1
|
Finney JD, Schuler PD, Rudloff JR, Agostin N, Lobanov OV, Siegler J, Shah MI, Guterman EL, Chamberlain JM, Ahmad FA. Evaluation of the Use of Ketamine in Prehospital Seizure Management: A Retrospective Review of the ESO Database. PREHOSP EMERG CARE 2024:1-12. [PMID: 39058382 DOI: 10.1080/10903127.2024.2382367] [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: 05/07/2024] [Revised: 07/12/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024]
Abstract
Objectives: Benzodiazepines are the primary antiseizure medication used by Emergency Medical Services (EMS) for seizures. Available literature in the United States and internationally shows 30% to 40% of seizures do not terminate with benzodiazepines called benzodiazepine refractory status epilepticus (BRSE). Ketamine is a potential treatment for BRSE due to its unique pharmacology. However, its application in the prehospital setting is mostly documented in case reports. Little is known about its use by EMS professionals for seizure management, whether as initial treatment or for BRSE, creating an opportunity to describe its current use and inform future research.Methods: We performed a retrospective review of 9-1-1 EMS encounters with a primary or secondary impression of seizure using the ESO Data Collaborative from 2018-2021. We isolated encounters during which ketamine was administered. We excluded medication administrations prior to EMS arrival and encounters without medication administration. Subgroup analysis was performed to control for airway procedure as an indication for ketamine administration. We also evaluated for co-administration with other antiseizure medications, dose and route of administration, and response to treatment.Results: We identified 99,576 encounters that met inclusion. There were 2,531/99,576 (2.54%) encounters with ketamine administration and 50.7% (1,283/2,531) received ketamine without an airway procedure. There were 616 cases (48%, 616/1,283) where ketamine was given without another antiseizure medication (ASM) and without any airway procedure. The remaining 667 (52%) cases received ketamine with at least one other ASM, most commonly midazolam (89%, 593/667). Adjusted for the growth in the ESO dataset, ketamine use by EMS professionals during encounters for seizures without an airway procedure increased from 0.90% (139/15,375) to 1.45% (416/28,651) an increase of 62% over the study period.Conclusions: In this retrospective review of the ESO Data Collaborative, ketamine administration for seizure encounters without an airway procedure increased over the study period, both as a single agent and with another ASM. Most ketamine administrations were for adult patients in the south and in urban areas. The frequency of BRSE, the need for effective treatment, and the growth in ketamine use warrant prospective prehospital research to evaluate the value of ketamine in prehospital seizure management.
Collapse
Affiliation(s)
- Joseph Daniel Finney
- Department of Pediatrics, Washington University in Saint Louis, 660 South Euclid Ave, Saint Louis, MO, 63126
| | - Paul D Schuler
- Department of Emergency Medicine, School of Medicine, University of Missouri, 1 Hospital Drive #M562, Columbia, MO 65201
| | - James R Rudloff
- Department of Pediatrics, Washington University in Saint Louis, Institute for Informatics Data Science and Biostatistics, 660 S Euclid, St. Louis 63110, MO
| | - Nicholas Agostin
- Department of Pediatrics, Washington University in Saint Louis, 660 South Euclid Ave, Saint Louis, MO, 63126
| | - Oleg V Lobanov
- Department of Neurology, Washington University, 660 S. Euclid Ave, MSC 8111-43-1260, St. Louis, MO 63110
| | - Jeffrey Siegler
- Department of Emergency Medicine, Washington University School of Medicine, MSC 8072-50-8000, 660 S. Euclid Ave, St. Louis, MO, 63110
| | - Manish I Shah
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, Suite 350, Palo Alto, CA 94304
| | - Elan L Guterman
- Philip R. Lee Institute for Health Policy Studies and Department of Neurology, University of California, San Francisco, 505 Parnassus Avenue, M798 Box 0114 San Francisco, CA 94143
| | - James M Chamberlain
- Pediatrics and Emergency Medicine, George Washington University, 111 Michigan Avenue, NW, Washington, DC 20010
| | - Fahd A Ahmad
- Department of Pediatrics, Washington University in Saint Louis, 660 South Euclid Ave, Saint Louis, MO, 63126
| |
Collapse
|
2
|
Wang S, Wu X, Xue T, Song Z, Tan X, Sun X, Wang Z. Efficacy and safety of levetiracetam versus valproate in patients with established status epilepticus: A systematic review and meta-analysis. Heliyon 2023; 9:e13380. [PMID: 36816301 PMCID: PMC9932733 DOI: 10.1016/j.heliyon.2023.e13380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 12/13/2022] [Accepted: 01/29/2023] [Indexed: 02/04/2023] Open
Abstract
Objective Status epilepticus (SE) is a common neurological emergency that is defined as a prolonged seizure or a series of seizures which often leads to irreversible damage. Levetiracetam (LEV) and valproate (VPA) are second-line anti-seizure drugs that are frequently used in patients with established SE (ESE). This meta-analysis compared the efficacy and safety of LEV and VPA for the treatment of ESE. Method MEDLINE, EMBASE, Central Register of Controlled Trials (CENTRAL), and clinicaltrials.gov were searched by two authors, which identified six randomized controlled trials (RCTs) that compared LEV and VPA for ESE. Results The six RCTs included 1213 patients (LEV group, n = 593; VPA group, n = 620). Integrated patient data information display LEV was not superior to VPA in terms of clinical seizure termination (63.55% vs. 64.08%, respectively; relative risk [RR] = 1.03, 95% confidence interval [CI] = 0.94-1.11, p = 0.55), with no significant differences between LEV and VPA in terms of good functional outcome at discharge (Glasgow Outcome Scale [GOS] = 4 or 5), intensive care unit (ICU) admission, adverse events, and mortality. There was no statistically significant difference between the two drugs in different age groups. Previous multicenter studies have demonstrated that VPA was slightly more effective than LEV, whereas single-center studies showed the opposite results. In addition, LEV and VPA had similar rates of clinical seizure termination, ICU admission, and adverse events between the age subgroups (ages <18 and >18 years). Conclusions Levetiracetam (LEV) was not superior to valproate (VPA) in terms of efficacy or safety outcomes. In addition, children (<18 years) and adults (>18 years) might have similar responses to LEV and VPA. Additional RCTs are required to verify our results.
Collapse
Affiliation(s)
- Shixin Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xin Wu
- Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, Jiangsu Province, China
| | - Tao Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhaoming Song
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xin Tan
- Department of Neurology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu Province, China
| | - Xiaoou Sun
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China,Corresponding author. Department of Neurosurgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, China.
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China,Corresponding author. Department of Neurosurgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, China.
| |
Collapse
|
3
|
Gore A, Neufeld-Cohen A, Egoz I, Baranes S, Gez R, Efrati R, David T, Dekel Jaoui H, Yampolsky M, Grauer E, Chapman S, Lazar S. Neuroprotection by delayed triple therapy following sarin nerve agent insult in the rat. Toxicol Appl Pharmacol 2021; 419:115519. [PMID: 33823148 DOI: 10.1016/j.taap.2021.115519] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/25/2021] [Accepted: 04/01/2021] [Indexed: 02/08/2023]
Abstract
The development of refractory status epilepticus (SE) induced by sarin intoxication presents a therapeutic challenge. In our current research we evaluate the efficacy of a delayed combined triple treatment in ending the abnormal epileptiform seizure activity (ESA) and the ensuing of long-term neuronal insult. SE was induced in male Sprague-Dawley rats by exposure to 1.2LD50 sarin insufficiently treated by atropine and TMB4 (TA) 1 min later. Triple treatment of ketamine, midazolam and valproic acid was administered 30 min or 1 h post exposure and was compared to a delayed single treatment with midazolam alone. Toxicity and electrocorticogram activity were monitored during the first week and behavioral evaluation performed 3 weeks post exposure followed by brain biochemical and immunohistopathological analyses. The addition of both single and triple treatments reduced mortality and enhanced weight recovery compared to the TA-only treated group. The triple treatment also significantly minimized the duration of the ESA, reduced the sarin-induced increase in the neuroinflammatory marker PGE2, the brain damage marker TSPO, decreased the gliosis, astrocytosis and neuronal damage compared to the TA+ midazolam or only TA treated groups. Finally, the triple treatment eliminated the sarin exposed increased open field activity, as well as impairing recognition memory as seen in the other experimental groups. The delayed triple treatment may serve as an efficient therapy, which prevents brain insult propagation following sarin-induced refractory SE, even if treatment is postponed for up to 1 h.
Collapse
Affiliation(s)
- Ariel Gore
- Department of Pharmacology, Israel Institute for Biological, Chemical and Environmental Sciences, Ness-Ziona 74100, Israel.
| | - Adi Neufeld-Cohen
- Department of Pharmacology, Israel Institute for Biological, Chemical and Environmental Sciences, Ness-Ziona 74100, Israel
| | - Inbal Egoz
- Department of Pharmacology, Israel Institute for Biological, Chemical and Environmental Sciences, Ness-Ziona 74100, Israel
| | - Shlomi Baranes
- Department of Pharmacology, Israel Institute for Biological, Chemical and Environmental Sciences, Ness-Ziona 74100, Israel
| | - Rellie Gez
- Department of Pharmacology, Israel Institute for Biological, Chemical and Environmental Sciences, Ness-Ziona 74100, Israel
| | - Rahav Efrati
- Department of Pharmacology, Israel Institute for Biological, Chemical and Environmental Sciences, Ness-Ziona 74100, Israel
| | - Tse'ela David
- The Veterinary Center for Pre-clinical Research, Israel Institute for Biological, Chemical and Environmental Sciences, Ness- Ziona 74100, Israel
| | - Hani Dekel Jaoui
- The Veterinary Center for Pre-clinical Research, Israel Institute for Biological, Chemical and Environmental Sciences, Ness- Ziona 74100, Israel
| | - Michael Yampolsky
- The Veterinary Center for Pre-clinical Research, Israel Institute for Biological, Chemical and Environmental Sciences, Ness- Ziona 74100, Israel
| | - Ettie Grauer
- Department of Pharmacology, Israel Institute for Biological, Chemical and Environmental Sciences, Ness-Ziona 74100, Israel
| | - Shira Chapman
- Department of Pharmacology, Israel Institute for Biological, Chemical and Environmental Sciences, Ness-Ziona 74100, Israel
| | - Shlomi Lazar
- Department of Pharmacology, Israel Institute for Biological, Chemical and Environmental Sciences, Ness-Ziona 74100, Israel.
| |
Collapse
|
4
|
Roynard P, Bilderback A, Dewey CW. Intravenous Ketamine Bolus(es) for the Treatment of Status Epilepticus, Refractory Status Epilepticus, and Cluster Seizures: A Retrospective Study of 15 Dogs. Front Vet Sci 2021; 8:547279. [PMID: 33681317 PMCID: PMC7925624 DOI: 10.3389/fvets.2021.547279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 01/07/2021] [Indexed: 12/02/2022] Open
Abstract
Status epilepticus (SE) and cluster seizures (CS) are common occurrences in veterinary neurology and frequent reasons of admission to veterinary hospitals. With prolonged seizure activity, gamma amino-butyric acid (GABA) receptors (GABAa receptors) become inactive, leading to a state of pharmacoresistance to benzodiazepines and other GABAergic medications, which is called refractory status epilepticus (RSE). Prolonged seizure activity is also associated with overexpression of N-methyl-D-aspartic (NMDA) receptors. Rodent models have shown the efficacy of ketamine (KET) in treating RSE, and its use has been reported in one canine case of RSE. Boluses of KET 5 mg/kg IV have become the preferred treatment for RSE in our hospital. A retrospective study was performed to evaluate and report our experience with KET IV bolus to treat prolonged and/or repeated seizure activity in cases of canine CS, SE, and RSE. A total of 15 dogs were retrieved, for 20 hospitalizations and 28 KET IV injections over 3 years. KET IV boluses were used 12 times for RSE (9 generalized seizures, 3 focal seizures) and KET terminated the episode of RSE 12/12 times (100%); however, seizures recurred 4/12 times (33%) within ≤6 h of KET IV bolus. When used for CS apart from episodes of RSE, KET IV bolus was associated with termination of the CS episode only 4/14 times (29%). Only 4/28 (14%) KET IV boluses were associated with adverse effects imputable only to the use of KET. One dog experienced a short, self-limited seizure activity during administration of KET IV, which was most likely related to a pre-mature use of KET IV (i.e., before GABAergic resistance and NMDA receptor overexpression had taken place). This study indicates that KET 5 mg/kg IV bolus may be successful for the treatment of RSE in dogs.
Collapse
Affiliation(s)
- Patrick Roynard
- Long Island Veterinary Specialists, Department of Neurology/Neurosurgery, Plainview, NY, United States
| | - Ann Bilderback
- VCA Northwest Veterinary Specialists, Clackamas, OR, United States
| | | |
Collapse
|
5
|
Golub D, Yanai A, Darzi K, Papadopoulos J, Kaufman B. Potential consequences of high-dose infusion of ketamine for refractory status epilepticus: case reports and systematic literature review. Anaesth Intensive Care 2018; 46:516-528. [PMID: 30189827 DOI: 10.1177/0310057x1804600514] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Our goal was to provide comprehensive data on the effectiveness of ketamine in refractory status epilepticus (RSE) and to describe the potential consequences of long-term ketamine infusion. Ketamine, an N-methyl D-aspartate (NMDA) receptor antagonist, blocks excitatory pathways contributing to ongoing seizure. While ketamine use is standard in anaesthetic induction, no definitive protocol exists for its use in RSE, and little is known about its adverse effects in long-term, high-dose administration. We present two cases of RSE that responded rapidly to ketamine infusion, both with fatal outcomes secondary to metabolic acidosis and cardiovascular collapse. We performed a systematic review of the application and consequences of ketamine use in RSE. PubMed, Ovid, MEDLINE and PMC were searched for articles describing ketamine treatment for RSE according to a predetermined search strategy and inclusion criteria. The systematic review revealed wide discrepancies in ketamine dosing (infusion maintenance dose range 0.0075-10.5 mg/kg/hour), but good outcomes in medically managed RSE (75% of studies reported moderate or complete seizure control in adults, 62.5% in paediatrics). Additionally, literature review elucidated a potentially causal relationship between prolonged ketamine infusion and both cardiovascular and metabolic dysregulation. Ketamine is effective in RSE by antagonising excitotoxic NMDA receptors. However, there is high variability in ketamine dosing and scarce data on its safety in long-term infusion. Metabolic acidosis and haemodynamic instability associated with the use of long-term, high-dose ketamine infusions must be of concern to clinicians administering ketamine to critically ill patients.
Collapse
Affiliation(s)
| | | | | | | | - B Kaufman
- Professor, Departments of Medicine, Anesthesiology, Neurology and Neurosurgery, NYU School of Medicine, New York, NY, USA
| |
Collapse
|
6
|
Rojas A, Wang W, Glover A, Manji Z, Fu Y, Dingledine R. Beneficial Outcome of Urethane Treatment Following Status Epilepticus in a Rat Organophosphorus Toxicity Model. eNeuro 2018; 5:ENEURO.0070-18.2018. [PMID: 29766039 PMCID: PMC5952304 DOI: 10.1523/eneuro.0070-18.2018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 03/21/2018] [Accepted: 03/22/2018] [Indexed: 01/07/2023] Open
Abstract
The efficacy of benzodiazepines to terminate electrographic status epilepticus (SE) declines the longer a patient is in SE. Therefore, alternative methods for ensuring complete block of SE and refractory SE are necessary. We compared the ability of diazepam and a subanesthetic dose of urethane to terminate prolonged SE and mitigate subsequent pathologies. Adult Sprague Dawley rats were injected with diisopropylfluorophosphate (DFP) to induce SE. Rats were administered diazepam (10 mg/kg, ip) or urethane (0.8 g/kg, s.c.) 1 h after DFP-induced SE and compared to rats that experienced uninterrupted SE. Large-amplitude and high-frequency spikes induced by DFP administration were quenched for at least 46 h in rats administered urethane 1 h after SE onset as demonstrated by cortical electroencephalography (EEG). By contrast, diazepam interrupted SE but seizures with high power in the 20- to 70-Hz band returned 6-10 h later. Urethane was more effective than diazepam at reducing hippocampal neurodegeneration, brain inflammation, gliosis and weight loss as measured on day 4 after SE. Furthermore, rats administered urethane displayed a 73% reduction in the incidence of spontaneous recurrent seizures after four to eight weeks and a 90% reduction in frequency of seizures in epileptic rats. By contrast, behavioral changes in the light/dark box, open field and a novel object recognition task were not improved by urethane. These findings indicate that in typical rodent SE models, it is the return of SE overnight, and not the initially intense 1-2 h of SE experience, that is largely responsible for neurodegeneration, accompanying inflammation, and the subsequent development of epilepsy.
Collapse
Affiliation(s)
- Asheebo Rojas
- Department of Pharmacology, Emory University, Atlanta, GA 30322
| | - Wenyi Wang
- Department of Pharmacology, Emory University, Atlanta, GA 30322
| | - Avery Glover
- Department of Pharmacology, Emory University, Atlanta, GA 30322
| | - Zahra Manji
- Department of Pharmacology, Emory University, Atlanta, GA 30322
| | - Yujiao Fu
- Department of Pharmacology, Emory University, Atlanta, GA 30322
| | | |
Collapse
|
7
|
Santana-Gomez CE, Alcantara-Gonzalez D, Luna-Munguia H, Banuelos-Cabrera I, Magdaleno-Madrigal V, Tamayo M, Rocha LL, Besio WG. Transcranial focal electrical stimulation reduces seizure activity and hippocampal glutamate release during status epilepticus. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:6586-9. [PMID: 26737802 DOI: 10.1109/embc.2015.7319902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Previously we demonstrated that noninvasive transcranial focal electrical stimulation (TFS) with sub-effective doses of diazepam reduces status epilepticus (SE)-induced neuronal damage. However, it was unclear if this neuroprotective effect is a consequence of the decrease in the glutamate release. The aim of the present study was to evaluate the effects of TFS on γ-Aminobutyric acid (GABA) and glutamate release in the hippocampus during pilocarpine-induced SE. After pilocarpine administration, the rats showed progressive behavioral changes that culminated in SE with a significant increase of GABA and glutamate (95 and 128% respectively), even more evident at the end of the experiment (120 and 182% respectively), 5 hours after pilocarpine injection and was associated with the prevalence of high-voltage rhythmic spikes and increased spectral power in the 4-90 Hz bands. The TFS application during the SE decreased the convulsive expression, the prevalence of high-voltage rhythmic spikes and spectral power in 4-8 Hz and 30-90 Hz bands. These effects were associated with lower release of GABA and glutamate in the hippocampus. These results support the anticonvulsive and neuroprotective effects induced by TFS.
Collapse
|
8
|
Pavone KJ, Akeju O, Sampson AL, Ling K, Purdon PL, Brown EN. Nitrous oxide-induced slow and delta oscillations. Clin Neurophysiol 2016; 127:556-564. [PMID: 26118489 PMCID: PMC4675698 DOI: 10.1016/j.clinph.2015.06.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 06/02/2015] [Accepted: 06/03/2015] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Switching from maintenance of general anesthesia with an ether anesthetic to maintenance with high-dose (concentration >50% and total gas flow rate >4 liters per minute) nitrous oxide is a common practice used to facilitate emergence from general anesthesia. The transition from the ether anesthetic to nitrous oxide is associated with a switch in the putative mechanisms and sites of anesthetic action. We investigated whether there is an electroencephalogram (EEG) marker of this transition. METHODS We retrospectively studied the ether anesthetic to nitrous oxide transition in 19 patients with EEG monitoring receiving general anesthesia using the ether anesthetic sevoflurane combined with oxygen and air. RESULTS Following the transition to nitrous oxide, the alpha (8-12 Hz) oscillations associated with sevoflurane dissipated within 3-12 min (median 6 min) and were replaced by highly coherent large-amplitude slow-delta (0.1-4 Hz) oscillations that persisted for 2-12 min (median 3 min). CONCLUSIONS Administration of high-dose nitrous oxide is associated with transient, large amplitude slow-delta oscillations. SIGNIFICANCE We postulate that these slow-delta oscillations may result from nitrous oxide-induced blockade of major excitatory inputs (NMDA glutamate projections) from the brainstem (parabrachial nucleus and medial pontine reticular formation) to the thalamus and cortex. This EEG signature of high-dose nitrous oxide may offer new insights into brain states during general anesthesia.
Collapse
Affiliation(s)
- Kara J Pavone
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Aaron L Sampson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kelly Ling
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Patrick L Purdon
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Emery N Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA; Department of Brain and Cognitive Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA; Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA.
| |
Collapse
|
9
|
Fernández-Torre JL, Kaplan PW, Hernández-Hernández MA. New understanding of nonconvulsive status epilepticus in adults: treatments and challenges. Expert Rev Neurother 2015; 15:1455-73. [DOI: 10.1586/14737175.2015.1115719] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
10
|
Purdon PL, Sampson A, Pavone KJ, Brown EN. Clinical Electroencephalography for Anesthesiologists: Part I: Background and Basic Signatures. Anesthesiology 2015; 123:937-60. [PMID: 26275092 PMCID: PMC4573341 DOI: 10.1097/aln.0000000000000841] [Citation(s) in RCA: 460] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The widely used electroencephalogram-based indices for depth-of-anesthesia monitoring assume that the same index value defines the same level of unconsciousness for all anesthetics. In contrast, we show that different anesthetics act at different molecular targets and neural circuits to produce distinct brain states that are readily visible in the electroencephalogram. We present a two-part review to educate anesthesiologists on use of the unprocessed electroencephalogram and its spectrogram to track the brain states of patients receiving anesthesia care. Here in part I, we review the biophysics of the electroencephalogram and the neurophysiology of the electroencephalogram signatures of three intravenous anesthetics: propofol, dexmedetomidine, and ketamine, and four inhaled anesthetics: sevoflurane, isoflurane, desflurane, and nitrous oxide. Later in part II, we discuss patient management using these electroencephalogram signatures. Use of these electroencephalogram signatures suggests a neurophysiologically based paradigm for brain state monitoring of patients receiving anesthesia care.
Collapse
Affiliation(s)
- Patrick L. Purdon
- Associate Bioengineer, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; Assistant Professor of Anaesthesia, Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
| | - Aaron Sampson
- Research Assistant, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kara J. Pavone
- Research Assistant, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emery N. Brown
- Anesthetist, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; Warren M. Zapol Professor of Anesthesia, Department of Anesthesia, Harvard Medical School, Boston, Massachusetts; Edward Hood Taplin Professor of Medical Engineering, Institute for Medical Engineering and Science and Harvard-Massachusetts Institute of Technology, Health Sciences and Technology Program, Professor of Computational Neuroscience, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts
| |
Collapse
|
11
|
Transcranial focal electrical stimulation reduces the convulsive expression and amino acid release in the hippocampus during pilocarpine-induced status epilepticus in rats. Epilepsy Behav 2015; 49:33-9. [PMID: 26006058 DOI: 10.1016/j.yebeh.2015.04.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 04/19/2015] [Indexed: 12/12/2022]
Abstract
The aim of the present study was to evaluate the effects of transcranial focal electrical stimulation (TFS) on γ-aminobutyric acid (GABA) and glutamate release in the hippocampus under basal conditions and during pilocarpine-induced status epilepticus (SE). Animals were previously implanted with a guide cannula attached to a bipolar electrode into the right ventral hippocampus and a concentric ring electrode placed on the skull surface. The first microdialysis experiment was designed to determine, under basal conditions, the effects of TFS (300 Hz, 200 μs biphasic square pulses, for 30 min) on afterdischarge threshold (ADT) and the release of GABA and glutamate in the hippocampus. The results obtained indicate that at low current intensities (<2800 μA), TFS enhances and decreases the basal extracellular levels of GABA and glutamate, respectively. However, TFS did not modify the ADT. During the second microdialysis experiment, a group of animals was subjected to SE induced by pilocarpine administration (300 mg/kg, i.p.; SE group). The SE was associated with a significant rise of GABA and glutamate release (up to 120 and 182% respectively, 5h after pilocarpine injection) and the prevalence of high-voltage rhythmic spikes and increased spectral potency of delta, gamma, and theta bands. A group of animals (SE-TFS group) received TFS continuously during 2h at 100 μA, 5 min after the establishment of SE. This group showed a significant decrease in the expression of the convulsive activity and spectral potency in gamma and theta bands. The extracellular levels of GABA and glutamate in the hippocampus remained at basal conditions. These results suggest that TFS induces anticonvulsant effects when applied during the SE, an effect associated with lower amino acid release. This article is part of a Special Issue entitled "Status Epilepticus".
Collapse
|
12
|
|
13
|
Shangguan Y, Liao H, Wang X. Clonazepam in the treatment of status epilepticus. Expert Rev Neurother 2015; 15:733-40. [DOI: 10.1586/14737175.2015.1056781] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
14
|
Treatment of Refractory Status Epilepticus: Better Evidence is Needed. Can J Neurol Sci 2015; 42:72-3. [DOI: 10.1017/cjn.2015.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
15
|
Early Use of the NMDA Receptor Antagonist Ketamine in Refractory and Superrefractory Status Epilepticus. Crit Care Res Pract 2015; 2015:831260. [PMID: 25649724 PMCID: PMC4306366 DOI: 10.1155/2015/831260] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 12/24/2014] [Indexed: 12/14/2022] Open
Abstract
Refractory status epilepticus (RSE) and superrefractory status epilepticus (SRSE) pose a difficult clinical challenge. Multiple cerebral receptor and transporter changes occur with prolonged status epilepticus leading to pharmacoresistance patterns unfavorable for conventional antiepileptics. In particular, n-methyl-d-aspartate (NMDA) receptor upregulation leads to glutamate mediated excitotoxicity. Targeting these NMDA receptors may provide a novel approach to otherwise refractory seizures. Ketamine has been utilized in RSE. Recent systematic review indicates 56.5% and 63.5% cessation in seizures in adults and pediatrics, respectively. No complications were described. We should consider earlier implementation of ketamine or other NMDA receptor antagonists, for RSE. Prospective study of early implementation of ketamine should shed light on the role of such medications in RSE.
Collapse
|
16
|
Abstract
BACKGROUND Our goal was to perform a systematic review of the literature on the use of modern inhalational anesthetic agents for refractory status epilepticus and their impact on seizure control. METHODS All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to March 2014), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and Grading of Recommendation Assessment Development and Education methodology by two independent reviewers. RESULTS Overall, 19 studies were identified, with 16 manuscripts and 3 meeting abstracts. A total of 46 patients were treated. Adult (n=28) and pediatric patients (n=18) displayed 92.9% and 94.4% seizure control with treatment, respectively. Isoflurane was used in the majority of cases. Hypotension was the only complication described. CONCLUSIONS Oxford level 4, Grading of Recommendation Assessment Development and Education D evidence exists to support the use of isoflurane in refractory status epilepticus to obtain burst suppression. Insufficient data exist to comment on the efficacy of desflurane and xenon at this time.
Collapse
|
17
|
|
18
|
Electroclinical progression of subtle generalized convulsive status epilepticus: description of a case. J Neurol 2013; 260:2913-6. [DOI: 10.1007/s00415-013-7156-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 09/21/2013] [Accepted: 10/10/2013] [Indexed: 11/30/2022]
|
19
|
Shanechi MM, Chemali JJ, Liberman M, Solt K, Brown EN. A brain-machine interface for control of medically-induced coma. PLoS Comput Biol 2013; 9:e1003284. [PMID: 24204231 PMCID: PMC3814408 DOI: 10.1371/journal.pcbi.1003284] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 08/07/2013] [Indexed: 11/19/2022] Open
Abstract
Medically-induced coma is a drug-induced state of profound brain inactivation and unconsciousness used to treat refractory intracranial hypertension and to manage treatment-resistant epilepsy. The state of coma is achieved by continually monitoring the patient's brain activity with an electroencephalogram (EEG) and manually titrating the anesthetic infusion rate to maintain a specified level of burst suppression, an EEG marker of profound brain inactivation in which bursts of electrical activity alternate with periods of quiescence or suppression. The medical coma is often required for several days. A more rational approach would be to implement a brain-machine interface (BMI) that monitors the EEG and adjusts the anesthetic infusion rate in real time to maintain the specified target level of burst suppression. We used a stochastic control framework to develop a BMI to control medically-induced coma in a rodent model. The BMI controlled an EEG-guided closed-loop infusion of the anesthetic propofol to maintain precisely specified dynamic target levels of burst suppression. We used as the control signal the burst suppression probability (BSP), the brain's instantaneous probability of being in the suppressed state. We characterized the EEG response to propofol using a two-dimensional linear compartment model and estimated the model parameters specific to each animal prior to initiating control. We derived a recursive Bayesian binary filter algorithm to compute the BSP from the EEG and controllers using a linear-quadratic-regulator and a model-predictive control strategy. Both controllers used the estimated BSP as feedback. The BMI accurately controlled burst suppression in individual rodents across dynamic target trajectories, and enabled prompt transitions between target levels while avoiding both undershoot and overshoot. The median performance error for the BMI was 3.6%, the median bias was -1.4% and the overall posterior probability of reliable control was 1 (95% Bayesian credibility interval of [0.87, 1.0]). A BMI can maintain reliable and accurate real-time control of medically-induced coma in a rodent model suggesting this strategy could be applied in patient care. Brain-machine interfaces (BMI) for closed-loop control of anesthesia have the potential to enable fully automated and precise control of brain states in patients requiring anesthesia care. Medically-induced coma is one such drug-induced state in which the brain is profoundly inactivated and unconscious and the electroencephalogram (EEG) pattern consists of bursts of electrical activity alternating with periods of suppression, termed burst suppression. Medical coma is induced to treat refractory intracranial hypertension and uncontrollable seizures. The state of coma is often required for days, making accurate manual control infeasible. We develop a BMI that can automatically and precisely control the level of burst suppression in real time in individual rodents. The BMI consists of novel estimation and control algorithms that take as input the EEG activity, estimate the burst suppression level based on this activity, and use this estimate as feedback to control the drug infusion rate in real time. The BMI maintains precise control and promptly changes the level of burst suppression while avoiding overshoot or undershoot. Our work demonstrates the feasibility of automatic reliable and accurate control of medical coma that can provide considerable therapeutic benefits.
Collapse
Affiliation(s)
- Maryam M. Shanechi
- School of Electrical and Computer Engineering, Cornell University, Ithaca, New York, United States of America
- Department of Electrical Engineering and Computer Science, University of California, Berkeley, California, United States of America
- * E-mail: (MMS); (ENB)
| | - Jessica J. Chemali
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Max Liberman
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Ken Solt
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Emery N. Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- * E-mail: (MMS); (ENB)
| |
Collapse
|
20
|
Besio W, Cuellar-Herrera M, Luna-Munguia H, Orozco-Suárez S, Rocha L. Effects of transcranial focal electrical stimulation alone and associated with a sub-effective dose of diazepam on pilocarpine-induced status epilepticus and subsequent neuronal damage in rats. Epilepsy Behav 2013; 28:432-6. [PMID: 23886585 DOI: 10.1016/j.yebeh.2013.06.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 06/15/2013] [Accepted: 06/18/2013] [Indexed: 10/26/2022]
Abstract
Experiments were conducted to evaluate the effects of transcranial focal electrical stimulation (TFS) applied via tripolar concentric ring electrodes, alone and associated with a sub-effective dose of diazepam (DZP) on the expression of status epilepticus (SE) induced by lithium-pilocarpine (LP) and subsequent neuronal damage in the hippocampus. Immediately before pilocarpine injection, male Wistar rats received TFS (300Hz, 200-μs biphasic square charge-balanced 50-mA constant current pulses for 2min) alone or combined with a sub-effective dose of DZP (0.41mg/kg, i.p.). In contrast with DZP or TFS alone, DZP plus TFS reduced the incidence of, and enhanced the latency to, mild and severe generalized seizures and SE induced by LP. These effects were associated with a significant reduction in the number of degenerated neurons in the hippocampus. The present study supports the notion that TFS combined with sub-effective doses of DZP may represent a therapeutic tool to induce anticonvulsant effects and reduce the SE-induced neuronal damage.
Collapse
Affiliation(s)
- Walter Besio
- Electrical, Computer, and Biomedical Engineering Department, University of Rhode Island, Kingston, RI, USA
| | | | | | | | | |
Collapse
|