Can anesthetic treatment worsen outcome in status epilepticus?

Propofol-Related Infusion Syndrome: A Bibliometric Analysis of the 100 Most-Cited Articles

Propofol-related infusion syndrome (PRIS) is a rare, yet life-threatening sequelae to prolonged administration of the anesthetic propofol in mechanically intubated patients. The condition is characterized by progressive multi-system organ failure and eventual mortality; of note, the predominant characteristics of PRIS involve but are not limited to cardiovascular impairment and collapse, metabolic and lactic acidosis, rhabdomyolysis, hyperkalemia, and acute renal failure. While potent or extended doses of propofol have been found to be the primary precipitating factor of this condition, others such as age, critical illness, steroid therapy, and hyperlipidemia have been discovered to play a role as well. This bibliometric analysis was done to reflect the current relevance and understanding of PRIS in recent literature. The SCOPUS database was utilized to conduct a search for articles with keywords "propofol infusion syndrome" and "propofol syndrome" from February 24, 2001, until April 16, 2023, with parameters for article title, citation number, citation per year, author, institution, publishing journal, and country of origin. PRIS was first defined in 1990, just a year after its approval by the Food and Drug Administration for use as a sedative-hypnotic. Since then, interest in PRIS slowly rose up to 13 publications per year in 2013. Seven papers on the topic were published in Critical Care Medicine, six in Neurocritical Care, and four in Anesthesia. The most common institutions were Mayo Clinic, Northeastern University, and Tufts Medical Center. To our knowledge, this is the first bibliometric analysis to evaluate the most influential publications about PRIS. A majority of the research is case-based, possibly owing to the rarity of the condition. Our research suggests that confounding factors outside the precipitating dosage of propofol may be implicated in the onset and progression of PRIS. This study could therefore bring renewed interest to the topic and lead to additional research focused on fully understanding the pathophysiology of PRIS in order to promote the development of novel diagnostics and treatment.

Comparing Patients With Isolated Seizures and Status Epilepticus in Intensive Care Units: An Observational Cohort Study

BACKGROUND AND OBJECTIVES

To assess the frequency of status epilepticus (SE) among seizing critically ill adult patients and to determine clinical differences between patients with isolated seizures and patients with SE in the intensive care unit (ICU).

METHODS

From 2015 to 2020, all consecutive adult ICU patients at a Swiss tertiary care center with isolated seizures or SE as reported by intensivists and/or consulting neurologists were identified by screening of all digital medical, ICU, and EEG records. Patients aged <18 years and patients with myoclonus due to hypoxic-ischemic encephalopathy but without seizures on EEG were excluded. The frequency of isolated seizures, SE, and clinical characteristics at seizure onset associated with SE were the primary outcomes. Uni- and multivariable logistic regression was performed to identify associations with the emergence of SE.

RESULTS

Among 404 patients with seizures, 51% had SE. Compared with patients with isolated seizures, patients with SE had a lower median Charlson Comorbidity Index (CCI) (3 vs 5, p < 0.001), fewer fatal etiologies (43.6% vs 80.5%, p < 0.001), higher median Glasgow coma scores (7 vs 5, p < 0.001), fever more frequently (27.5% vs 7.5%, p < 0.001), shorter median ICU and hospital stay (ICU: 4 vs 5 days, p = 0.039; hospital stay: 13 vs 15 days, p = 0.045), and recovered to premorbid function more often (36.8% vs 17%, p < 0.001). Multivariable analyses revealed decreased odds ratios (ORs) for SE with increasing CCI (OR 0.91, 95% CI 0.83-0.99), fatal etiology (OR 0.15, 95% CI 0.08-0.29), and epilepsy (OR 0.32, 95% CI 0.16-0.63). Systemic inflammation was an additional association with SE after excluding patients with seizures as the reason for ICU admission (ORfor CRP 1.01, 95% CI 1.00-1.01; ORfor fever 7.35, 95% CI 2.84-19.0). Although fatal etiologies and increasing CCI remained associated with low odds for SE after excluding anesthetized patients and hypoxic-ischemic encephalopathy, inflammation remained associated in all subgroups except patients with epilepsy.

DISCUSSION

Among all ICU patients with seizures, SE emerged frequently and seen in every second patient. Besides the unexpected low odds for SE with higher CCI, fatal etiology, and epilepsy, the association of inflammation with SE in the critically ill without epilepsy represents a potential treatment target and deserves further attention.

Balancing the risks and benefits of anesthetics in status epilepticus

PURPOSE

According to international guidelines, status epilepticus refractory to first- and second-line antiseizure medication should be treated with anesthetics. Therefore, continuously delivered intravenous midazolam, propofol, or barbiturates are recommended as third-line therapy. While electroencephalographically (EEG)-controlled titration of anesthetics to seizure termination or to the emergence of an EEG burst-suppression pattern makes sense, evidence of the efficacy and tolerability of such third-line treatment is limited and concerns regarding the risks of anesthesia remain. The lack of treatment alternatives and persistent international discord reflecting contradictory results from some studies leave clinicians on their own when deciding to escalate treatment. In this conference-accompanying narrative review, we highlight the challenges of EEG-monitored third-line treatment and discuss recent studies that examined earlier administration of anesthetics.

RESULTS

Based on the literature, maintaining continuous burst suppression is difficult despite the constant administration of anesthetics, and the evidence for burst suppression as an adequate surrogate target is limited by methodological shortcomings as acknowledged by international guidelines. In our Swiss cohort including 102 patients with refractory status epilepticus, burst suppression as defined by the American Clinical Neurophysiology Society's Critical Care EEG Terminology 2021 was established in only 21%. Besides case reports suggesting that rapid but short-termed anesthesia can be sufficient to permanently stop seizures, a study including 205 patients revealed that anesthesia as second-line treatment was associated with a shorter median duration of status epilepticus (0.5 versus 12.5 days, p < 0.001), median ICU (2 versus 5.5 days, p < 0.001) and hospital stay (8 versus 17 days, p < 0.001) with equal rates of complications when compared to anesthesia as third-line treatment.

CONCLUSIONS

Recent investigations have led to important findings and new insights regarding the use of anesthetics in refractory status epilepticus. However, numerous methodological limitations and remaining questions need to be considered when it comes to the translation into clinical practice, and, in consequence, call for prospective randomized studies. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.

Constant rate infusion of diazepam or propofol for the management of canine cluster seizures or status epilepticus

INTRODUCTION

Cluster seizures (CS) and status epilepticus (SE) in dogs are severe neurological emergencies that require immediate treatment. Practical guidelines call for constant rate infusion (CRI) of benzodiazepines or propofol (PPF) in patients with seizures not responding to first-line treatment, but to date only few studies have investigated the use of CRI in dogs with epilepsy.

STUDY DESIGN

Retrospective clinical study.

METHODS

Dogs that received CRI of diazepam (DZP) or PPF for antiepileptic treatment during hospitalization at the Veterinary Teaching Hospital of the University of Turin for CS or SE between September 2016 and December 2019 were eligible for inclusion. Favorable outcome was defined as cessation of clinically visible seizure activity within few minutes from the initiation of the CRI, no seizure recurrence within 24 h after discontinuation of CRI through to hospital discharge, and clinical recovery. Poor outcome was defined as recurrence of seizure activity despite treatment or death in hospital because of recurrent seizures, catastrophic consequences of prolonged seizures or no return to an acceptable neurological and clinical baseline, despite apparent control of seizure activity. Comparisons between the number of patients with favorable outcome and those with poor outcome in relation to type of CRI, seizure etiology, reason for presentation (CS or SE), sex, previous AED therapy and dose of PPF CRI were carried out.

RESULTS

A total of 37 dogs, with 50 instances of hospitalization and CRI administered for CS or SE were included in the study. CRI of diazepam (DZP) or PPF was administered in 29/50 (58%) and in 21/50 (42%) instances of hospitalization, respectively. Idiopathic epilepsy was diagnosed in 21/37 (57%), (13/21 tier I and 8/21 tier II); structural epilepsy was diagnosed in 6/37 (16%) of which 4/6 confirmed and 2/6 suspected. A metabolic or toxic cause of seizure activity was recorded in 7/37 (19%). A total of 38/50 (76%) hospitalizations were noted for CS and 12/50 (24%) for SE. In 30/50 (60%) instances of hospitalization, the patient responded well to CRI with cessation of seizure activity, no recurrence in the 24 h after discontinuation of CRI through to hospital discharge, whereas a poor outcome was recorded for 20/50 (40%) cases (DZP CRI in 12/50 and PPF CRI in 8/50). Comparison between the number of patients with favorable outcome and those with poor outcome in relation to type of CRI, seizure etiology, reason for presentation (CS or SE), sex and previous AED therapy was carried out but no statistically significant differences were found.

CONCLUSIONS

The present study is the first to document administration of CRI of DZP or PPF in a large sample of dogs with epilepsy. The medications appeared to be tolerated without major side effects and helped control seizure activity in most patients regardless of seizure etiology. Further studies are needed to evaluate the effects of CRI duration on outcome and complications.

Factors associated with the use of anesthetic drug infusion in patients with status epilepticus and their relation to outcome: a prospective study

Status epilepticus (SE) is one of the most dreadful neurological emergencies; unfortunately, studies targeting SE are still inadequate. This study aims to identify factors associated with the use of CIVAD in patients presenting with status epilepticus and detect those impact the clinical outcome. A prospective study involving 144 episodes of SE in 144 patients. Patients were categorized according to whether or not they received CIVAD. Subjects underwent clinical assessment, brain imaging, and EEG. The consciousness level was assessed using the Glasgow coma scale (GCS) and the Full outline of responsiveness (FOUR) scale. SE severity score (STESS) and Epidemiology-based mortality score (EMSE) were used as scales for outcome prediction. Continuous IV anesthetic drug infusion was initiated in 36% of patients (+ CIVAD). Such groups showed a significantly worse initial level of consciousness (< 0.001), an unstable course of seizure evolution (0.009), and all of them showed abnormal EEG patterns. A significantly higher number of patients (+ CIVAD) developed complications (< 0.001), had higher outcome prediction scores (< 0.001), and mortality rates (< 0.001) compared to those who did not need CIVAD (- CIVAD). Mortality was associated with acute symptomatic etiology and higher total doses of propofol. Among the study population, mortality among patients who received CIVAD was associated with acute symptomatic SE and prolonged propofol infusion rather than any clinical parameters or predictor scores.

Management of Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus

PURPOSE OF REVIEW

Status epilepticus is a serious condition caused by disorders and diseases that affect the central nervous system. In status epilepticus, hypersynchronous epileptic activity lasts longer than the usual duration of isolated self-limited seizures (time t1), which causes neuronal damage or alteration of neuronal networks at a certain time point (time t2), depending on the type of and duration of status epilepticus. The successful management of status epilepticus includes both the early termination of seizure activity and the earliest possible identification of a causative etiology, which may require independent acute treatment. In nonconvulsive status epilepticus, patients present only with subtle clinical signs or even without any visible clinical manifestations. In these cases, EEG allows for the assessment of cerebral function and identification of patterns in need of urgent treatment.

RECENT FINDINGS

In 2015, the International League Against Epilepsy proposed a new definition and classification of status epilepticus, encompassing four axes: symptomatology, etiology, EEG, and age. Various validation studies determined the practical usefulness of EEG criteria to identify nonconvulsive status epilepticus. The American Clinical Neurophysiology Society has incorporated these criteria into their most recent critical care EEG terminology in 2021. Etiology, age, symptomatology, and the metabolic demand associated with an increasing duration of status epilepticus are the most important determinants of prognosis. The consequences of status epilepticus can be visualized in vivo by MRI studies.

SUMMARY

The current knowledge about status epilepticus allows for a more reliable diagnosis, earlier treatment, and improved cerebral imaging of its consequences. Outcome prediction is a soft tool for estimating the need for intensive care resources.

Safety and Efficacy of Coma Induction Following First-Line Treatment in Status Epilepticus: A 2-Center Study

OBJECTIVE

To explore the safety and efficacy of artificial coma induction to treat status epilepticus (SE) immediately after first-line antiseizure treatment instead of following the recommended approach of first using second-line drugs.

METHODS

Clinical and electrophysiologic data of all adult patients treated for SE from 2017 to 2018 in the Swiss academic medical care centers from Basel and Geneva were retrospectively assessed. Primary outcomes were return to premorbid neurologic function and in-hospital death. Secondary outcomes were the emergence of complications during SE, duration of SE, and intensive care unit (ICU) and hospital stays.

RESULTS

Of 230 patients, 205 received treatment escalation after first-line medication. Of those, 27.3% were directly treated with artificial coma and 72.7% with second-line nonanesthetic antiseizure drugs. Of the latter, 16.6% were subsequently put on artificial coma after failure of second-line treatment. Multivariable analyses revealed increasing odds for coma induction after first-line treatment with younger age, the presence of convulsions, and an increased SE severity as quantified by the Status Epilepticus Severity Score (STESS). While outcomes and complications did not differ compared to patients with treatment escalation according to the guidelines, coma induction after first-line treatment was associated with shorter SE duration and ICU and hospital stays.

CONCLUSIONS

Early induction of artificial coma is performed in more than every fourth patient and especially in younger patients presenting with convulsions and more severe SE. Our data demonstrate that this aggressive treatment escalation was not associated with an increase in complications but with shorter duration of SE and ICU and hospital stays.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that early induction of artificial coma after unsuccessful first-line treatment for SE is associated with shorter duration of SE and ICU and hospital stays compared to the use of a second-line nonanesthetic antiseizure drug instead of or before anesthetics, without an associated increase in complications.

Status epilepticus - time is brain and treatment considerations

PURPOSE OF REVIEW

Status epilepticus is a neurological emergency associated with high morbidity and mortality. There is a lack of robust data to guide the management of this neurological emergency beyond the initial treatment. This review examines recent literature on treatment considerations including the choice of continuous anesthetics or adjunctive anticonvulsant, the cause of the status epilepticus, and use of nonpharmacologic therapies.

RECENT FINDINGS

Status epilepticus remains undertreated and mortality persists to be unchanged over the past 30 years. New anticonvulsant choices, such as levetiracetam and lacosamide have been explored as alternative emergent therapies. Anecdotal reports on the use of other generation anticonvulsants and nonpharmacologic therapies for the treatment of refractory and super-refractory status epilepticus have been described.Finally, recent evidence has examined etiology-guided management of status epilepticus in certain patient populations, such as immune-mediated, paraneoplastic or infectious encephalitis and anoxic brain injury.

SUMMARY

Randomized clinical trials are needed to determine the role for newer generation anticonvulsants and nonpharmacologic modalities for the treatment of epilepticus remains and evaluate the long-term outcomes associated with continuous anesthetics.

Clinical outcomes and treatments effectiveness in status epilepticus resolved by antiepileptic drugs: A five-year observational study

Objective

To evaluate clinical outcomes and treatment effectiveness of status epilepticus finally resolved by nonbenzodiazepine antiepileptic drugs (AEDs).

Methods

All consecutive SE episodes observed from September 1, 2013, to September 1, 2018, and resolved by AEDs were considered. Diagnosis and classification of SE followed the 2015 ILAE proposal. Nonconvulsive status (NCSE) diagnosis was confirmed according to the Salzburg EEG criteria. The modified Rankin Scale and deaths at 30 days from onset were used to evaluate outcomes.

Results

A total of 277 status episodes (mean age 71 years; 61% female) were treated and resolved by antiepileptic drugs after 382 treatment trials. 68% of the SE resolved after AED use as first/second treatment line, while subsequent trials with AEDs gave an additional 32% resolution. A return to baseline conditions was observed in 48% of the patients, while overall mortality was 19% without significant changes across the study years. Mortality was higher in NCSE than in convulsive SE (22.5% vs 12.9%; P < .05), while mortality did not differ in SE episodes resolved by a first/second AED trial (17.2%) versus SE resolved by successive treatment trials (18.9%). The resolution rate of intravenous AEDs was 82% for valproate, 77% for lacosamide, 71% for phenytoin, and 62% for levetiracetam. No significant differences were found in head-to-head comparison, but for the valproate-levetiracetam one that was related to NCSE episodes in which valproate resulted to be effective in 86% of the trials while levetiracetam in 62% (P < .002).

Significance

A high short-term mortality, stable over time, was observed in SE despite resolution of seizures, especially in SE with nonconvulsive semiology. Comparative AED efficacy showed no significant differences except for higher resolution rate for valproate versus levetiracetam in NCSE.

The anesthetic drug treatment of refractory and super-refractory status epilepticus around the world: Results from a global audit

Multinational and multicenter registries collecting cases of refractory and super-refractory status epilepticus help to understand what the current practice in the treatment of such conditions is and can improve the rational therapy. We prospectively collected 776 cases of refractory status epilepticus requiring continuous intravenous anesthetic drugs in an intensive care unit setting, through online questionnaires compiled by the treating physicians in 50 countries. Initiation of an intravenous anaesthetic drug was relatively delayed in middle-income compared with high-income countries. There were marked regional differences in the choice of initial intravenous anaesthetic drug. Generally, midazolam was the most commonly used initial anesthetic drug (56%), followed by propofol (35%), in Europe, propofol was preferred over midazolam. In addition to anesthesia, 26% of cases received some form of immunosuppression (with corticosteroids and/or intravenous immunoglobulin). In this observational study, outcome was not affected by choice or sequence of anesthetic drugs, and nor was the use of barbiturate anesthetics associated with poorer outcome. The proportion of patients responding to cycles of different anaesthetic drugs was high even after failure of the earlier anesthetics, but the neurological outcome progressively worsened the longer anaesthetic drugs were needed and the longer the status epilepticus continued. However, even in the 158 patients who required three or more different anaesthetic trials, 49% had seizure control on tapering the third anesthetic, and 20% had a good neurological outcome anywhere. For these reasons we believe that it is important to persist with therapy in patients who are intractable initially, especially as etiology, not the number of duration of anesthesia, is the primary determinant of prognosis. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".

Impact of timing of continuous intravenous anesthetic drug treatment on outcome in refractory status epilepticus

Background

Patients in refractory status epilepticus (RSE) may require treatment with continuous intravenous anesthetic drugs (cIVADs) for seizure control. The use of cIVADs, however, was recently associated with poor outcome in status epilepticus (SE), raising the question of whether cIVAD therapy should be delayed for attempts to halt seizures with repeated non-anesthetic antiepileptic drugs. In this study, we aimed to determine the impact of differences in therapeutic approaches on RSE outcome using timing of cIVAD therapy as a surrogate for treatment aggressiveness.

Methods

This was a retrospective cohort study over 14 years (n = 77) comparing patients with RSE treated with cIVADs within and after 48 h after RSE onset, and functional status at last follow-up was the primary outcome (good = return to premorbid baseline or modified Rankin Scale score of less than 3). Secondary outcomes included discharge functional status, in-hospital mortality, RSE termination, induction of burst suppression, use of thiopental, duration of RSE after initiation of cIVADs, duration of mechanical ventilation, and occurrence of super-refractory SE. Analysis was performed on the total cohort and on subgroups defined by RSE severity according to the Status Epilepticus Severity Score (STESS) and by the variables contained therein.

Results

Fifty-three (68.8%) patients received cIVADs within the first 48 h. Early cIVAD treatment was independently associated with good outcome (adjusted risk ratio [aRR] 3.175, 95% confidence interval [CI] 1.273–7.918; P = 0.013) as well as lower chance of both induction of burst suppression (aRR 0.661, 95% CI 0.507–0.861; P = 0.002) and use of thiopental (aRR 0.446, 95% CI 0.205–0.874; P = 0.043). RSE duration after cIVAD initiation was shorter in the early cIVAD cohort (hazard ratio 1.796, 95% CI 1.047–3.081; P = 0.033). Timing of cIVAD use did not impact the remaining secondary outcomes. Subgroup analysis revealed early cIVAD impact on the primary outcome to be driven by patients with STESS of less than 3.

Conclusions

Patients with RSE treated with cIVADs may benefit from early initiation of such therapy.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2235-2) contains supplementary material, which is available to authorized users.

Long-term outcomes of status epilepticus: A critical assessment

We reviewed 37 studies reporting long-term outcomes after a status epilepticus (SE) episode in pediatric and adult populations. Study design, length of follow-up, outcome measures, domains investigated (mortality, SE recurrence, subsequent epilepsy, cognitive outcome, functional outcome, or quality of life), and predictors of long-term outcomes are summarized. Despite heterogeneity in the design of prior studies, overall risk of poor long-term outcome after SE is high in both children and adults. Etiology is the main determinant of outcome, and the effect of age or SE duration is often difficult to distinguish from the underlying cause. The effect of the treatment on long-term outcome after SE is still unknown.

Hidden in plain sight: Non-convulsive status epilepticus-Recognition and management

Non-convulsive status epilepticus (NCSE) is an electroclinical state associated with an altered level of consciousness but lacking convulsive motor activity. It can present in a multitude of ways, but classification based on the clinical presentation and electroencephalographic appearances assists in determining prognosis and planning treatment. The aggressiveness of treatment should be based on the likely prognosis and the underlying cause of the NCSE.

An update on the recognition and treatment of non-convulsive status epilepticus in the intensive care unit

INTRODUCTION

Non-convulsive status epilepticus (NCSE) is a complex and diverse condition which is often an under-recognised entity in the intensive care unit. When NCSE is identified the optimal treatment strategy is not always clear. Areas covered: This review is based on a literature review of the key literature in the field over the last 5-10 years. The articles were selected based on their importance to the field by the authors. Expert commentary: This review discusses the complex situations when a neurological consultation may occur in a critical care setting and provides an update on the latest evidence regarding the recognition of NCSE and the decision making around determining the aggressiveness of treatment. It also considers the ictal-interictal continuum of conditions which may be met with, particularly in the era of continuous EEG, and provides an approach for dealing with these. Suggestions for how the field will develop are discussed.

Transition from intravenous to enteral ketamine for treatment of nonconvulsive status epilepticus

Background

Nonconvulsive status epilepticus (NCSE) is a diagnosis that is often challenging and one that may progress to refractory NCSE. Ketamine is a noncompetitive N-methyl-d-aspartate antagonist that increasingly has been used to treat refractory status epilepticus. Current Neurocritical Care Society guidelines recommend intravenous (IV) ketamine infusion as an alternative treatment for refractory status epilepticus in adults. On the other hand, enteral ketamine use in NCSE has been reported in only 6 cases (1 adult and 5 pediatric) in the literature to date.

Case presentation

A 33-year-old woman with a history of poorly controlled epilepsy presented with generalized tonic-clonic seizures, followed by recurrent focal seizures that evolved into NCSE. This immediately recurred within 24 h of a prior episode of NCSE that was treated with IV ketamine. Considering her previous response, she was started again on an IV ketamine infusion, which successfully terminated NCSE. This time, enteral ketamine was gradually introduced while weaning off the IV formulation. Treatment with enteral ketamine was continued for 6 months and then tapered off. There was no recurrence of NCSE or seizures and no adverse events noted during the course of treatment.

Conclusion

This case supports the use of enteral ketamine as a potential adjunct to IV ketamine in the treatment of NCSE, especially in cases without coma. Introduction of enteral ketamine may reduce seizure recurrence, duration of stay in ICU, and morbidity associated with intubation.

Continuous electroencephalographic-monitoring in the ICU: an overview of current strengths and future challenges

PURPOSE OF REVIEW

In ICUs, numerous physiological parameters are continuously monitored and displayed. Yet, functional monitoring of the organ of primary concern, the brain, is not routinely performed. Despite the benefits of ICU use of continuous electroencephalographic (EEG)-monitoring (cEEG) is increasingly recognized, several issues nevertheless seem to hamper its widespread clinical implementation.

RECENT FINDINGS

Utilization of ICU cEEG has significantly improved detection and characterization of cerebral pathology, prognostication and clinical management in specific patient groups. Potential solutions to several remaining challenges are currently being established. Descriptive EEG-terminology is evolving, whereas logistical issues are dealt with using telemedicine and quantitative EEG trends, training of nonexpert personnel and development of specialized detection algorithms. These concerted solutions are advancing cEEG-registration towards cEEG-monitoring. Notwithstanding these advances, obstacles such as ambiguous EEG-interpretation and differences in treatment based on EEG-findings need yet to be overcome.

SUMMARY

In selected critically ill patient groups, ICU cEEG has clear benefits over (repeated) standard EEG or no functional brain monitoring at all and if available, cEEG should be used. However, several issues preventing optimal ICU cEEG usage persist and should be further explored.

[Can treatment with anesthetic anticonvulsive drugs worsen outcome in status epilepticus?]

BACKGROUND AND OBJECTIVES

Nowadays, there is an ongoing discussion about the risks and benefits of anesthetic treatment concerning outcome in status epilepticus (SE). Therefore, we performed a retrospective database analysis to examine the influence of treatment with anesthetic drugs and narcosis in SE on mortality and disability.

METHODS

All treatment episodes of SE at the Department of Neurology of the University of Rostock between 01 January 2000 and 31 December 2009 were evaluated. SE severity before treatment, mortality, and disability at discharge were taken into account.

RESULTS

Of 167 treatment episodes of SE, 34 included treatment with anesthetic anticonvulsive drugs and narcosis. In the treatment episodes with use of anesthetic anticonvulsive drugs and narcosis, there was a more than twofold increased risk for death compared to the other treatment episodes. However, due to sample size this difference was not significant (p = 0.09). Cardiopulmonary complications were the cause of death in 4 of 5 patients dying during treatment episodes with anesthetic anticonvulsive drugs and narcosis. At discharge, disability as measured with the Modified Rankin Scale was higher in patients treated with anesthetic anticonvulsive drugs and narcosis than in the others (p = 0.03). A subgroup analysis revealed that especially in patients with nonconvulsive SE with impaired consciousness treatment with narcosis was associated with a higher rate of new deficits or mortality (p = 0.012).

CONCLUSIONS

Especially when considering narcosis for treatment of nonconvulsive SE, risks and benefits should be carefully weighed. When treating SE with anesthetic drugs and narcosis, everything has to be done to avoid cardiopulmonary complications.

Anesthetics and Outcome in Status Epilepticus: A Matched Two-Center Cohort Study

BACKGROUND

The use of anesthetics has been linked to poor outcome in patients with status epilepticus (SE). This association, however, may be confounded, as anesthetics are mostly administered in patients with more severe SE and critical illnesses.

OBJECTIVE

To minimize treatment-selection bias, we assessed the association between continuously administered intravenous anesthetic drugs (IVADs) and outcome in SE patients by a matched two-center study design.

METHODS

This cohort study was performed at the Johns Hopkins Bayview Medical Center, Baltimore, MD, USA and the University Hospital Basel, Basel, Switzerland. All consecutive adult SE patients from 2005 to 2013 were included. Odds ratios (ORs) for death and unfavorable outcome (Glasgow Outcome Score [GOS] 1-3) associated with administration of IVADs were calculated. To account for confounding by known outcome determinants (age, level of consciousness, worst seizure type, acute/fatal etiology, mechanical ventilation, and SE duration), propensity score matching and coarsened exact matching were performed in addition to multivariable regression models.

RESULTS

Among 406 consecutive patients, 139 (34.2%) were treated with IVADs. Logistic regression analyses of the unmatched and matched cohorts revealed increased odds for death and unfavorable outcome in survivors who had received IVADs (unmatched: OR_death = 3.13, 95% confidence interval [CI] 1.47-6.60 and OR_GOS1-3 = 2.51, 95% CI 1.37-4.60; propensity score matched: OR_death = 3.29, 95% CI 1.35-8.05 and OR_GOS1-3 = 2.27, 95% CI 1.02-5.06; coarsened exact matched: OR_death = 2.19, 95% CI 1.27-3.78 and OR_GOS1-3 = 3.94, 95% CI 2.12-7.32).

CONCLUSION

The use of IVADs in SE is associated with death and unfavorable outcome in survivors independent of known confounders and using different statistical approaches. Randomized trials are needed to determine if these associations are biased by outcome predictors not yet identified and hence not accounted for in this study.

Intravenous anesthesia in treatment of nonconvulsive status epilepticus: Characteristics and outcomes

OBJECTIVE

To determine factors associated with continuous anesthetic drug (IVAD) use in nonconvulsive status epilepticus (NCSE).

METHODS

Retrospective cohort study of patients who met clinical and EEG criteria of NCSE from 2009 to 2014 at a tertiary academic medical center. Patients were categorized according to IVAD use. Outcome variables were response to treatment and in-hospital death. We used descriptive analyses for baseline characteristics and outcome variable differences among patients who did and did not receive IVAD.

RESULTS

Forty-three patients had a total of 45 NCSE episodes. IVAD was used in 69% of the episodes. Patients treated with IVAD were younger (53.1 ± 14.1 vs 64.1 ± 13.3, p = 0.019). The episodes treated with IVAD occurred more frequently in patients with an acute neurologic pathology (58% vs 21%, p = 0.024) and those presenting in a coma (39% vs 7%, p = 0.030). NCSE resolved in 74% of the patients who received IVAD. Duration of NCSE did not differ significantly by treatment group. There were total 13 in-hospital deaths: ten in IVAD users vs three in the no-IVAD group (p > 0.05). Only one in-hospital death appeared to be a direct consequence of IVAD use. Mortality was more common among episodes that were not treated according to the published status epilepticus treatment guidelines compared to the episodes where guidelines were followed.

CONCLUSION

Our findings showed that factors such as younger age, acute neurologic pathology and coma at presentation were associated with IVAD use in patients with NCSE. These factors should be controlled in the future outcome and effectiveness studies to determine the effect of IVAD use on outcome of NCSE.