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Hepsø SW, Lee M, Noszka K, Wollertsen YM, Holmaas G, Kristensen E, Eichele T, Bjork MH, Griffiths ST, Hikmat O. Refractory and super-refractory status epilepticus in children and adolescents: A population-based study. Seizure 2024; 120:116-123. [PMID: 38941802 DOI: 10.1016/j.seizure.2024.06.023] [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: 04/19/2024] [Revised: 06/10/2024] [Accepted: 06/23/2024] [Indexed: 06/30/2024] Open
Abstract
PURPOSE Refractory (RSE) and super-refractory status epilepticus (SRSE) are serious medical emergencies whose long-term outcomes depend on the timeliness of their management. Population-based clinical and epidemiological data on these conditions are sparse. We aimed to provide a detailed description of the epidemiology and clinical course of RSE and SRSE in children and adolescents and identify potential prognostic biomarkers. METHODS In this retrospective population-based study, patients aged one month to 18 years who fulfilled the RSE/SRSE diagnostic criteria and were admitted to the intensive care unit of Haukeland University Hospital from 2012 to 2021 were considered eligible. Detailed clinical and laboratory findings along with information on management and outcomes were systematically analyzed. RESULTS Forty-three patients with 52 episodes of RSE/SRSE were identified. The incidence rate was 3.13 per 100,000 per year. The median time from SE onset to the administration of the first rescue drug was 13 min, and from the first rescue drug to second- and third-line treatments, 83 and 66 min, respectively. All patients were alive at discharge. CONCLUSION Delays in treatment were observed in various stages of the clinical course of RSE/SRSE. Improvement measures targeting the prompt administration of recuse mediation and subsequent treatment escalation are needed.
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Affiliation(s)
- Seline W Hepsø
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Maya Lee
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Kristoffer Noszka
- Department of Clinical Neurophysiology, Haukeland University Hospital, Bergen, Norway
| | | | - Gunhild Holmaas
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Erle Kristensen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway; Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway
| | - Tom Eichele
- Department of Clinical Neurophysiology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway
| | - Marte-Helene Bjork
- Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway; Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Silja T Griffiths
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Omar Hikmat
- Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway; Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.
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Wieruszewski ED, ElSaban M, Wieruszewski PM, Smischney NJ. Inhaled volatile anesthetics in the intensive care unit. World J Crit Care Med 2024; 13:90746. [PMID: 38633473 PMCID: PMC11019627 DOI: 10.5492/wjccm.v13.i1.90746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/19/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024] Open
Abstract
The discovery and utilization of volatile anesthetics has significantly transformed surgical practices since their inception in the mid-19th century. Recently, a paradigm shift is observed as volatile anesthetics extend beyond traditional confines of the operating theatres, finding diverse applications in intensive care settings. In the dynamic landscape of intensive care, volatile anesthetics emerge as a promising avenue for addressing complex sedation requirements, managing refractory lung pathologies including acute respiratory distress syndrome and status asthmaticus, conditions of high sedative requirements including burns, high opioid or alcohol use and neurological conditions such as status epilepticus. Volatile anesthetics can be administered through either inhaled route via anesthetic machines/devices or through extracorporeal membrane oxygenation circuitry, providing intensivists with multiple options to tailor therapy. Furthermore, their unique pharmacokinetic profiles render them titratable and empower clinicians to individualize management with heightened accuracy, mitigating risks associated with conventional sedation modalities. Despite the amounting enthusiasm for the use of these therapies, barriers to widespread utilization include expanding equipment availability, staff familiarity and training of safe use. This article delves into the realm of applying inhaled volatile anesthetics in the intensive care unit through discussing their pharmacology, administration considerations in intensive care settings, complication considerations, and listing indications and evidence of the use of volatile anesthetics in the critically ill patient population.
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Affiliation(s)
| | - Mariam ElSaban
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | | | - Nathan J Smischney
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
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3
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Factors associated with mortality in patients with super-refractory status epilepticus. Sci Rep 2022; 12:9670. [PMID: 35690663 PMCID: PMC9188563 DOI: 10.1038/s41598-022-13726-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/26/2022] [Indexed: 11/08/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is a critical condition in which seizures persist despite anesthetic use for 24 h or longer. High mortality has been reported in patients with SRSE, but the cause of death remains unclear. We investigated the factors associated with mortality, including clinical characteristics, SE etiologies and severities, treatments, and responses in patients with SRSE in a 13-year tertiary hospital-based retrospective cohort study comparing these parameters between deceased and surviving patients. SRSE accounted for 14.2% of patients with status epilepticus, and 28.6% of SRSE patients died. Deceased patients were mostly young or middle-aged without known systemic diseases or epilepsy. All deceased patients experienced generalized convulsive status epilepticus and failure of anesthetic tapering-off, significantly higher than survivors. An increased number of second-line anesthetics besides midazolam was observed in the deceased (median, 3, interquartile range 2–3) compared to surviving (1, 1–1; p = 0.0006) patients with prolonged use durations (p = 0.047). For mortality, the cut-off number of second-line anesthetics was 1.5 (AUC = 0.906, p = 0.004). Deceased patients had significantly higher renal and cardiac complications and metabolic acidosis than survivors. In SRSE management, multi-anesthetic use should be carefully controlled to avoid systemic complications and mortality.
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Jense A, Douville A, Weiss A. The safety of rapid infusion levetiracetam: A systematic review. Pharmacotherapy 2022; 42:495-503. [PMID: 35502462 DOI: 10.1002/phar.2687] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/11/2022] [Accepted: 04/11/2022] [Indexed: 11/07/2022]
Abstract
Epilepsy is a common diagnosis and can quickly progress to status epilepticus which requires rapid treatment. Levetiracetam is a frequent treatment choice in these situations. The approved administration of intravenous levetiracetam is an infusion over 15 min. In recent years, studies have been published on faster infusion rates of levetiracetam. The objective of this review is to discuss the safety of levetiracetam as an intravenous push at a rate quicker than recommended. A literature search using PubMed, Cochrane Library, ClinicalTrials.gov, and Google Scholar resulted in 192 articles. Inclusion criteria consisted of English language, human studies, use of levetiracetam administered intravenously at a rate faster than 15 min, discussion of safety, and full-text availability. After screening, nine articles remained for inclusion. Of the nine articles, one was a prospective, open-label study, six were retrospective studies, and two were open-label, randomized controlled trials. The most common rapid infusion speed was 5 min and doses ranged from 280 to 4500 mg. Some of these trials used undiluted levetiracetam and many reported that peripheral access was used for a portion or all of the administrations. There were few adverse effects, including specific adverse effects relating to medication concentration and speed of infusion, in all the studies. Administration of intravenous levetiracetam at a rate faster than recommended in the labeling information appears to be safe and tolerable and can be given via a peripheral line. Rapid infusion of levetiracetam is a beneficial method of administration in an acute care setting where patients need rapid attainment of therapeutic levels of antiepileptic medications. Additional research is needed to ensure that rapid administration of intravenous levetiracetam is as efficacious as the traditional dosing method.
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Affiliation(s)
- Alexa Jense
- UCHealth Memorial Hospital, Colorado Springs, Colorado, USA
| | | | - Ashley Weiss
- UCHealth Memorial Hospital, Colorado Springs, Colorado, USA
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5
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Cruickshank M, Imamura M, Booth C, Aucott L, Counsell C, Manson P, Scotland G, Brazzelli M. Pre-hospital and emergency department treatment of convulsive status epilepticus in adults: an evidence synthesis. Health Technol Assess 2022; 26:1-76. [PMID: 35333156 PMCID: PMC8977974 DOI: 10.3310/rsvk2062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Convulsive status epilepticus is defined as ≥ 5 minutes of either continuous seizure activity or repetitive seizures without regaining consciousness. It is regarded as an emergency condition that requires prompt treatment to avoid hospitalisation and to reduce morbidity and mortality. Rapid pre-hospital first-line treatment of convulsive status epilepticus is currently benzodiazepines, administered either by trained caregivers in the community (e.g. buccal midazolam, rectal diazepam) or by trained health professionals via intramuscular or intravenous routes (e.g. midazolam, lorazepam). There is a lack of clarity about the optimal treatment for convulsive status epilepticus in the pre-hospital setting. OBJECTIVES To assess the current evidence on the clinical effectiveness and cost-effectiveness of treatments for adults with convulsive status epilepticus in the pre-hospital setting. DATA SOURCES We searched major electronic databases, including MEDLINE, EMBASE, PsycInfo®, CINAHL, CENTRAL, NHS Economic Evaluation Database, Health Technology Assessment Database, Research Papers in Economics, and the ISPOR Scientific Presentations Database, with no restrictions on publication date or language of publication. Final searches were carried out on 21 July 2020. REVIEW METHODS Systematic review of randomised controlled trials assessing adults with convulsive status epilepticus who received treatment before or on arrival at the emergency department. Eligible treatments were any antiepileptic drugs offered as first-line treatments, regardless of their route of administration. Primary outcomes were seizure cessation, seizure recurrence and adverse events. Two reviewers independently screened all citations identified by the search strategy, retrieved full-text articles, extracted data and assessed the risk of bias of the included trials. Results were described narratively. RESULTS Four trials (1345 randomised participants, of whom 1234 were adults) assessed the intravenous or intramuscular use of benzodiazepines or other antiepileptic drugs for the pre-hospital treatment of convulsive status epilepticus in adults. Three trials at a low risk of bias showed that benzodiazepines were effective in stopping seizures. In particular, intramuscular midazolam was non-inferior to intravenous lorazepam. The addition of levetiracetam to clonazepam did not show clear advantages over clonazepam alone. One trial at a high risk of bias showed that phenobarbital plus optional phenytoin was more effective in terminating seizures than diazepam plus phenytoin. The median time to seizure cessation from drug administration varied from 1.6 minutes to 15 minutes. The proportion of people with recurrence of seizures ranged from 10.4% to 19.1% in two trials reporting this outcome. Across trials, the rates of respiratory depression among participants receiving active treatments were generally low (from 6.4% to 10.6%). The mortality rate ranged from 2% to 7.6% in active treatment groups and from 6.2% to 15.5% in control groups. Only one study based on retrospective observational data met the criteria for economic evaluation; therefore, it was not possible to draw any robust conclusions on cost-effectiveness. LIMITATIONS The limited number of identified trials and their differences in terms of treatment comparisons and outcomes hindered any meaningful pooling of data. None of the included trials was conducted in the UK and none assessed the use of buccal midazolam or rectal diazepam. The review of economic evaluations was hampered by lack of suitable data. CONCLUSIONS Both intravenous lorazepam and intravenous diazepam administered by paramedics are more effective than a placebo in the treatments of adults with convulsive status epilepticus, and intramuscular midazolam is non-inferior to intravenous lorazepam. Large well-designed clinical trials are needed to establish which benzodiazepines are more effective and preferable in the pre-hospital setting. STUDY REGISTRATION This study is registered as PROSPERO CRD42020201953. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 26, No. 20. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Mari Imamura
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Carl Counsell
- Institute of Applied Health Sciences, University of Aberdeen, UK
- NHS Grampian, Aberdeen, UK
| | - Paul Manson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Services Research Unit and Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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6
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Cruickshank M, Imamura M, Counsell C, Aucott L, Manson P, Booth C, Scotland G, Brazzelli M. Management of the first stage of convulsive status epilepticus in adults: a systematic review of current randomised evidence. J Neurol 2022; 269:3420-3429. [PMID: 35094154 PMCID: PMC9217864 DOI: 10.1007/s00415-022-10979-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/18/2022] [Accepted: 01/18/2022] [Indexed: 01/03/2023]
Abstract
Background Convulsive status epilepticus is the most severe form of epilepsy and requires urgent treatment. We synthesised the current evidence on first-line treatments for controlling seizures in adults with convulsive status epilepticus before, or at, arrival at hospital. Methods We conducted a systematic review of randomised controlled trials (RCTs) assessing antiepileptic drugs offered to adults as first-line treatments. Major electronic databases were searched. Results Four RCTs (1234 adults) were included. None were conducted in the UK and none assessed the use of buccal or intranasal midazolam. Both intravenous lorazepam and intravenous diazepam administered by paramedics were more effective than placebo and, notably, intramuscular midazolam was non-inferior to intravenous lorazepam. Overall, median time to seizure cessation from drug administration varied from 2 to 15 min. Rates of respiratory depression among participants receiving active treatments ranged from 6.4 to 10.6%. Mortality ranged from 2 to 7.6% in active treatment groups and 6.2 to 15.5% in control groups. Conclusions Intravenous and intramuscular benzodiazepines are safe and effective in this clinical context. Further research is needed to establish the most clinically and cost-effective first-line treatment and preferable mode of administration. Head-to-head trials comparing buccal versus intranasal midazolam versus rectal diazepam would provide useful information to inform the management of the first stage of convulsive status epilepticus in adults, especially when intravenous or intramuscular access is not feasible. Approaches to improve adherence to clinical guidelines on the use of currently available benzodiazepines for the first-line treatment of convulsive status epilepticus should also be considered.
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Affiliation(s)
| | - Mari Imamura
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Carl Counsell
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- NHS Grampian, Aberdeen, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Paul Manson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Corinne Booth
- Independent Consultant, Health Economist, Glasgow, UK
| | - Graham Scotland
- Health Services Research Unit and Health Economics Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
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7
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Ko A, Kwon HE, Kim HD. Updates on the ketogenic diet therapy for pediatric epilepsy. Biomed J 2021; 45:19-26. [PMID: 34808422 PMCID: PMC9133260 DOI: 10.1016/j.bj.2021.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/25/2021] [Accepted: 11/07/2021] [Indexed: 12/11/2022] Open
Abstract
The ketogenic diet (KD) is a high-fat, low-carbohydrate diet, in which fat, instead of glucose, acts as a major energy source through the production of ketone bodies. The KD was formally introduced in 1921 to mimic the biochemical changes associated with fasting and gained recognition as a potent treatment for pediatric epilepsy in the mid-1990s. Recent clinical and scientific knowledge supports the use of the KD in drug-resistant epilepsy patients for its anti-seizure efficacy, safety, and tolerability. The KD is also receiving growing attention as a potential treatment option for other neurological disorders. This article will review on the recent updates on the KD, focusing on its mechanisms of action, its alternatives, expansion on its use in terms of age groups and different regions in the world, and future issues.
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Affiliation(s)
- Ara Ko
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
| | - Hye Eun Kwon
- Department of Pediatrics, International St. Mary's Hospital, Catholic Kwandong University, College of Medicine, Incheon, Republic of Korea
| | - Heung Dong Kim
- Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Morgan JE, Wilson SC, Travis BJ, Bagri KH, Pagarigan KT, Belski HM, Jackson C, Bounader KM, Coppola JM, Hornung EN, Johnson JE, McCarren HS. Refractory and Super-Refractory Status Epilepticus in Nerve Agent-Poisoned Rats Following Application of Standard Clinical Treatment Guidelines. Front Neurosci 2021; 15:732213. [PMID: 34566572 PMCID: PMC8462486 DOI: 10.3389/fnins.2021.732213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/16/2021] [Indexed: 12/24/2022] Open
Abstract
Nerve agents (NAs) induce a severe cholinergic crisis that can lead to status epilepticus (SE). Current guidelines for treatment of NA-induced SE only include prehospital benzodiazepines, which may not fully resolve this life-threatening condition. This study examined the efficacy of general clinical protocols for treatment of SE in the specific context of NA poisoning in adult male rats. Treatment with both intramuscular and intravenous benzodiazepines was entirely insufficient to control SE. Second line intervention with valproate (VPA) initially terminated SE in 35% of rats, but seizures always returned. Phenobarbital (PHB) was more effective, with SE terminating in 56% of rats and 19% of rats remaining seizure-free for at least 24 h. The majority of rats demonstrated refractory SE (RSE) and required treatment with a continuous third-line anesthetic. Both ketamine (KET) and propofol (PRO) led to high levels of mortality, and nearly all rats on these therapies had breakthrough seizure activity, demonstrating super-refractory SE (SRSE). For the small subset of rats in which SE was fully resolved, significant improvements over controls were observed in recovery metrics, behavioral assays, and brain pathology. Together these data suggest that NA-induced SE is particularly severe, but aggressive treatment in the intensive care setting can lead to positive functional outcomes for casualties.
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Affiliation(s)
- Julia E Morgan
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, United States
| | - Sara C Wilson
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, United States
| | - Benjamin J Travis
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, United States
| | - Kathryn H Bagri
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, United States
| | - Kathleen T Pagarigan
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, United States
| | - Hannah M Belski
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, United States
| | - Cecelia Jackson
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, United States
| | - Kevin M Bounader
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, United States
| | - Jessica M Coppola
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, United States
| | - Eden N Hornung
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, United States
| | - James E Johnson
- Comparative Pathology Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, United States
| | - Hilary S McCarren
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, United States
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9
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Madžar D, Reindl C, Mrochen A, Hamer HM, Huttner HB. Value of initial C-reactive protein levels in status epilepticus outcome prediction. Epilepsia 2021; 62:e48-e52. [PMID: 33609292 DOI: 10.1111/epi.16842] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 11/24/2022]
Abstract
The role of neuroinflammation in the pathophysiology of seizures is increasingly recognized, and the evaluation of potential biochemical markers of inflammatory processes in seizures and status epilepticus (SE), such as C-reactive protein (CRP), has gained attention. The present study assessed the first CRP level obtained in an SE episode regarding its value for SE outcome prediction. Among 362 admissions for SE during the study period, 231 episodes satisfied the inclusion criteria. Higher initial CRP concentrations were independently associated with in-hospital mortality and poor functional outcome at discharge in logistic regression models adjusting for SE severity, severity of SE etiology, and development of treatment refractoriness. Therefore, initial CRP levels may add to the prediction of SE prognosis. The pathomechanisms through which CRP is linked with the prognosis of SE, however, remain to be established.
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Affiliation(s)
- Dominik Madžar
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Caroline Reindl
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Anne Mrochen
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Hajo M Hamer
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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10
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Abstract
Management of acute neurologic disorders in the emergency department is multimodal and may require the use of medications to decrease morbidity and mortality secondary to neurologic injury. Clinicians should form an individualized treatment approach with regard to various patient specific factors. This review article focuses on the pharmacotherapy for common neurologic emergencies that present to the emergency department, including traumatic brain injury, central nervous system infections, status epilepticus, hypertensive emergencies, spinal cord injury, and neurogenic shock.
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Affiliation(s)
- Kyle M DeWitt
- Emergency Medicine, Department of Pharmacy, The University of Vermont Medical Center, 111 Colchester Avenue, Mailstop 272 BA1, Burlington, VT 05401, USA.
| | - Blake A Porter
- Emergency Medicine, Department of Pharmacy, The University of Vermont Medical Center, 111 Colchester Avenue, Mailstop 272 BA1, Burlington, VT 05401, USA. https://twitter.com/RxEmergency
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11
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Reindl C, Sprügel MI, Sembill JA, Mueller TM, Hagen M, Gerner ST, Kuramatsu JB, Hamer HM, Huttner HB, Madžar D. Influence of new versus traditional antiepileptic drugs on course and outcome of status epilepticus. Seizure 2020; 74:20-25. [DOI: 10.1016/j.seizure.2019.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 10/18/2019] [Accepted: 11/05/2019] [Indexed: 01/13/2023] Open
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12
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Lin CH, Lu YT, Ho CJ, Shih FY, Tsai MH. The Different Clinical Features Between Autoimmune and Infectious Status Epilepticus. Front Neurol 2019; 10:25. [PMID: 30814971 PMCID: PMC6381771 DOI: 10.3389/fneur.2019.00025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 01/09/2019] [Indexed: 12/14/2022] Open
Abstract
Objective: The prognosis of status epilepticus (SE) is highly related to the underlying etiology. Inflammation of the central nervous system (CNS), including infection and autoimmune encephalitis, is one of the treatable conditions causing SE. The initial presentation of infectious and autoimmune CNS disorders can be quite similar, which may be difficult to differentiate at the beginning. However, treatment for these entities can be quite different. In this study, we aim to identify the differences in clinical features among patients with infectious and autoimmune SE, which could help the clinicians to select initial investigation and ensuing therapies that may improve overall outcomes. Methods: This was a retrospective study that included 501 patients with SE within a period of 10.5-years. Patients with inflammatory etiology were collected and separated into infectious and autoimmune SE. The symptoms at onset, SE semiology, status epilepticus severity score, and END-IT score at admission, treatment for SE, and outcome (modified Rankin Scale) on discharge and last follow-up were recorded. Data on the first cerebrospinal fluid, electroencephalography, and magnetic resonance imaging were also collected. Results: Forty-six (9.2%) of the 501 patients had SE with inflammatory etiology. Twenty-five (5%) patients were autoimmune SE and 21 (4.2%) were infectious SE. Patients with autoimmune SE have younger age and female predominance. As for clinical presentations, psychosis, non-convulsive SE, and super refractory SE were more common in patients with autoimmune SE. Nevertheless, the prognosis showed no difference between the two groups. Conclusion: The different initial clinical presentations and patient characteristics may provide some clues about the underlying etiology of SE. When inflammatory etiology is suspected in patients with SE, younger age, female sex, psychosis, non-convulsive SE, and super refractory SE are clinical features that suggest an autoimmune etiology.
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Affiliation(s)
- Chih-Hsiang Lin
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Yan-Ting Lu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Chen-Jui Ho
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Fu-Yuan Shih
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Meng-Han Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
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13
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Madžar D, Reindl C, Giede-Jeppe A, Bobinger T, Sprügel MI, Knappe RU, Hamer HM, Huttner HB. Impact of timing of continuous intravenous anesthetic drug treatment on outcome in refractory status epilepticus. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:317. [PMID: 30463604 PMCID: PMC6249897 DOI: 10.1186/s13054-018-2235-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/15/2018] [Indexed: 12/04/2022]
Abstract
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.
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Affiliation(s)
- Dominik Madžar
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Neurology, Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Caroline Reindl
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Neurology, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Antje Giede-Jeppe
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Neurology, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Tobias Bobinger
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Neurology, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Maximilian I Sprügel
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Neurology, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Ruben U Knappe
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Neurology, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hajo M Hamer
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Neurology, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hagen B Huttner
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Neurology, Schwabachanlage 6, 91054, Erlangen, Germany
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Ostendorf AP, Merison K, Wheeler TA, Patel AD. Decreasing Seizure Treatment Time Through Quality Improvement Reduces Critical Care Utilization. Pediatr Neurol 2018; 85:58-66. [PMID: 30054195 DOI: 10.1016/j.pediatrneurol.2018.05.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/26/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Rapid, effective treatment for status epilepticus reduces associated morbidity and mortality, yet medication delivery remains slow in many hospitalized patients. We utilized quality improvement (QI) methodology to improve treatment times for hospitalized children with status epilepticus. We hypothesized rapid initial seizure treatment would decrease seizure morbidity. METHODS We utilized QI and statistical process control analysis in a nonintensive care setting within a tertiary care pediatric hospital. We performed Plan-Do-Study-Act cycles including (1) revising the nursing process for responding to seizures, (2) emphasizing intranasal midazolam over intravenous lorazepam, (3) relocating medications and supplies, (4) developing documentation tools and reinforcing correct processes, (5) developing and disseminating an online education module for residents and nurse practitioners, and (6) completing standardization to intranasal midazolam. RESULTS Seventeen months after starting the project, 66 seizures had been treated with a benzodiazepine in a median (p25-p75) time of 7.5 minutes (5 to 10), decreased from a baseline of 14 minutes (8-30) (P = 0.01). The proportion of patients receiving a benzodiazepine in 10 minutes or less improved from 39% to 79%. The proportion of patients transferred to intensive care decreased from a baseline of 39% to 9% (P < 0.005), resulting in an estimated $2.1 million in mitigated hospital charges. Significant harm did not occur during the implementation of these interventions. CONCLUSIONS Children with status epilepticus were treated with benzodiazepines more rapidly and effectively following implementation of QI methodology. These interventions reduced utilization of critical care and mitigated hospital charges.
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Affiliation(s)
- Adam P Ostendorf
- Neurology Division, Department of Pediatrics, The Ohio State University, Columbus, Ohio; Nationwide Children's Hospital, Columbus, Ohio.
| | | | | | - Anup D Patel
- Neurology Division, Department of Pediatrics, The Ohio State University, Columbus, Ohio; Nationwide Children's Hospital, Columbus, Ohio
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15
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Reindl C, Knappe RU, Sprügel MI, Sembill JA, Mueller TM, Hamer HM, Huttner HB, Madžar D. Comparison of scoring tools for the prediction of in-hospital mortality in status epilepticus. Seizure 2018; 56:92-97. [PMID: 29455141 DOI: 10.1016/j.seizure.2018.01.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Several scoring tools have been developed for the prognostication of outcome after status epilepticus (SE). In this study, we compared the performances of STESS (Status Epilepticus Severity Score), mSTESS (modified STESS), EMSE-EAL (Epidemiology-based Mortality Score in Status Epilepticus- Etiology, Age, Level of Consciousness) and END-IT (Encephalitis-NCSE-Diazepam resistance-Image abnormalities-Tracheal intubation) in predicting in-hospital mortality after SE. METHOD Data collected retrospectively from a cohort of 287 patients with SE were used to calculate STESS, mSTESS, EMSE-EAL, and END-IT scores. The differences between the scores' performances were determined by means of area under the ROC curve (AUC) comparisons and McNemar testing. RESULTS The in-hospital mortality rate was 11.8%. The AUC of STESS (0.628; 95% confidence interval (CI), 0.529-0.727) was similar to that of mSTESS (0.620; 95% CI, 0.510-0.731), EMSE-EAL (0.556; 95% CI, 0.446-0.665), and END-IT (0.659; 95% CI, 0.550-0.768; p > .05 for each comparison) in predicting in-hospital mortality. STESS with a cutoff of 3 was found to have lowest specificity and number of correctly classified episodes. EMSE-EAL with a cutoff at 40 had highest specificity and showed a trend towards more correctly classified episodes while sensitivity tended to be low. END-IT with a cutoff of 3 had the most balanced sensitivity-specificity ratio. CONCLUSIONS EMSE-EAL is as easy to calculate as STESS and tended towards higher diagnostic accuracy. Adding information on premorbid functional status to STESS did not enhance outcome prediction. END-IT was not superior to other scores in prediction of in-hospital mortality despite including information of diagnostic work-up and response to initial treatment.
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Affiliation(s)
- Caroline Reindl
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Ruben U Knappe
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Maximilian I Sprügel
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Jochen A Sembill
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Tamara M Mueller
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Hajo M Hamer
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Hagen B Huttner
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Dominik Madžar
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
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16
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Madžar D, Knappe RU, Reindl C, Giede-Jeppe A, Sprügel MI, Beuscher V, Gollwitzer S, Hamer HM, Huttner HB. Factors associated with occurrence and outcome of super-refractory status epilepticus. Seizure 2017; 52:53-59. [PMID: 28963934 DOI: 10.1016/j.seizure.2017.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/19/2017] [Accepted: 09/07/2017] [Indexed: 02/09/2023] Open
Abstract
PURPOSE Super-refractory status epilepticus (SRSE) represents a challenging medical condition with high morbidity and mortality. In this study, we aimed to establish variables related to SRSE development and outcome. METHODS We retrospectively screened our databases for refractory SE (RSE) and SRSE episodes between January 2001 and January 2015. Baseline demographics, SE characteristics, and variables reflecting the clinical course were compared in order to identify factors independently associated with SRSE occurrence. Within the SRSE cohort, predictors of in-hospital mortality as well as good functional outcome in survivors to discharge were established through univariate and multivariable analyses. RESULTS A total of 131 episodes were included, among those 46 (35.1%) meeting the criteria of SRSE. Comparison of RSE and SRSE episodes revealed a lower premorbid mRS score (odds ratio (OR) per mRS point, 0.769; p=0.039) and non-convulsive SE (NCSE) in coma (OR, 4.216; p=0.008) as independent predictors of SRSE. SRSE in-hospital mortality was associated with age (OR, 1.091 per increasing year; p=0.020) and worse premorbid functional status (OR, 1.938 per mRS point; p=0.044). Good functional outcome in survivors was independently related to shorter SRSE duration (OR, 0.714 per day; p=0.038). CONCLUSION Better premorbid functional status and NCSE in coma as worst seizure type indicate a role of acute underlying etiologies in the development of SRSE. In-hospital mortality in SRSE is determined by nonmodifiable factors, while functional outcome in survivors depends on seizure duration underscoring the need of achieving rapid seizure termination.
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Affiliation(s)
- Dominik Madžar
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Ruben U Knappe
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Caroline Reindl
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Antje Giede-Jeppe
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Maximilian I Sprügel
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Vanessa Beuscher
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Stephanie Gollwitzer
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Hajo M Hamer
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Hagen B Huttner
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
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Lee T, Warrick BJ, Sarangarm P, Alunday RL, Bussmann S, Smolinske SC, Seifert SA. Levetiracetam in toxic seizures. Clin Toxicol (Phila) 2017; 56:175-181. [DOI: 10.1080/15563650.2017.1355056] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ted Lee
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Brandon J. Warrick
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
- New Mexico Poison and Drug Information Center, Albuquerque, NM, USA
| | - Preeyaporn Sarangarm
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Robert L. Alunday
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Silas Bussmann
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Susan C. Smolinske
- New Mexico Poison and Drug Information Center, Albuquerque, NM, USA
- College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
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18
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Josephson SA, Ferro J, Cohen A, Webb A, Lee E, Vespa PM. Quality improvement in neurology: Inpatient and emergency care quality measure set: Executive summary. Neurology 2017; 89:730-735. [PMID: 28733339 DOI: 10.1212/wnl.0000000000004230] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 04/10/2017] [Indexed: 12/30/2022] Open
Affiliation(s)
- S Andrew Josephson
- From the Department of Neurology (S.A.J.), University of California San Francisco; Vassar Brothers Medical Center (J.F.), Poughkeepsie, NY; Massachusetts General Hospital (A.C.), Department of Neurology, Boston; Department of Neurology (A.W.), Emory School of Medicine, Atlanta, GA; American Academy of Neurology (E.L.), Minneapolis, MN; and Department of Neurology (P.M.V.), University of California Los Angeles
| | - John Ferro
- From the Department of Neurology (S.A.J.), University of California San Francisco; Vassar Brothers Medical Center (J.F.), Poughkeepsie, NY; Massachusetts General Hospital (A.C.), Department of Neurology, Boston; Department of Neurology (A.W.), Emory School of Medicine, Atlanta, GA; American Academy of Neurology (E.L.), Minneapolis, MN; and Department of Neurology (P.M.V.), University of California Los Angeles
| | - Adam Cohen
- From the Department of Neurology (S.A.J.), University of California San Francisco; Vassar Brothers Medical Center (J.F.), Poughkeepsie, NY; Massachusetts General Hospital (A.C.), Department of Neurology, Boston; Department of Neurology (A.W.), Emory School of Medicine, Atlanta, GA; American Academy of Neurology (E.L.), Minneapolis, MN; and Department of Neurology (P.M.V.), University of California Los Angeles
| | - Adam Webb
- From the Department of Neurology (S.A.J.), University of California San Francisco; Vassar Brothers Medical Center (J.F.), Poughkeepsie, NY; Massachusetts General Hospital (A.C.), Department of Neurology, Boston; Department of Neurology (A.W.), Emory School of Medicine, Atlanta, GA; American Academy of Neurology (E.L.), Minneapolis, MN; and Department of Neurology (P.M.V.), University of California Los Angeles
| | - Erin Lee
- From the Department of Neurology (S.A.J.), University of California San Francisco; Vassar Brothers Medical Center (J.F.), Poughkeepsie, NY; Massachusetts General Hospital (A.C.), Department of Neurology, Boston; Department of Neurology (A.W.), Emory School of Medicine, Atlanta, GA; American Academy of Neurology (E.L.), Minneapolis, MN; and Department of Neurology (P.M.V.), University of California Los Angeles
| | - Paul M Vespa
- From the Department of Neurology (S.A.J.), University of California San Francisco; Vassar Brothers Medical Center (J.F.), Poughkeepsie, NY; Massachusetts General Hospital (A.C.), Department of Neurology, Boston; Department of Neurology (A.W.), Emory School of Medicine, Atlanta, GA; American Academy of Neurology (E.L.), Minneapolis, MN; and Department of Neurology (P.M.V.), University of California Los Angeles
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Abstract
Critically ill patients with seizures are either admitted to the intensive care unit because of uncontrolled seizures requiring aggressive treatment or are admitted for other reasons and develop seizures secondarily. These patients may have multiorgan failure and severe metabolic and electrolyte disarrangements, and may require complex medication regimens and interventions. Seizures can be seen as a result of an acute systemic illness, a primary neurologic pathology, or a medication side-effect and can present in a wide array of symptoms from convulsive activity, subtle twitching, to lethargy. In this population, untreated isolated seizures can quickly escalate to generalized convulsive status epilepticus or, more frequently, nonconvulsive status epileptics, which is associated with a high morbidity and mortality. Status epilepticus (SE) arises from a failure of inhibitory mechanisms and an enhancement of excitatory pathways causing permanent neuronal injury and other systemic sequelae. Carrying a high 30-day mortality rate, SE can be very difficult to treat in this complex setting, and a portion of these patients will become refractory, requiring narcotics and anesthetic medications. The most significant factor in successfully treating status epilepticus is initiating antiepileptic drugs as soon as possible, thus attentiveness and recognition of this disease are critical.
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Affiliation(s)
- J Ch'ang
- Neurological Institute, Columbia University, New York, NY, USA
| | - J Claassen
- Neurological Institute, Columbia University, New York, NY, USA.
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20
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Glauser T, Shinnar S, Gloss D, Alldredge B, Arya R, Bainbridge J, Bare M, Bleck T, Dodson WE, Garrity L, Jagoda A, Lowenstein D, Pellock J, Riviello J, Sloan E, Treiman DM. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr 2016; 16:48-61. [PMID: 26900382 PMCID: PMC4749120 DOI: 10.5698/1535-7597-16.1.48] [Citation(s) in RCA: 676] [Impact Index Per Article: 84.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
CONTEXT The optimal pharmacologic treatment for early convulsive status epilepticus is unclear. OBJECTIVE To analyze efficacy, tolerability and safety data for anticonvulsant treatment of children and adults with convulsive status epilepticus and use this analysis to develop an evidence-based treatment algorithm. DATA SOURCES Structured literature review using MEDLINE, Embase, Current Contents, and Cochrane library supplemented with article reference lists. STUDY SELECTION Randomized controlled trials of anticonvulsant treatment for seizures lasting longer than 5 minutes. DATA EXTRACTION Individual studies were rated using predefined criteria and these results were used to form recommendations, conclusions, and an evidence-based treatment algorithm. RESULTS A total of 38 randomized controlled trials were identified, rated and contributed to the assessment. Only four trials were considered to have class I evidence of efficacy. Two studies were rated as class II and the remaining 32 were judged to have class III evidence. In adults with convulsive status epilepticus, intramuscular midazolam, intravenous lorazepam, intravenous diazepam and intravenous phenobarbital are established as efficacious as initial therapy (Level A). Intramuscular midazolam has superior effectiveness compared to intravenous lorazepam in adults with convulsive status epilepticus without established intravenous access (Level A). In children, intravenous lorazepam and intravenous diazepam are established as efficacious at stopping seizures lasting at least 5 minutes (Level A) while rectal diazepam, intramuscular midazolam, intranasal midazolam, and buccal midazolam are probably effective (Level B). No significant difference in effectiveness has been demonstrated between intravenous lorazepam and intravenous diazepam in adults or children with convulsive status epilepticus (Level A). Respiratory and cardiac symptoms are the most commonly encountered treatment-emergent adverse events associated with intravenous anticonvulsant drug administration in adults with convulsive status epilepticus (Level A). The rate of respiratory depression in patients with convulsive status epilepticus treated with benzodiazepines is lower than in patients with convulsive status epilepticus treated with placebo indicating that respiratory problems are an important consequence of untreated convulsive status epilepticus (Level A). When both are available, fosphenytoin is preferred over phenytoin based on tolerability but phenytoin is an acceptable alternative (Level A). In adults, compared to the first therapy, the second therapy is less effective while the third therapy is substantially less effective (Level A). In children, the second therapy appears less effective and there are no data about third therapy efficacy (Level C). The evidence was synthesized into a treatment algorithm. CONCLUSIONS Despite the paucity of well-designed randomized controlled trials, practical conclusions and an integrated treatment algorithm for the treatment of convulsive status epilepticus across the age spectrum (infants through adults) can be constructed. Multicenter, multinational efforts are needed to design, conduct and analyze additional randomized controlled trials that can answer the many outstanding clinically relevant questions identified in this guideline.
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Affiliation(s)
- Tracy Glauser
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shlomo Shinnar
- Departments of Neurology, Pediatrics, and Epidemiology and Population Health, and the Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | | | - Brian Alldredge
- School of Pharmacy, University of California, San Francisco, CA
| | - Ravindra Arya
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jacquelyn Bainbridge
- Department of Clinical Pharmacy, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Mary Bare
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Thomas Bleck
- Departments of Neurological Sciences, Neurosurgery, Medicine, and Anesthesiology, Rush University Medical Center, Chicago, IL
| | - W. Edwin Dodson
- Departments of Neurology and Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Lisa Garrity
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andy Jagoda
- Department of Emergency Medicine, Mount Sinai Hospital, Mount Sinai School of Medicine, New York, NY
| | - Daniel Lowenstein
- Department of Neurology, University of California, San Francisco, CA
| | - John Pellock
- Division of Pediatric Neurology, Virginia Commonwealth University, Richmond, VA
| | | | - Edward Sloan
- Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL
| | - David M. Treiman
- Division of Neurology, Barrow Neurological Institute, Phoenix, AZ
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21
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Admissions to paediatric intensive care units (PICU) with refractory convulsive status epilepticus (RCSE): A two-year multi-centre study. Seizure 2015; 29:153-61. [DOI: 10.1016/j.seizure.2015.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 04/03/2015] [Accepted: 04/04/2015] [Indexed: 11/18/2022] Open
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Kang BS, Jung KH, Shin JW, Moon JS, Byun JI, Lim JA, Moon HJ, Kim YS, Lee ST, Chu K, Lee SK. Induction of burst suppression or coma using intravenous anesthetics in refractory status epilepticus. J Clin Neurosci 2015; 22:854-8. [PMID: 25744078 DOI: 10.1016/j.jocn.2014.11.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 11/05/2014] [Indexed: 10/23/2022]
Abstract
General anesthetic-induced coma therapy has been recommended for the treatment of refractory status epilepticus (RSE). However, the influence of electroencephalographic (EEG) burst suppression (BS) on outcomes still remains unclear. This study investigated the impact of intravenous anesthetic-induced BS on the prognosis of RSE using a retrospective analysis of all consecutive adult patients who received intravenous anesthetic treatment for RSE at the Seoul National University Hospital between January 2006 and June 2011. Twenty-two of the 111 episodes of RSE were enrolled in this study. Of the 22 RSE patients, 12 (54.5%) were women and 18 (81.4%) exhibited generalized convulsive status epilepticus. Sixteen patients (72.7%) were classified as having acute symptomatic etiology, including three patients with anoxic encephalopathy, and others with remote symptomatic etiology. Only two patients (9.1%) had a favorable Status Epilepticus Severity Score (0-2) at admission. All patients received midazolam (MDZ) as a primary intravenous anesthetic drug for RSE treatment; three (13.6%) received MDZ and propofol, and one (4.5%) received MDZ and pentobarbital. The rates of mortality and poor outcome at discharge were 13.6% (n=3) and 54.5% (n=12), respectively. While BS was achieved in six (27.5%) patients, it was not associated with mortality or poor outcome. Induced BS was associated with prolonged hospital stay in subgroup analysis when excluding anoxic encephalopathy. Our results suggest that induction of BS for treating RSE did not affect mortality or outcome at discharge and may lead to an increased length of hospital stay.
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Affiliation(s)
- Bong Su Kang
- Department of Neurology, Korea University Anam Hospital, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, 101, Daehangno, Chongro-Gu, Seoul 110-744, South Korea
| | - Jeong-Won Shin
- Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Jang Sup Moon
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, 101, Daehangno, Chongro-Gu, Seoul 110-744, South Korea
| | - Jung-Ick Byun
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, 101, Daehangno, Chongro-Gu, Seoul 110-744, South Korea
| | - Jung-Ah Lim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, 101, Daehangno, Chongro-Gu, Seoul 110-744, South Korea
| | - Hye Jin Moon
- Department of Neurology, Dongsan Medical Center, Keimyung University, Daegu, South Korea
| | - Young-Soo Kim
- Department of Neurology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, 101, Daehangno, Chongro-Gu, Seoul 110-744, South Korea
| | - Kon Chu
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, 101, Daehangno, Chongro-Gu, Seoul 110-744, South Korea
| | - Sang Kun Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, College of Medicine, Seoul National University, 101, Daehangno, Chongro-Gu, Seoul 110-744, South Korea.
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Paquette V, Culley C, Greanya ED, Ensom MHH. Lacosamide as adjunctive therapy in refractory epilepsy in adults: a systematic review. Seizure 2014; 25:1-17. [PMID: 25645629 DOI: 10.1016/j.seizure.2014.11.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/14/2014] [Accepted: 11/18/2014] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To review the evidence for efficacy and safety of lacosamide in adult patients with refractory epilepsy and refractory status epilepticus (RSE). METHODS A systematic literature search of MEDLINE, PubMed, EMBASE, IPA, Google and Google Scholar (through October 2014) was performed. RESULTS Fourteen studies assessing lacosamide in 3509 refractory epilepsy patients were included. In 3 RCTs, more patients had at least 50% reduction in seizure frequency with lacosamide compared to placebo with 38.3-41.1%, 38.1-41.2%, and 18.3-25.8%, in the 400 mg/day, 600 mg/day, and placebo groups, respectively. In non-comparative trials, 18-69% of patients achieved at least 50% reduction in seizure frequency, and 1.7-26.2% achieved seizure freedom. Non-responders were documented in two trials, with 26.2-34% having no response. Thirteen studies assessing lacosamide in 390 RSE patients were included. When assessing lacosamide's ability to terminate RSE, one comparative cohort study found no improvement in SE duration or seizure control with addition of lacosamide. Another study documented no difference compared to use of phenytoin. Eleven descriptive studies using lacosamide as add-on RSE therapy revealed seizure termination rates of 0-100% (median 64.7%). In all patients receiving lacosamide, dizziness (21.8%), vision disturbances (10.4%), drowsiness (7.4%), headache (7.0%), nausea (6.5%), and coordination problems (5.8%) were the most common adverse effects. CONCLUSION Based on evidence to date, adjunctive lacosamide is a treatment option to reduce seizure frequency in patients with refractory epilepsy and terminate seizures in patients with RSE. The safety information summary can be used to advise patients of potential adverse effects.
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Affiliation(s)
- Vanessa Paquette
- Department of Pharmacy, Children's and Women's Health Center of British Columbia, 4480 Oak Street, Vancouver, British Columbia, Canada V6H 3V4.
| | - Celia Culley
- Department of Pharmacy, Royal Jubilee Hospital, 1352 Bay Street, Victoria, British Columbia, Canada V8R 1J8.
| | - Erica D Greanya
- Department of Pharmacy, Victoria General Hospital, 1 Hospital Way, Victoria, British Columbia, Canada V8Z 6R5; Faculty of Pharmaceutical Sciences, The University of British Columbia, 2405 Wesbrook Mall, Vancouver, British Columbia, Canada V6T 1Z3.
| | - Mary H H Ensom
- Department of Pharmacy, Children's and Women's Health Center of British Columbia, 4480 Oak Street, Vancouver, British Columbia, Canada V6H 3V4; Faculty of Pharmaceutical Sciences, The University of British Columbia, 2405 Wesbrook Mall, Vancouver, British Columbia, Canada V6T 1Z3.
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Clemency BM, Ott JA, Tanski CT, Bart JA, Lindstrom HA. Parenteral midazolam is superior to diazepam for treatment of prehospital seizures. PREHOSP EMERG CARE 2014; 19:218-23. [PMID: 25291522 DOI: 10.3109/10903127.2014.959220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Diazepam and midazolam are commonly used by paramedics to treat seizures. A period of drug scarcity was used as an opportunity to compare their effectiveness in treating prehospital seizures. METHODS A retrospective chart review of a single, large, commercial agency during a 29-month period was performed. The period included alternating shortages of both medications. Ambulances were stocked with either diazepam or midazolam based on availability of the drugs. Adult patients who received at least 1 parenteral dose of diazepam or midazolam for treatment of seizures were included. The regional prehospital protocol recommended 5 mg intravenous (IV) diazepam, 5 mg intramuscular (IM) diazepam, 5 mg IM midazolam, or 2.5 mg IV midazolam. Medication effectiveness was compared with respect to the primary end point: cessation of seizure without repeat seizure during the prehospital encounter. RESULTS A total of 440 study subjects received 577 administrations of diazepam or midazolam and met the study criteria. The subjects were 52% male, with a mean age of 48 (range 18-94) years. A total of 237 subjects received 329 doses of diazepam, 64 (27%) were treated with first-dose IM. A total of 203 subjects received 248 doses of midazolam; 71 (35%) were treated with first-dose IM. Seizure stopped and did not recur in 49% of subjects after parenteral diazepam and 65% of subjects after parenteral midazolam (p = 0.002). Diazepam and midazolam exhibited similar first dose success for IV administration (58 vs. 62%; p = 0.294). Age, gender, seizure history, hypoglycemia, the presence of trauma, time to first administration, prehospital contact time, and frequency of IM administration were similar between groups. CONCLUSION For parenteral administration, midazolam demonstrated superior first-dose seizure suppression. This study demonstrates how periods of drug scarcity can be utilized to study prehospital medication effectiveness.
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Vooturi S, Jayalakshmi S, Sahu S, Mohandas S. Prognosis and predictors of outcome of refractory generalized convulsive status epilepticus in adults treated in neurointensive care unit. Clin Neurol Neurosurg 2014; 126:7-10. [PMID: 25194304 DOI: 10.1016/j.clineuro.2014.07.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 06/09/2014] [Accepted: 07/19/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the etiological profile, clinical characteristics and outcome of patients with refractory generalized convulsive status epilepticus treated in Neurological Intensive Care Unit (NICU). METHODS In this open cohort study, data of 126 patients, aged 18 years and above, with convulsive status epilepticus (SE) admitted in NICU was collected. Status epilepticus was defined as seizures lasting for more than five minutes without regaining consciousness. Refractory SE (RSE) was defined as SE refractory to 2 antiepileptic drugs and requiring anesthetic agents for seizure control. Survival and regression analysis were done to analyze the outcome and factors predicting outcome respectively in the study population. RESULTS Out of 126 patients, 81 patients had non -refractory status epilepticus (NRSE); 45 (35.7%) had RSE. Acute symptomatic etiology was noted in 58.6% of entire cohort. Significantly higher percentage of patients with RSE had an etiology of CNS infections than NRSE group (44.4% vs. 23.5%; P=0.0171). Amongst the CNS infections, viral encephalitis was significantly higher in RSE than NRSE patients (31% vs. 6.2%; P=0.0004). All the patients with RSE required mechanical ventilation. Overall mortality was 19%. The mortality in RSE was 42% (19 out of 45), significantly higher when compared to NRSE where only 6% (5 out of 81) died. On logistic regression, the only predictor of death was fever with an odds ratio of 8.55 (P=0.024). CONCLUSION CNS infections, especially viral encephalitis and complications of mechanical ventilation were significantly higher in adult RSE patients. Although mortality is higher in adult patients with RSE, etiology does not contribute to mortality; however fever predicts mortality in these patients. Aggressive management of underlying etiology and prevention of systemic complications may improve outcome in adult RSE patients.
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Affiliation(s)
- Sudhindra Vooturi
- Department of Neurology, Krishna Institute of Medical Sciences, Minister Road, Secunderabad500 003, Andhra Pradesh, India
| | - Sita Jayalakshmi
- Department of Neurology, Krishna Institute of Medical Sciences, Minister Road, Secunderabad500 003, Andhra Pradesh, India.
| | - Sambit Sahu
- Department of Critical Care, Krishna Institute of Medical Sciences, Minister Road, Secunderabad500 003, Andhra Pradesh, India
| | - Surath Mohandas
- Department of Neurology, Krishna Institute of Medical Sciences, Minister Road, Secunderabad500 003, Andhra Pradesh, India
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Sánchez Fernández I, Abend NS, Agadi S, An S, Arya R, Carpenter JL, Chapman KE, Gaillard WD, Glauser TA, Goldstein DB, Goldstein JL, Goodkin HP, Hahn CD, Heinzen EL, Mikati MA, Peariso K, Pestian JP, Ream M, Riviello JJ, Tasker RC, Williams K, Loddenkemper T. Gaps and opportunities in refractory status epilepticus research in children: a multi-center approach by the Pediatric Status Epilepticus Research Group (pSERG). Seizure 2013; 23:87-97. [PMID: 24183923 PMCID: PMC6387832 DOI: 10.1016/j.seizure.2013.10.004] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 10/07/2013] [Accepted: 10/09/2013] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Status epilepticus (SE) is a life-threatening condition that can be refractory to initial treatment. Randomized controlled studies to guide treatment choices, especially beyond first-line drugs, are not available. This report summarizes the evidence that guides the management of refractory convulsive SE (RCSE) in children, defines gaps in our clinical knowledge and describes the development and works of the 'pediatric Status Epilepticus Research Group' (pSERG). METHODS A literature review was performed to evaluate current gaps in the pediatric SE and RCSE literature. In person and online meetings helped to develop and expand the pSERG network. RESULTS The care of pediatric RCSE is largely based on extrapolations of limited evidence derived from adult literature and supplemented with case reports and case series in children. No comparative effectiveness trials have been performed in the pediatric population. Gaps in knowledge include risk factors for SE, biomarkers of SE and RCSE, second- and third-line treatment options, and long-term outcome. CONCLUSION The care of children with RCSE is based on limited evidence. In order to address these knowledge gaps, the multicenter pSERG was established to facilitate prospective collection, analysis, and sharing of de-identified data and biological specimens from children with RCSE. These data will allow identification of treatment strategies associated with better outcomes and delineate evidence-based interventions to improve the care of children with SE.
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Affiliation(s)
- Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Department of Child Neurology, Hospital Sant Joan de Déu, University of Barcelona, Spain
| | - Nicholas S Abend
- Division of Neurology, The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Satish Agadi
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Sookee An
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
| | - Jessica L Carpenter
- Department of Epilepsy, Neurophysiology, and Critical Care Neurology, The Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Kevin E Chapman
- Department of Pediatrics and Neurology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
| | - William D Gaillard
- Department of Epilepsy, Neurophysiology, and Critical Care Neurology, The Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Tracy A Glauser
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
| | - David B Goldstein
- Center for Human Genome Variation, Duke University Medical Center, Duke University, Durham, NC, United States
| | - Joshua L Goldstein
- Division of Neurology, Department of Pediatrics, Ann & Robert Lurie's Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Howard P Goodkin
- Department of Neurology and Department of Pediatrics, The University of Virginia Health System, Charlottesville, VA, United States
| | - Cecil D Hahn
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Erin L Heinzen
- Center for Human Genome Variation, Duke University Medical Center, Duke University, Durham, NC, United States
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, NC, United States
| | - Katrina Peariso
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
| | - John P Pestian
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
| | - Margie Ream
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, NC, United States
| | - James J Riviello
- Division of Pediatric Neurology, Department of Neurology, New York University Langone Medical Center, New York University School of Medicine, New York, NY, United States
| | - Robert C Tasker
- Department of Neurology, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Korwyn Williams
- Division of Pediatric Neurology, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
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Liberalesso PBN, Garzon E, Yacubian EM, Sakamoto AC. Higher mortality rate is associated with advanced age and periodic lateralized epileptiform discharges in patients with refractory status epilepticus. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 71:153-8. [DOI: 10.1590/s0004-282x2013000300005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 10/05/2012] [Indexed: 11/21/2022]
Abstract
ObjectiveTo evaluate clinical data, electroencephalogram, etiology, classification, treatment, morbidity, and mortality in acute refractory status epilepticus.MethodsFifteen patients, mean age of 41.3 years-old, six males, with refractory status epilepticus, were retrospectively studied. All of them were followed by serial electroencephalogram or continuous electroencephalographic monitoring.ResultsThe most common comorbidity was hypertension. Seven (46.7%) patients were diagnosed with previous symptomatic focal epilepsy. More than one etiology was identified in 40.0% of the cases. Status epilepticus partial complex was the most common (n=14, 93.3%), and discrete seizures were the most observed initial ictal pattern. Continuous intravenous midazolam was used in nine (60.0%) patients and continuous thiopental in three (20.0%). Nine (60.0%) participants died, one (6.6%) had neurological sequelae, and five (33.3%) presented no neurological sequelae.ConclusionsHigher mortality rate was associated with advanced age and periodic lateralized epileptiform discharges. Midazolam proved to be a safe drug. The refractory status epilepticus is related to high mortality.
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Generalized Convulsive Status Epilepticus in Adults and Children: Treatment Guidelines and Protocols. Emerg Med Clin North Am 2011; 29:51-64. [DOI: 10.1016/j.emc.2010.08.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Sinha S, Prashantha D, Thennarasu K, Umamaheshwara Rao G, Satishchandra P. Refractory status epilepticus: A developing country perspective. J Neurol Sci 2010; 290:60-5. [DOI: 10.1016/j.jns.2009.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 11/16/2009] [Accepted: 11/17/2009] [Indexed: 12/01/2022]
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Management of refractory status epilepticus at a tertiary care centre in a developing country. Seizure 2010; 19:109-11. [PMID: 20034814 DOI: 10.1016/j.seizure.2009.11.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Revised: 09/30/2009] [Accepted: 11/20/2009] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Refractory status epilepticus (RSE) is a common Neurological Emergency with increased mortality and morbidity in developing countries where facilities of intubation, adequate ventilation, Intensive Care Units (ICUs) and general anaesthesia are not ubiquitously available. Treatment protocols use antiepileptic drugs (AEDs) and need ICU facilities after failure of standard AEDs. Our aim was to see the response to two additional drugs in the armamentarium against refractory status, that is, valproate and levetiracetam. METHODS Patients with generalized RSE admitted in neurology and neurosurgery services at AIIMS during December 2006 to June 2008 were included in the study. The patients were allotted to two groups based on certain criteria. Demographic details, reason for delay, etiology precipitating status, ongoing AEDs therapy, duration of status, the time taken for cessation along with clinical, EEG and MRI correlates were noted. Outcome parameters were analyzed by an independent blinded observer. RESULTS 82 patients with RSE were studied out of which 41 patients were given IV valproate (Group A) and 41 patients were given IV levetiracetam (Group B). Cessation of status failed in 13 patients in valproate group and 11 patients in levetiracetam group. Majority of the patients did not require ICU settings despite being classified as refractory. CONCLUSION RSE can be controlled with intravenous loading and maintenance of valproate or levetiracetam which do not cause respiratory depression, hypotension, need of intubation and ICU care. These must always be considered in a developing country scenario where ICU facilities are not always available or while transporting to centres where these facilities are available.
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Agan K, Afsar N, Midi I, Us O, Aktan S, Aykut-Bingol C. Predictors of refractoriness in a Turkish status epilepticus data bank. Epilepsy Behav 2009; 14:651-4. [PMID: 19435569 DOI: 10.1016/j.yebeh.2009.02.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Revised: 02/04/2009] [Accepted: 02/07/2009] [Indexed: 11/19/2022]
Abstract
Refractory status epilepticus (RSE) is known to constitute approximately 10-50% of all cases of status epilepticus (SE) and is associated with significant morbidity and mortality. In the present study, data from a prospectively collected SE database were analyzed. Patients with RSE (defined as a SE episode requiring a second line of intravenous treatment following intravenous phenytoin) were compared with patients with nonrefractory SE (NRSE); 290 episodes of SE were identified, of which 108 (38%) were defined as RSE. Univariate analysis revealed that age, female gender, SE type, SE duration, and acute etiology were associated with refractoriness, whereas electroencephalographic patterns were not. Nonconvulsive SE, which is probably associated with delays in treatment initiation, was a predictor of RSE, although it was not retained as a predictor in multivariate analysis. In the latter analysis, female gender (odds ratio: 1.815, 95% CI: 1.053-3.126) and acute etiology (odds ratio: 0.619, 95% CI: 0.429-0.894) were shown to be the only significant independent predictors of refractoriness.
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Affiliation(s)
- Kadriye Agan
- Department of Neurology, Marmara University Hospital, Istanbul, Turkey
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Drislane FW, Blum AS, Lopez MR, Gautam S, Schomer DL. Duration of refractory status epilepticus and outcome: loss of prognostic utility after several hours. Epilepsia 2009; 50:1566-71. [PMID: 19175387 DOI: 10.1111/j.1528-1167.2008.01993.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Outcome for patients with status epilepticus (SE) depends strongly on etiology. Duration of SE is also predictive, at least in the first 2 h, but beyond this it is unclear that duration of SE influences outcome significantly. We sought to determine the influence of duration of SE on outcome in patients with prolonged SE, and to compare this influence with that of other factors. METHODS We reviewed the clinical course and outcome of 119 patients with SE, diagnosed by both clinical manifestations and electroencephalography (EEG) evidence. Using univariate and multivariate analyses, we sought predictors of outcome (survival vs. death or vegetative state) among age, etiology (epilepsy, anoxia or severe hypoxia, or other), presence of earlier epilepsy, multiple medical problems, presentation in coma, and type of SE (focal or generalized). RESULTS Median duration of SE was 48 h. Survival was greater with a shorter duration, especially when <10 h (69% vs. 31% for longer duration; p < 0.05). Epilepsy as the etiology, and an earlier diagnosis of epilepsy offered a favorable prognosis (p < 0.01), but only the former on multivariate analysis. Coma and SE caused by anoxia/hypoxia were unfavorable factors. Once corrected for etiology, presentation in coma, and type of SE (focal or generalized), duration of SE did not have a significant effect on outcome. Overall mortality was high, 65%, but 10 patients survived SE lasting over 3.5 days. CONCLUSIONS A duration of <10 h was associated with better outcome in SE, but this was not significant once etiology, presentation in coma, and type of SE were accounted for. Etiology of SE is still the primary determinant of outcome. Unless it follows anoxia, prolonged SE should not be considered a hopeless condition.
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Affiliation(s)
- Frank W Drislane
- Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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Seizures and impairment of consciousness. HANDBOOK OF CLINICAL NEUROLOGY 2008. [PMID: 18631826 DOI: 10.1016/s0072-9752(07)01713-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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Pohlmann-Eden B, Stephani U, Krägeloh-Mann I, Schmitt B, Brandl U, Holtkamp M. [Management of refractory status epilepticus from a neurologic and neuropediatric perspective]. DER NERVENARZT 2008; 78:871-82. [PMID: 17457562 DOI: 10.1007/s00115-007-2257-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Status epilepticus is a frequent neurologic emergency that is refractory to benzodiazepines and phenytoin in 60% to 70% of cases. Patients commonly require management in an intensive care unit incorporating aggressive treatment with intravenous anaesthetics. Treatment guidelines commonly comment on initial pharmacologic management in detail, as they can refer to data from randomised controlled trials. In contrast, recommendations for the management of refractory status epilepticus often are sparse, as they rely on data from retrospective or uncontrolled prospective studies only. Since status epilepticus is refractory in every third patient, a critical analysis of the available data and a review focussing on the further management of this condition are urgently needed. The Koenigstein Team, a panel of expert epileptologists and neuropediatricians, discussed at its 31(st) meeting in March 2006 the clinical and experimental aspects and implicit prognostic variables of refractory status epilepticus. Here we present the results of that discussion and state recommendations from a neurologic and neuropediatric perspective for current und future management of refractory status epilepticus.
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Affiliation(s)
- B Pohlmann-Eden
- Epilepsie-Zentrum Bethel, Evangelisches Krankenhaus Bielefeld, Bielefeld, Germany
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Murthy JMK, Jayalaxmi SS, Kanikannan MA. Convulsive status epilepticus: clinical profile in a developing country. Epilepsia 2007; 48:2217-23. [PMID: 17651412 DOI: 10.1111/j.1528-1167.2007.01214.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE In developing countries optimal care of status epilepticus (SE) is associated with major barriers, particularly transportation. METHODS A prospective study of SE was performed between 1994 and 1996 to determine the clinical profile, response to treatment and outcome, Glasgow Outcome Scale (GOS). RESULTS Of the 85 patients admitted, the mean age was 33 years (8-75 years), 16% <16 years of age. The mean duration of SE before admission was 18.02 h (1-72 h). Only 23 (28%) patients, all locals, presented within <3 h of onset. Etiology included acute symptomatic (54%), remote symptomatic (7%), cryptogenic (19%), and established epilepsy (20%). Central nervous system infections accounted for 24 (28%) of the etiologies. Seventy-five (88%) patients responded to first-line drugs and 10 (12%) required second-line drugs. The mean duration of SE was significantly long in nonresponders (Mean +/- SD: 32.6 +/- 20.11 vs. 15.2 +/- 18.32, p < 0.006). Duration (p < 0.01; OR 1.04, 95% CI 1.01-1.07) and acute symptomatic etiology (p < 0.038; OR 10.38, 95% CI 1.13-95.09) were the independent predictors of no-response to first-line drugs. Of the nine deaths (10.5%), eight were in acute symptomatic group. Predictors of mortality included female sex (p < 0.017, OR 13.41, 95% CI 1.59-115.38) and lack of response to first-line drugs (p < 0.0001, OR 230.27, 95% CI 8.78-6037.19). Longer duration was associated with poor GOS 1-4 (p = 0.001). Of the 37 patients with <6 h, 81% had GOC5 outcome. CONCLUSION This study suggests that longer duration of SE and acute symptomatic etiology are independent predictors of lack of response to first-line drugs. Failure to respond to first-line drugs and duration predict the outcome.
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Affiliation(s)
- Jagarlapudi M K Murthy
- Department of Neurology, The Institute of Neurological Sciences, CARE Hospital, Hyderabad, India.
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Abstract
Refractory status epilepticus (RSE) is an important and serious clinical problem that typically requires prolonged and high-level intensive care, and is often associated with poor outcome. This review addresses some of the current issues concerning the management of RSE, including recent definitions used for clinical studies, epidemiology, clinical course, and outcome. Current approaches to treatment, including the now relatively standard use of intravenous anesthetic agents, as well as emerging therapies utilizing drugs such as valproate and topiramate, are discussed as well.
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Affiliation(s)
- Daniel H Lowenstein
- Department of Neurology, University of California, San Francisco, CA 94143, USA.
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Chung SS, Wang NC, Treiman DM. Comparative Efficacy and Safety of Antiepileptic Drugs for the Treatment of Status Epilepticus. J Pharm Pract 2007. [DOI: 10.1177/0897190007305134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Status epilepticus (SE) is a medical emergency with high mortality rate. Common causes of SE include noncompliance with antiepileptic medications, drug- and alcohol-related etiologies, and central nervous system (CNS) infections. Because prolonged seizures can cause neuronal damage, treatment should be initiated promptly to avoid potential complications. Previous studies support intravenous (IV) lorazepam as first-line therapy and IV phenytoin or fosphenytoin as a second-line medication. If first-and second-line medications fail to control SE, further treatment with propofol, pentobarbital, midazolam, or other medications should be considered. Many of the drugs currently used to control SE are associated with sedation, respiratory suppression, hypotension, cardiac dysrhythmia, and anaphylactic reactions. Therefore, IV valproate or other newer antiepileptic drugs may be considered as an alternative third-line therapy for those who cannot tolerate the hypotensive effects of other anticonvulsants. This paper reviews comparative effectiveness and safety concerns among frequently used medications for SE.
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Affiliation(s)
- Steve S. Chung
- Epilepsy Research and Monitoring Unit, Neurology Residency Program, Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona,
| | - Norman C. Wang
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - David M. Treiman
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Dara SI, Tungpalan LA, Manno EM, Lee VH, Moder KG, Keegan MT, Fulgham JR, Brown DR, Berge KH, Whalen FX, Roy TK. Prolonged coma from refractory status epilepticus. Neurocrit Care 2006; 4:140-2. [PMID: 16627903 DOI: 10.1385/ncc:4:2:140] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Status epilepticus is a life-threatening medical condition. In its most severe form, refractory status epilepticus (RSE) seizures may not respond to first and second-line anti-epileptic drugs. RSE is associated with a high mortality and significant medical complications in survivors with prolonged hospitalizations. METHODS We describe the clinical course of RSE in the setting of new onset lupus in a 31-year-old male who required prolonged barbiturate coma. RESULTS Seizure stopped on day 64 of treatment. Prior to the resolution of seizures, discussion around withdrawal of care took place between the physicians and patient's family. Medical care was continued because of the patient's age, normal serial MRI studies, and the patient's reversible medical condition. CONCLUSION Few evidence-based data exist to guide management of RSE. Our case emphasizes the need for continuous aggressive therapy when neuroimaging remains normal.
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Affiliation(s)
- Saqib I Dara
- Critical Care Service, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Peets AD, Berthiaume LR, Bagshaw SM, Federico P, Doig CJ, Zygun DA. Prolonged refractory status epilepticus following acute traumatic brain injury: a case report of excellent neurological recovery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:R725-8. [PMID: 16280070 PMCID: PMC1414004 DOI: 10.1186/cc3884] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Accepted: 10/03/2005] [Indexed: 11/10/2022]
Abstract
Introduction Refractory status epilepticus (RSE) secondary to traumatic brain injury (TBI) may be under-recognized and is associated with significant morbidity and mortality. Methods This case report describes a 20 year old previously healthy woman who suffered a severe TBI as a result of a motor vehicle collision and subsequently developed RSE. Pharmacological coma, physiological support and continuous electroencephalography (cEEG) were undertaken. Results Following 25 days of pharmacological coma, electrographic and clinical seizures subsided and the patient has made an excellent cognitive recovery. Conclusion With early identification, aggressive physiological support, appropriate monitoring, including cEEG, and an adequate length of treatment, young trauma patients with no previous seizure history and limited structural damage to the brain can have excellent neurological recovery from prolonged RSE.
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Affiliation(s)
- Adam D Peets
- Research Fellow, Department of Critical Care, University of Calgary, Calgary, Alberta, Canada
| | - Luc R Berthiaume
- Research Fellow, Departments of Critical Care Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- Research Fellow, Departments of Critical Care Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Paolo Federico
- Assistant Professor, Department of Neurosciences, University of Calgary, Alberta, Calgary, Canada
| | - Christopher J Doig
- Associate Professor, Departments of Critical Care Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - David A Zygun
- Assistant Professor, Departments of Critical Care Medicine, Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Kang DC, Lee YM, Lee J, Kim HD, Coe C. Prognostic factors of status epilepticus in children. Yonsei Med J 2005; 46:27-33. [PMID: 15744802 PMCID: PMC2823054 DOI: 10.3349/ymj.2005.46.1.27] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2003] [Accepted: 09/14/2004] [Indexed: 11/27/2022] Open
Abstract
We retrospectively reviewed the medical records of 189 children who were admitted to the Pediatric Neurology Department at Yonsei University College of Medicine with status epilepticus (SE) between April, 1994 and April, 2003. The children were followed up for a mean duration of 17 months. We analyzed the clinical findings and the relationships between neurologic sequelae, recurrence, age of onset, presumptive causes, types of seizure, seizure duration and the presence of fever. Mean age at SE onset was 37 months. Incidences by seizure type classification were generalized convulsive SE in 73.5%, and non-convulsive SE in 26.5%. The incidences of presumptive causes of SE were idiopathic 40.7%, epilepsy 29.1%, remote 16.4% and acute symptomatic in 13.3%. Among all the patients, febrile episodes occurred in 35.4%, especially in patients under 3 year old, and 38.4% of these were associated with febrile illness regardless of presumptive cause. Neurologic sequelae occurred in 33% and the mortality rate was 3%. Neurologic sequelae were lower in patients that presented with an idiopathic etiology and higher in generalized convulsive SE patients. The recurrence of SE was higher in patients with a remote symptomatic epileptic etiology, and generalized convulsive SE showed higher rates of recurrence. Based on this retrospective study, the neurologic outcomes and recurrence of SE were found to be strongly associated with etiology and seizure type. Age, seizure duration and the presence of febrile illness were found to have no effect on outcome.
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Affiliation(s)
- Du Cheol Kang
- Department of Pediatrics, Institute of Handicapped Children, Yongdong Severance Hospital, Yonsei University College of Medicine, 146-92 Dogok- dong, Kangnam-gu, Seoul 135-720, Korea
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Duane DC, Ng YT, Rekate HL, Chung S, Bodensteiner JB, Kerrigan JF. Treatment of Refractory Status Epilepticus with Hemispherectomy. Epilepsia 2004; 45:1001-4. [PMID: 15270771 DOI: 10.1111/j.0013-9580.2004.60303.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 7-year-old boy with left hemiparesis secondary to right hemispheric cortical dysplasia was admitted to the hospital with increasing numbers of seizures. Magnetic resonance imaging showed a small dysplastic right hemisphere with abnormally thickened gyri and an apparently normal left hemisphere. Previous video-electroencephalogram (EEG) monitoring showed bilateral independent spikes and generalized slow spike-and-wave episodes on EEG and [18F]fluorodeoxyglucose (FDG) positron emission tomography scan demonstrated scattered areas of regional hypometabolism bilaterally; therefore hemispherectomy was not undertaken at that time. During this hospital stay, nonconvulsive status epilepticus developed and was refractory to multiple medical therapies including pentobarbital (PTB) coma. Burst-suppression pattern during PTB coma appeared to be generalized spike and wave, but when EEG was reviewed with increased time resolution spikes suggested a right hemisphere origin. The patient underwent bilateral intracarotid amobarbital spike-suppression test that showed only minimal suppression of epileptiform discharges with injection of the left carotid, but complete suppression of spike activity after right-sided carotid injection. A right hemispherectomy was performed with complete cessation of status epilepticus. Postoperative EEG showed no epileptiform discharges. Patient follow-up was limited to 12 months after surgery. The patient had regained the ability to walk unaided and was seizure free with a single antiepileptic medication. This case illustrates a potentially life-saving procedure for refractory status epilepticus and several techniques including a spike-suppression test to aid in prediction of cessation of seizures after hemispherectomy.
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Affiliation(s)
- Dawn C Duane
- Division of Child Neurology, Children's Health Center, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA.
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Abstract
OBJECTIVE The goal of this study was to report the effectiveness of topiramate in treating status epilepticus. METHODS Three patients with status epilepticus were treated with topiramate 500 mg twice daily for 2-5 days, with the dose gradually tapered thereafter to 200 mg twice daily. The patients' clinical status and EEG recordings were followed. RESULTS Patient 1 was admitted for subacute encephalopathy that was complicated by secondarily generalized status epilepticus resistant to lorazepam, fosphenytoin, and pentobarbital coma. Topiramate was added and, 2 days later, pentobarbital was tapered with no recurrence of ictal discharges as the patient improved clinically. Patient 2 had end-stage liver disease and was hospitalized for peritonitis, and his course was complicated by partial status epilepticus. Topiramate was started and, 2 days later, his mental status improved as repeat EEG showed no further ictal discharges although periodic epileptiform discharges were seen in the left centroparietal area. The patient later died from complications of variceal bleeding. Patient 3 suffered cardiopulmonary arrest, and developed postanoxic seizures, which did not respond to lorazepam, fosphenytoin, valproate, and propofol coma as continuous EEG recordings showed recurrent generalized ictal discharges. Two days after topiramate was started, propofol was tapered and discontinued and EEG showed generalized slow wave activity and no ictal discharges. The patient was discharged to another facility 12 days later. CONCLUSIONS Topiramate was effective in treating two patients with refractory generalized status epilepticus and one with complex partial status epilepticus. It should therefore be considered as an option in these situations, especially when other medications cannot be used.
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Affiliation(s)
- Meriem K Bensalem
- Department of Neurology, University of Kentucky Medical Center, L-445 Kentucky clinic, 740 South Limestone, 40536-0284, Lexington, KY, USA
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46
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Abstract
BACKGROUND New antiepileptic drugs (AEDs) have provided alternatives to traditional treatment paradigms for status epilepticus (SE). METHODS To determine current treatment preferences for generalized convulsive status epilepticus (GCSE), we surveyed 106 members of the Critical Care or Epilepsy sections of the American Academy of Neurology. RESULTS Most respondents initially treat patients with intravenous (IV) lorazepam (76%), followed by phenytoin or fosphenytoin (95%) if first-line therapy fails. Preferences for GCSE refractory to two AEDs (RSE) varied: 43% would give phenobarbital, 19% would give one of three continuous-infusion (cIV) AEDs (pentobarbital, midazolam, propofol), and 16% would give IV valproic acid. About half indicated "burst suppression" (56%) and half indicated "elimination of seizures" (41%) as the titration goal for cIV-AED therapy. About half (42%) would add a new cIV-AED, and the other half (41%) would not add another agent to treat electrographic SE refractory to four AEDs. DISCUSSION In accordance with published trials and general guidelines, neurologists most often use lorazepam followed by phenytoin or fosphenytoin as first-line and second-line therapies for GCSE. There is no consensus for third-line or fourth-line treatment for RSE. The treatment of RSE needs to be studied in a large, prospective, randomized, multicenter trial.
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Affiliation(s)
- Jan Claassen
- Division of Critical Care Neurology, Department of Neurology, Neurological Institute, Columbia University College of Physicians and Surgeons, 710 West 168th Street, Unit 39, New York, NY 10032, USA
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Critical Care Management of Refractory Status Epilepticus. Intensive Care Med 2002. [DOI: 10.1007/978-1-4757-5551-0_68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
The approach to treatment of status epilepticus has changed because of the demonstration of decreased mortality with rapid intervention, completion of a randomized, double-blind VA Cooperative study comparing first-line agents, and further understanding of the pathophysiologic changes discovered in experimental animal studies. This article reviews the treatments of generalized convulsive status epilepticus in the prehospital, emergency department, and intensive care unit settings.
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Affiliation(s)
- B J Smith
- Department of Neurology, Henry Ford Hospital and Medical Centers, Detroit, Michigan 48202, USA
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Prasad A, Worrall BB, Bertram EH, Bleck TP. Propofol and midazolam in the treatment of refractory status epilepticus. Epilepsia 2001; 42:380-6. [PMID: 11442156 DOI: 10.1046/j.1528-1157.2001.27500.x] [Citation(s) in RCA: 159] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To explore outcome differences between propofol and midazolam (MDL) therapy for refractory status epilepticus (RSE). METHODS Retrospective chart review of consecutive patients treated for RSE between 1995 and 1999. RESULTS We found 14 patients treated primarily with propofol and six with MDL. Propofol and MDL therapy achieved 64 and 67% complete clinical seizure suppression, and 78 and 67% electrographic seizure suppression, respectively. Overall mortality, although not statistically significant, was higher with propofol (57%) than with MDL (17%) (p = 0.16). Subgroup mortality data in propofol and MDL patients based on APACHE II (Acute Physiology and Chronic Health Evaluation) score did not show statistically significant differences except for propofol-treated patients with APACHE II score > or = 20, who had a higher mortality (p = 0.05). Reclassifying the one patient treated with both agents to the MDL group eliminated this statistically significant difference (p = 0.22). CONCLUSIONS In our small sample of RSE patients, propofol and MDL did not differ in clinical and electrographic seizure control. Seizure control and overall survival rates, with the goal of electrographic seizure elimination or burst suppression rather than latter alone, were similar to previous reports. In RSE patients with APACHE II score > or = 20, survival with MDL may be better than with propofol. A large multicenter, prospective, randomized comparison is needed to clarify these data. If comparable efficacy of these agents in seizure control is borne out, tolerance with regard to hemodynamic compromise, complications, and mortality may dictate the choice of RSE agents.
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Affiliation(s)
- A Prasad
- F.E. Dreifuss Comprehensive Epilepsy Program, and Department of Neurology, University of Virginia, Charlottesville 22908, USA
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Abstract
Refractory epileptic state (RES) is defined by severe seizures that are resistant to antiepileptic drug treatment. Diagnostic errors such as pseudo-seizures and encephalopathies with triphasic waves must be distinguished at an early stage from cases of RES. The latter are symptomatic of a focal brain lesion or severe systemic disease, most frequently metabolic in origin. The treatment of such conditions is aimed at correction of the underlying cause. A nosographic issue that is still a subject of discussion and which requires further study, i.e., PLEDS, will also be discussed in this article.
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Affiliation(s)
- F Assal
- Unité d'EEG, clinique de neurologie, hôpital cantonal universitaire, Genève, Suisse
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