administration, patients had received a median of two (Q1 2.0, Q3 3.0) anesthetics and three (Q1 2.0, Q3 4.0) antiepileptic drugs. Forty percent of patients (17/42) received propofol: 65 % prior to (S)-KET; 35 % at the same time with (S)-KET. Seven patients received a median bolus of (S)-KET of 200 mg (Q1 200, Q3 250) followed by a continuous infusion, while 35 started with a continuous infusion (maximum rate median 2.55 mg/kg/h; Q1 2.09, Q3 3.22). In 64 % of patients (27/42), (S)-KET was the last drug before SE cessation; in five patients, it was given with propofol at the same time. Median duration of administration was 4 days (Q1 2.0, Q3 6.8). Overall (S)-KET treatment was well tolerated, adverse effects were not observed, and overall mortality was 45.2 %. CONCLUSIONS Treatment of SRSE in adult patients with (S)-KET led to resolution of status in 64 %. No adverse events were found, indicating a favorable safety profile.
Collapse
Affiliation(s)
- Julia Höfler
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Alexandra Rohracher
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Georg Zimmermann
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria ,Department of Mathematics, Paris Lodron University, Salzburg, Austria
| | - Judith Dobesberger
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Georg Pilz
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Markus Leitinger
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Giorgi Kuchukhidze
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria ,Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Kevin Butz
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria ,Department of Psychology, Paris Lodron University, Salzburg, Austria
| | - Alexandra Taylor
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria ,Department of Psychology, Paris Lodron University, Salzburg, Austria
| | - Helmut Novak
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria. .,Centre for Cognitive Neuroscience, Salzburg, Austria.
| |
Collapse
|
26
|
Chen HY, Albertson TE, Olson KR. Treatment of drug-induced seizures. Br J Clin Pharmacol 2015; 81:412-9. [PMID: 26174744 DOI: 10.1111/bcp.12720] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/03/2015] [Accepted: 07/07/2015] [Indexed: 01/01/2023] Open
Abstract
Seizures are a common complication of drug intoxication, and up to 9% of status epilepticus cases are caused by a drug or poison. While the specific drugs associated with drug-induced seizures may vary by geography and change over time, common reported causes include antidepressants, stimulants and antihistamines. Seizures occur generally as a result of inadequate inhibitory influences (e.g., gamma aminobutyric acid, GABA) or excessive excitatory stimulation (e.g. glutamate) although many other neurotransmitters play a role. Most drug-induced seizures are self-limited. However, status epilepticus occurs in up to 10% of cases. Prolonged or recurrent seizures can lead to serious complications and require vigorous supportive care and anticonvulsant drugs. Benzodiazepines are generally accepted as the first line anticonvulsant therapy for drug-induced seizures. If benzodiazepines fail to halt seizures promptly, second line drugs include barbiturates and propofol. If isoniazid poisoning is a possibility, pyridoxine is given. Continuous infusion of one or more anticonvulsants may be required in refractory status epilepticus. There is no role for phenytoin in the treatment of drug-induced seizures. The potential role of ketamine and levetiracetam is promising but not established.
Collapse
Affiliation(s)
- Hsien-Yi Chen
- California Poison Control System, Department of Clinical Pharmacy, University of California, San Francisco, USA.,Department of Emergency Medicine, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Clinical Pharmacology & Toxicology, San Francisco General Hospital, San Francisco, USA
| | - Timothy E Albertson
- California Poison Control System, Department of Clinical Pharmacy, University of California, San Francisco, USA.,Department of Internal Medicine, University of California Davis School of Medicine and Veterans Administration Northern California Health Care System, California
| | - Kent R Olson
- California Poison Control System, Department of Clinical Pharmacy, University of California, San Francisco, USA.,Division of Clinical Pharmacology & Toxicology, San Francisco General Hospital, San Francisco, USA
| |
Collapse
|
27
|
Abstract
Status epilepticus (SE) represents the most severe form of epilepsy. It is one of the most common neurologic emergencies, with an incidence of up to 61 per 100,000 per year and an estimated mortality of 20 %. Clinically, tonic-clonic convulsive SE is divided into four subsequent stages: early, established, refractory, and super-refractory. Pharmacotherapy of status epilepticus, especially of its later stages, represents an "evidence-free zone," due to a lack of high-quality, controlled trials to inform clinical decisions. This comprehensive narrative review focuses on the pharmacotherapy of SE, presented according to the four-staged approach outlined above, and providing pharmacological properties and efficacy/safety data for each antiepileptic drug according to the strength of scientific evidence from the available literature. Data sources included MEDLINE and back-tracking of references in pertinent studies. Intravenous lorazepam or intramuscular midazolam effectively control early SE in approximately 63-73 % of patients. Despite a suboptimal safety profile, intravenous phenytoin or phenobarbital are widely used treatments for established SE; alternatives include valproate, levetiracetam, and lacosamide. Anesthetics are widely used in refractory and super-refractory SE, despite the current lack of trials in this field. Data on alternative treatments in the later stages are limited. Valproate and levetiracetam represent safe and effective alternatives to phenobarbital and phenytoin for treatment of established SE persisting despite first-line treatment with benzodiazepines. To date there are no class I data to support recommendations for most antiepileptic drugs for established, refractory, and super-refractory SE. Limiting the methodologic heterogeneity across studies is required and high-class randomized, controlled trials to inform clinicians about the best treatment in established and refractory status are needed.
Collapse
Affiliation(s)
- Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University Salzburg, Ignaz Harrerstrasse 79, 5020, Salzburg, Austria,
| | | | | | | |
Collapse
|
28
|
|
29
|
|
30
|
Tarocco A, Ballardini E, Garani G. Use of ketamine in a newborn with refractory status epilepticus: a case report. Pediatr Neurol 2014; 51:154-6. [PMID: 24938144 DOI: 10.1016/j.pediatrneurol.2014.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 03/05/2014] [Accepted: 03/10/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Brain malformations represent a major cause of refractory seizures. Standardized protocols to treat status epilepticus of newborn are not available in the literature. PATIENT We present a case report of use of ketamine administered to a late preterm with Pierre Robin sequence, lissencephaly, polymicrogyria, and severe epilepsy. RESULTS The infusion of ketamine permitted resolution of status epilepticus, cardiorespiratory stabilization, and improved parental care for 15 days. No significant side effects were noted. CONCLUSION In the literature there are few studies regarding the use of ketamine for refractory status epilepticus, and only in nine of these described the use of, ketamine in children (2 months-18 years). This is the first report to document the effective use of ketamine in the newborn with status epilepticus.
Collapse
Affiliation(s)
- Anna Tarocco
- Department of Medical Sciences, Pediatric Section, S. Anna University Hospital, Ferrara, Italy
| | - Elisa Ballardini
- Department of Medical Sciences, Neonatology and NICU, S. Anna University Hospital, Ferrara, Italy.
| | - Giampaolo Garani
- Department of Medical Sciences, Neonatology and NICU, S. Anna University Hospital, Ferrara, Italy
| |
Collapse
|
31
|
Abstract
Status epilepticus (SE) still results in significant mortality and morbidity. Whereas mortality depends mainly on the age of the patient as well as the cause, morbidity is often due to the myriad of complications that occur during prolonged admission to an intensive care environment. Although SE is a clinical diagnosis in most cases (convulsant), its treatment requires support by continuous electroencephalographic recording to ensure cessation of potential nonconvulsive elements of SE. Treatment has recently changed to incorporate four stages and must be initiated at the earliest possible time.
Collapse
|
32
|
Zeiler FA, Kaufmann AM, Gillman LM, West M, Silvaggio J. Ketamine for medically refractory status epilepticus after elective aneurysm clipping. Neurocrit Care 2014; 19:119-24. [PMID: 23702695 DOI: 10.1007/s12028-013-9858-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Medically refractory status epilepticus, without an identifiable cause, post elective aneurysm clipping is a rare event. OBJECTIVE To describe the two cases of refractory status epilepticus post elective aneurysm clipping, without an identifiable cause, and discuss the potential role for early consideration of ketamine. METHODS Retrospectively reviewed two patients at our institution who developed refractory status epilepticus post elective aneurysm clipping, without a defined cause. RESULTS Two patients who underwent elective aneurysm clipping developed medically refractory status epilepticus post-craniotomy. No structural, vascular, infectious, or metabolic cause was identified. Seizure control failed with multiple medications and intravenous sedatives over the period of weeks in both. Ketamine was instituted at 20 and 40 mg/kg/min in these patients. Within hours of starting ketamine, burst suppression was obtained in both. Medications were all tapered over the next month, and both the patients recovered to be cognitively normal, with mild residual morbidity secondary to critical care polyneuropathy. CONCLUSIONS Refractory status epilepticus, in the absence of an identifiable etiology, in elective aneurysm clipping is a rare event. Consideration should be given for the early use of ketamine in refractory status epilepticus.
Collapse
Affiliation(s)
- F A Zeiler
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada.
| | | | | | | | | |
Collapse
|
33
|
Use of ketamine for control of refractory seizures during the intraoperative period. J Neurosurg Anesthesiol 2014; 26:412-3. [PMID: 24577426 DOI: 10.1097/ana.0000000000000050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
34
|
|
35
|
Bernard SA, Smith K, Porter R, Jones C, Gailey A, Cresswell B, Cudini D, Hill S, Moore B, St Clair T. Paramedic rapid sequence intubation in patients with non-traumatic coma. Emerg Med J 2014; 32:60-4. [PMID: 24473409 DOI: 10.1136/emermed-2013-202930] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Pre-hospital intubation by paramedics is widely used in comatose patients prior to transportation to hospital, but the optimal technique for intubation is uncertain. One approach is paramedic rapid sequence intubation (RSI), which may improve outcomes in adult patients with traumatic brain injury. However, many patients present to emergency medical services with coma of non-traumatic cause and the role of paramedic RSI in these patients remains uncertain. METHODS The electronic Victorian Ambulance Clinical Information System was searched for the term 'suxamethonium' between 2008 and 2011. We reviewed the patient care records and included patients with suspected non-traumatic coma who were treated and transported by road-based paramedics. Demographics, intubation conditions, vital signs (before and after drug administration) and complications were recorded. Younger patients (<60 years) were compared with older patients. RESULTS There were 1152 paramedic RSI attempts of which 551 were for non-traumatic coma. The success rate for intubation was 97.5%. There was a significant drop in blood pressure in younger patients (<60 years) with the mean systolic blood pressure decreasing by 16 mm Hg (95% CI 11 to 21). In older patients, the systolic blood pressure also decreased significantly by 20 mm Hg (95% CI 17 to 24). Four patients suffered brief cardiac arrest during pre-hospital care, all of whom were successfully resuscitated and transported to hospital. CONCLUSIONS Paramedic RSI in patients with non-traumatic coma has a high procedural success rate. Further studies are required to determine whether this procedure improves outcomes.
Collapse
Affiliation(s)
- S A Bernard
- Ambulance Victoria, Doncaster, Victoria, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia The Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - K Smith
- Ambulance Victoria, Doncaster, Victoria, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - R Porter
- The Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - C Jones
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - A Gailey
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - B Cresswell
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - D Cudini
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - S Hill
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - B Moore
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - T St Clair
- Ambulance Victoria, Doncaster, Victoria, Australia
| |
Collapse
|
36
|
Griffith CA, Hoffmann DE. Status epilepticus attributed to inadvertent intrathecal injection of cefazolin during myelography. J Vet Emerg Crit Care (San Antonio) 2013; 23:631-6. [PMID: 24304840 DOI: 10.1111/vec.12117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 10/01/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe a case of status epilepticus believed to be a consequence of inadvertent intrathecal administration of cefazolin in a dog undergoing a myelogram. CASE SUMMARY A 4-year-old, 6.5 kg, male neutered Dachshund was referred for evaluation of an acute onset hind limb paraparesis. While performing a lumbar myelogram, cefazolin was inadvertently injected into the ventral subarachnoid space. Subsequent refractory seizure activity was attributed to the epileptogenic effects of intrathecally administered cefazolin. Supportive therapy led to eventual complete recovery. NEW OR UNIQUE INFORMATION PROVIDED Although epileptogenic effects of intrathecally administered cefazolin are well documented in the human and experimental animal model literature, to the authors' knowledge this has not been characterized in the veterinary literature. This case highlights the need to be diligent and mindful when one administers medications, and describes the management of a dog adversely affected as a consequence of a medical error.
Collapse
Affiliation(s)
- Carrie A Griffith
- Akron Veterinary Referral and Emergency Center, 1321 Centerview Circle, Akron, OH 44321
| | | |
Collapse
|
37
|
Abstract
Viral encephalitis causes an altered level of consciousness, which may be associated with fever, seizures, focal deficits, CSF pleocytosis, and abnormal neuroimaging. Potential pathogens include HSV, VZV, enterovirus, and in some regions, arboviruses. Autoimmune (eg, anti-NMDA receptor) and paraneoplastic encephalitis are responsible for some cases where no pathogen is identified. Indications for ICU admission include coma, status epilepticus and respiratory failure. Timely initiation of anti-viral therapy is crucial while relevant molecular and serological test results are being performed. Supportive care should be directed at the prevention and treatment of cerebral edema and other physiological derangements which may contribute to secondary neurological injury.
Collapse
Affiliation(s)
- Andreas H Kramer
- Department of Critical Care Medicine and Clinical Neurosciences, Foothills Medical Center, McCaig Tower, 3134 Hospital Drive NW, Calgary, AB T2N 2T9, Canada.
| |
Collapse
|
38
|
Esaian D, Joset D, Lazarovits C, Dugan PC, Fridman D. Ketamine Continuous Infusion for Refractory Status Epilepticus in a Patient With Anticonvulsant Hypersensitivity Syndrome. Ann Pharmacother 2013; 47:1569-76. [DOI: 10.1177/1060028013505427] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Diana Esaian
- New York University Langone Medical Center, New York, NY, USA
| | - Danielle Joset
- New York University Langone Medical Center, New York, NY, USA
| | | | - Patricia C. Dugan
- New York University Langone Medical Center Comprehensive Epilepsy Center, New York, NY, USA
| | - David Fridman
- New York University Langone Medical Center, New York, NY, USA
| |
Collapse
|
39
|
Capovilla G, Beccaria F, Beghi E, Minicucci F, Sartori S, Vecchi M. Treatment of convulsive status epilepticus in childhood: Recommendations of the Italian League Against Epilepsy. Epilepsia 2013; 54 Suppl 7:23-34. [DOI: 10.1111/epi.12307] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Giuseppe Capovilla
- Child Neuropsychiatry Department; Epilepsy Center; C. Poma Hospital; Mantua Italy
| | - Francesca Beccaria
- Child Neuropsychiatry Department; Epilepsy Center; C. Poma Hospital; Mantua Italy
| | - Ettore Beghi
- Department of Neuroscience; IRCCS-Institute of Pharmacological Research “Mario Negri”; Milan Italy
| | - Fabio Minicucci
- Clinical Neurophysiology; San Raffaele Hospital; Milan Italy
| | - Stefano Sartori
- Pediatric Neurology and Clinical Neurophysiology Unit; Department of Pediatrics; University of Padova; Padova Italy
| | - Marilena Vecchi
- Pediatric Neurology and Clinical Neurophysiology Unit; Department of Pediatrics; University of Padova; Padova Italy
| |
Collapse
|
40
|
Buchhalter J. Treatment of super-refractory status epilepticus: the sooner the better with less adverse effects. Epilepsy Curr 2013; 13:217-8. [PMID: 24348110 PMCID: PMC3854726 DOI: 10.5698/1535-7597-13.5.217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
41
|
Gaspard N, Foreman B, Judd LM, Brenton JN, Nathan BR, McCoy BM, Al-Otaibi A, Kilbride R, Fernández IS, Mendoza L, Samuel S, Zakaria A, Kalamangalam GP, Legros B, Szaflarski JP, Loddenkemper T, Hahn CD, Goodkin HP, Claassen J, Hirsch LJ, Laroche SM. Intravenous ketamine for the treatment of refractory status epilepticus: a retrospective multicenter study. Epilepsia 2013; 54:1498-503. [PMID: 23758557 PMCID: PMC3731413 DOI: 10.1111/epi.12247] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE To examine patterns of use, efficacy, and safety of intravenous ketamine for the treatment of refractory status epilepticus (RSE). METHODS Multicenter retrospective review of medical records and electroencephalography (EEG) reports in 10 academic medical centers in North America and Europe, including 58 subjects, representing 60 episodes of RSE that were identified between 1999 and 2012. Seven episodes occurred after anoxic brain injury. KEY FINDINGS Permanent control of RSE was achieved in 57% (34 of 60) of episodes. Ketamine was felt to have contributed to permanent control ("possible" or "likely" responses) in 32% (19 of 60) including seven (12%) in which ketamine was the last drug added (likely responses). Four of the seven likely responses, but none of the 12 possible ones, occurred in patients with postanoxic brain injury. No likely responses were observed when infusion rates were lower than 0.9 mg/kg/h, when ketamine was introduced at least 8 days after SE onset, or after failure of seven or more drugs. Ketamine was discontinued due to possible adverse events in five patients. Complications were mostly attributed to concurrent drugs, especially other anesthetics. Mortality rate was 43% (26 of 60), but was lower when SE was controlled within 24 h of ketamine initiation (16% vs. 56%, p = 0.0047). SIGNIFICANCE Ketamine appears to be a relatively effective and safe drug for the treatment of RSE. This retrospective series provides preliminary data on effective dose and appropriate time of intervention to aid in the design of a prospective trial to further define the role of ketamine in the treatment of RSE.
Collapse
Affiliation(s)
- Nicolas Gaspard
- Comprehensive Epilepsy Center, Department of Neurology, School of Medicine, Yale-New Haven Hospital, Yale University, New Haven, Connecticut 06520, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Dionisio S, Brown H, Boyle R, Blum S. Managing the generalised tonic-clonic seizure and preventing progress to status epilepticus: a stepwise approach. Intern Med J 2013; 43:739-46. [DOI: 10.1111/imj.12168] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 04/08/2013] [Indexed: 12/01/2022]
Affiliation(s)
- S. Dionisio
- Department of Neurology; Princess Alexandra Hospital
| | - H. Brown
- Department of Neurology; Princess Alexandra Hospital
| | - R. Boyle
- Department of Neurology; Princess Alexandra Hospital
| | | |
Collapse
|
43
|
Bösel J, Dziewas R. [Sedation and weaning in neurocritical care: can concepts from general critical care be applied?]. DER NERVENARZT 2013; 83:1533-41. [PMID: 23129066 DOI: 10.1007/s00115-012-3527-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The translation of modern principles of sedation and weaning from mechanical ventilation from general intensive care to neurocritical care has to take into account specific aspects of brain-injured patients. These include interactions with intracranial hypertension, disturbed autoregulation, a higher frequency of seizures and an increased risk of delirium. The advantages of sedation protocols, scoring tools to steer sedation and analgesia and an individualized choice of drugs with emphasis on analgesia gain more interest and importance in neurocritical care as well, but have not been thoroughly investigated so far. When weaning neurological intensive care unit (ICU) patients from the ventilator and approaching extubation it has to be acknowledged that conventional ICU criteria for weaning and extubation can only have an orienting character and that dysphagia is much more frequent in these patients.
Collapse
Affiliation(s)
- J Bösel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Deutschland.
| | | |
Collapse
|
44
|
Suidan GL, Brill A, De Meyer SF, Voorhees JR, Cifuni SM, Cabral JE, Wagner DD. Endothelial Von Willebrand factor promotes blood-brain barrier flexibility and provides protection from hypoxia and seizures in mice. Arterioscler Thromb Vasc Biol 2013; 33:2112-20. [PMID: 23825365 DOI: 10.1161/atvbaha.113.301362] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Aberrant blood-brain barrier (BBB) permeability is a hallmark pathology of many central nervous system diseases. von Willebrand factor (VWF) is stored in endothelial Weibel-Palade bodies from where it is released on activation into plasma and basement membrane. The role of VWF in endothelial homeostasis is unclear. The goal of this study was to assess the role of VWF in disease models associated with increased BBB permeability. APPROACH AND RESULTS We did not find any differences in BBB permeability to Evans blue dye at baseline between wild-type and VWF(-/-) animals. We next used 2 models presenting with increased BBB permeability, hypoxia/reoxygenation and pilocarpine-induced status epilepticus, to assess the response of VWF(-/-) animals. In both models, VWF(-/-) mice maintained a tighter BBB than wild-type mice. VWF(-/-) mice fared worse in both conditions, with ≈ 100% of VWF(-/-) mice dying within 120 minutes after pilocarpine administration, whereas >80% of wild-type animals survived. Investigation into the status of tight junction proteins revealed that VWF(-/-) mice expressed more claudin-5 at baseline. In vitro work confirmed that the presence of subendothelial VWF is inhibitory to claudin-5 expression. CONCLUSIONS VWF deficiency confers partial preservation of BBB integrity after hypoxia/reoxygenation and seizures. Surprisingly, this decrease in BBB permeability did not result in protection of animals because they demonstrated more severe pathology in both models compared with wild-type animals. These data suggest that a rigid BBB is detrimental (to the organism) during certain disease states and that VWF release may provide desired flexibility under stress.
Collapse
|
45
|
Synowiec AS, Singh DS, Yenugadhati V, Valeriano JP, Schramke CJ, Kelly KM. Ketamine use in the treatment of refractory status epilepticus. Epilepsy Res 2013; 105:183-8. [DOI: 10.1016/j.eplepsyres.2013.01.007] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 12/12/2012] [Accepted: 01/07/2013] [Indexed: 11/17/2022]
|
46
|
Dorandeu F, Dhote F, Barbier L, Baccus B, Testylier G. Treatment of status epilepticus with ketamine, are we there yet? CNS Neurosci Ther 2013; 19:411-27. [PMID: 23601960 PMCID: PMC6493567 DOI: 10.1111/cns.12096] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 02/23/2013] [Accepted: 02/23/2013] [Indexed: 12/24/2022] Open
Abstract
Status epilepticus (SE), a neurological emergency both in adults and in children, could lead to brain damage and even death if untreated. Generalized convulsive SE (GCSE) is the most common and severe form, an example of which is that induced by organophosphorus nerve agents. First- and second-line pharmacotherapies are relatively consensual, but if seizures are still not controlled, there is currently no definitive data to guide the optimal choice of therapy. The medical community seems largely reluctant to use ketamine, a noncompetitive antagonist of the N-methyl-d-aspartate glutamate receptor. However, a review of the literature clearly shows that ketamine possesses, in preclinical studies, antiepileptic properties and provides neuroprotection. Clinical evidences are scarcer and more difficult to analyze, owing to a use in situations of polytherapy. In absence of existing or planned randomized clinical trials, the medical community should make up its mind from well-conducted preclinical studies performed on appropriate models. Although potentially active, ketamine has no real place for the treatment of isolated seizures, better accepted drugs being used. Its best usage should be during GCSE, but not waiting for SE to become totally refractory. Concerns about possible developmental neurotoxicity might limit its pediatric use for refractory SE.
Collapse
Affiliation(s)
- Frederic Dorandeu
- Département de Toxicologie et risques chimiques, Institut de Recherche Biomédicale des Armées - Centre de Recherches du Service de Santé des Armées (IRBA-CRSSA), La Tronche Cedex, France.
| | | | | | | | | |
Collapse
|
47
|
Dorandeu F, Barbier L, Dhote F, Testylier G, Carpentier P. Ketamine combinations for the field treatment of soman-induced self-sustaining status epilepticus. Review of current data and perspectives. Chem Biol Interact 2013; 203:154-9. [DOI: 10.1016/j.cbi.2012.09.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 09/25/2012] [Accepted: 09/26/2012] [Indexed: 12/21/2022]
|
48
|
Roberts DJ, Haroon B, Hall RI. Sedation for critically ill or injured adults in the intensive care unit: a shifting paradigm. Drugs 2012; 72:1881-916. [PMID: 22950534 DOI: 10.2165/11636220-000000000-00000] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
As most critically ill or injured patients will require some degree of sedation, the goal of this paper was to comprehensively review the literature associated with use of sedative agents in the intensive care unit (ICU). The first and selected latter portions of this article present a narrative overview of the shifting paradigm in ICU sedation practices, indications for uninterrupted or prolonged ICU sedation, and the pharmacology of sedative agents. In the second portion, we conducted a structured, although not entirely systematic, review of the available evidence associated with use of alternative sedative agents in critically ill or injured adults. Data sources for this review were derived by searching OVID MEDLINE and PubMed from their first available date until May 2012 for relevant randomized controlled trials (RCTs), systematic reviews and/or meta-analyses and economic evaluations. Advances in the technology of mechanical ventilation have permitted clinicians to limit the use of sedation among the critically ill through daily sedative interruptions or other means. These practices have been reported to result in improved mortality, a decreased length of ICU and hospital stay and a lower risk of drug-associated delirium. However, in some cases, prolonged or uninterrupted sedation may still be indicated, such as when patients develop intracranial hypertension following traumatic brain injury. The pharmacokinetics of sedative agents have clinical importance and may be altered by critical illness or injury, co-morbid conditions and/or drug-drug interactions. Although use of validated sedation scales to monitor depth of sedation is likely to reduce adverse events, they have no utility for patients receiving neuromuscular receptor blocking agents. Depth of sedation monitoring devices such as the Bispectral Index (BIS©) also have limitations. Among existing RCTs, no sedative agent has been reported to improve the risk of mortality among the critically ill or injured. Moreover, although propofol may be associated with a shorter time to tracheal extubation and recovery from sedation than midazolam, the risk of hypertriglyceridaemia and hypotension is higher with propofol. Despite dexmedetomidine being linked with a lower risk of drug-associated delirium than alternative sedative agents, this drug increases risk of bradycardia and hypotension. Among adults with severe traumatic brain injury, there are insufficient data to suggest that any single sedative agent decreases the risk of subsequent poor neurological outcomes or mortality. The lack of examination of confounders, including the type of healthcare system in which the investigation was conducted, is a major limitation of existing pharmacoeconomic analyses, which likely limits generalizability of their results.
Collapse
Affiliation(s)
- Derek J Roberts
- Departments of Surgery, Community Health Sciences (Division of Epidemiology) and Critical Care Medicine, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada
| | | | | |
Collapse
|
49
|
Shakarjian MP, Velíšková J, Stanton PK, Velíšek L. Differential antagonism of tetramethylenedisulfotetramine-induced seizures by agents acting at NMDA and GABA(A) receptors. Toxicol Appl Pharmacol 2012; 265:113-21. [PMID: 23022509 DOI: 10.1016/j.taap.2012.08.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 08/13/2012] [Accepted: 08/30/2012] [Indexed: 01/08/2023]
Abstract
Tetramethylenedisulfotetramine (TMDT) is a highly lethal neuroactive rodenticide responsible for many accidental and intentional poisonings in mainland China. Ease of synthesis, water solubility, potency, and difficulty to treat make TMDT a potential weapon for terrorist activity. We characterized TMDT-induced convulsions and mortality in male C57BL/6 mice. TMDT (ip) produced a continuum of twitches, clonic, and tonic-clonic seizures decreasing in onset latency and increasing in severity with increasing dose; 0.4mg/kg was 100% lethal. The NMDA antagonist, ketamine (35mg/kg) injected ip immediately after the first TMDT-induced seizure, did not change number of tonic-clonic seizures or lethality, but increased the number of clonic seizures. Doubling the ketamine dose decreased tonic-clonic seizures and eliminated lethality through a 60min observation period. Treating mice with another NMDA antagonist, MK-801, 0.5 or 1mg/kg ip, showed similar effects as low and high doses of ketamine, respectively, and prevented lethality, converting status epilepticus EEG activity to isolated interictal discharges. Treatment with these agents 15min prior to TMDT administration did not increase their effectiveness. Post-treatment with the GABA(A) receptor allosteric enhancer diazepam (5mg/kg) greatly reduced seizure manifestations and prevented lethality 60min post-TMDT, but ictal events were evident in EEG recordings and, hours post-treatment, mice experienced status epilepticus and died. Thus, TMDT is a highly potent and lethal convulsant for which single-dose benzodiazepine treatment is inadequate in managing electrographic seizures or lethality. Repeated benzodiazepine dosing or combined application of benzodiazepines and NMDA receptor antagonists is more likely to be effective in treating TMDT poisoning.
Collapse
Affiliation(s)
- Michael P Shakarjian
- Department of Environmental Health Science, School of Health Sciences and Practice, Institute of Public Health, New York Medical College, Valhalla, NY, 10595, USA.
| | | | | | | |
Collapse
|