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Yan M, Sun T, Liu J, Chang Q. The efficacy and safety of ketamine in the treatment of super-refractory status epilepticus: a systematic review. J Neurol 2024; 271:3942-3952. [PMID: 38782798 PMCID: PMC11233303 DOI: 10.1007/s00415-024-12453-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Ketamine, as an anesthetic, has been considered for terminating status epilepticus (SE); however, due to the urgency and severity of the condition, there are currently no randomized controlled trials internationally assessing the efficacy of ketamine for treating super-refractory status epilepticus. Similarly, there appears to be a lack of systematic reviews addressing this topic in the literature. Therefore, this systematic review aims to explore the effectiveness and safety of ketamine for terminating super-refractory status epilepticus. METHODS We conducted a systematic search on PubMed, EMBASE, and Web of Science databases. Manuscripts unrelated to the research on super-refractory status epilepticus were excluded, as were manuscripts published in non-English languages. The quality assessment and risk of bias were evaluated using the MINORS criteria. Data extraction was limited to qualitative synthesis due to the unsuitability of the data for meta-analysis. RESULTS Out of 782 studies retrieved from electronic databases, 11 met the inclusion criteria. Among them, 10 studies were retrospective, and 1 study was prospective. Patient data for inclusion were sourced from the case registries of the researchers' respective hospitals. Across all included studies, the administration of ketamine significantly reduced the duration of status epilepticus and demonstrated higher safety compared to patients not receiving ketamine treatment for super-refractory status epilepticus. Additionally, early administration of ketamine correlated with improved treatment outcomes. The risk of bias across all studies was deemed low. CONCLUSION This systematic review suggests that ketamine may be a feasible treatment option for super-refractory status epilepticus. However, given the critical nature of super-refractory status epilepticus, clinicians should prioritize its termination over evaluating the efficacy of specific medications, ensuring patient safety remains paramount. If feasible in real-world medical settings, future research should focus on designing randomized controlled trials to observe the specific efficacy and mechanisms of ketamine. Careful validation is necessary before considering ketamine as a first-line treatment for super-refractory status epilepticus.
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Affiliation(s)
- Mingyuan Yan
- Beijing University of Chinese Medicine, Beijing, China
| | - Tianye Sun
- Beijing University of Chinese Medicine, Beijing, China
| | - Jinmin Liu
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Qing Chang
- Dongfang Hospital, Beijing University of Chinese Medicine, No.6 Fangxingyuan Fengtai District, Beijing, 100078, China.
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Adhikari A, Yadav SK, Nepal G, Aryal R, Baral P, Neupane P, Paudel A, Pantha B, Acharya S, Shrestha GS, Khadayat R. Use of ketamine in Super Refractory Status Epilepticus: a systematic review. Neurol Res Pract 2024; 6:33. [PMID: 38926769 PMCID: PMC11210084 DOI: 10.1186/s42466-024-00322-7] [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: 01/18/2024] [Accepted: 04/03/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVE This review specifically investigates ketamine's role in SRSE management. METHODS PubMed, EMBASE, and Google Scholar databases were searched from inception to May 1st, 2023, for English-language literature. Inclusion criteria encompassed studies on SRSE in humans of all ages and genders treated with ketamine. RESULTS In this systematic review encompassing 19 studies with 336 participants, age ranged from 9 months to 86 years. Infections, anoxia, and metabolic issues emerged as the common causes of SRSE, while some cases had unknown origins, termed as NORSE (New Onset RSE) or FIRESs (Febrile Infection-Related Epilepsy Syndrome). Most studies categorized SRSE cases into convulsive (N = 105) and non-convulsive (N = 197). Ketamine was used after failed antiepileptics and anesthetics in 17 studies, while in others, it was a first or second line of treatment. Dosages varied from 0.5 mg/kg (bolus) and 0.2-15 mg/kg/hour (maintenance) in adults and 1-3 mg/kg (bolus) and 0.5-3 mg/kg/hour (maintenance) in pediatrics, lasting one to 30 days. Ketamine was concurrently used with other drugs in 40-100% of cases, most frequently propofol and midazolam. Seizure resolution rate varied from 53.3 to 91% and 40-100% in larger (N = 42-68) and smaller case series (N = 5-20) respectively. Seizure resolution occurred in every case of case report except in one in which the patient died. Burst suppression in EEG was reported in 12 patients from two case series and two case reports. Recurrence was reported in 11 patients from five studies. The reported all-cause mortality varied from 38.8 to 59.5% and 0-36.4% in larger and smaller case series., unrelated directly to ketamine dosage or duration. SIGNIFICANCE Ketamine demonstrates safety and effectiveness in SRSE, offering advantages over GABAergic drugs by acting on NMDA receptors, providing neuroprotection, and reducing vasopressor requirement.
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Affiliation(s)
| | - Sushil Kumar Yadav
- Intern, Institute of Medicine, Tribhuvan University Teaching Hospital, 44600, Kathmandu, Nepal.
| | - Gaurav Nepal
- Intern, Institute of Medicine, Tribhuvan University Teaching Hospital, 44600, Kathmandu, Nepal
| | - Roshan Aryal
- Intern, Institute of Medicine, Tribhuvan University Teaching Hospital, 44600, Kathmandu, Nepal
| | - Pratik Baral
- Intern, Institute of Medicine, Tribhuvan University Teaching Hospital, 44600, Kathmandu, Nepal
| | - Peter Neupane
- Jibjibe Primary Health Care Centre, 45003, Dhaibung, Rasuwa, Nepal
| | | | - Barsha Pantha
- Post Graduate Institute of Medical Education and Research, 160012, Chandigarh, India
| | - Sulav Acharya
- Intern, Institute of Medicine, Tribhuvan University Teaching Hospital, 44600, Kathmandu, Nepal
| | - Gentle Sunder Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, 44600, Maharajgunj, Kathmandu, Nepal
| | - Ramesh Khadayat
- Intern, Institute of Medicine, Tribhuvan University Teaching Hospital, 44600, Kathmandu, Nepal
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García-Ruiz M, Rodríguez PM, Palliotti L, Lastras C, Romeral-Jiménez M, Morales IG, Rey CP, Rodrigo-Gisbert M, Campos-Fernández D, Santamarina E, Carbonell BP. Ketamine in the treatment of refractory and super-refractory status epilepticus: Experience from two centres. Seizure 2024; 117:13-19. [PMID: 38301485 DOI: 10.1016/j.seizure.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 02/03/2024] Open
Abstract
PURPOSE There is insufficient evidence on the management of refractory status epilepticus (RSE) and super-RSE (SRSE). Ketamine is a N-methyl-d-aspartate receptor antagonist in the treatment of these entities. Our objectives were to study the effectiveness and safety of ketamine in the treatment of adult patients with RSE and SRSE, to determine the factors that can influence the response to ketamine, and to explore its use in patients without mechanical ventilation. METHODS Adult patients who had received intravenous ketamine for the treatment of RSE or SRSE at Hospital Universitario Clínico San Carlos (Madrid, Spain) or Hospital Universitari Vall d'Hebron (Barcelona, Spain) from 2017 to 2023 were retrospectively analysed. RESULTS This study included 58 adult patients, mean (standard deviation) age 60.2 (15.7) years, of whom 41 (70.7 %) were male; 33 (56.9 %) patients responded to ketamine without recurrence, with a low rate of adverse effects (8.6 %). The presence of SRSE at the time of ketamine initiation (OR 0.287, p = 0.028) and the time elapsed between status epilepticus onset and ketamine administration (OR 0.991, p = 0.034) were associated with worse response to ketamine. Patients treated without mechanical ventilation had similar rates of response without recurrence (62.5% vs 56.9 %) and lower mortality (37.5% vs 53.5 %) compared to the overall group. CONCLUSION Ketamine is an effective drug with few adverse effects. Prompt administration should be considered in patients with RSE requiring anaesthesia, in patients with SRSE, and in patients with RSE who do not respond to standard antiseizure drugs and in whom mechanical ventilation is not advised.
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Affiliation(s)
- Manuel García-Ruiz
- Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
| | - Pablo Mayo Rodríguez
- Epilepsy Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
| | - Luca Palliotti
- Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
| | - Clara Lastras
- Epilepsy Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
| | - María Romeral-Jiménez
- Epilepsy Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
| | - Irene García Morales
- Epilepsy Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain; Epilepsy Unit, Neurology Department, Hospital Ruber Internacional, Calle de La Masó, 38, Madrid 28034, Spain.
| | - Cándido Pardo Rey
- Neurology and Traumatology Unit, Intensive Care Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
| | - Marc Rodrigo-Gisbert
- Neurology Department, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron, 119, Barcelona 08035, Spain
| | - Daniel Campos-Fernández
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron, 119, Barcelona 08035, Spain
| | - Estevo Santamarina
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron, 119, Barcelona 08035, Spain
| | - Beatriz Parejo Carbonell
- Epilepsy Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
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Kimmons LA, Alzayadneh M, Metter EJ, Alsherbini K. Safety and Efficacy of Ketamine Without Intubation in the Management of Refractory Seizures: A Case Series. Neurocrit Care 2024; 40:689-697. [PMID: 37610640 DOI: 10.1007/s12028-023-01811-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/11/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Continuous infusion ketamine has demonstrated efficacy in the management of refractory seizures yet does not suppress respiratory drive like other continuous infusion anesthetics (CIAs) used for this indication. The aim of this study is to describe the safety and efficacy of ketamine infusions in patients with refractory seizure without intubation. METHODS We analyzed a retrospective cohort of adult patients who were not intubated at the time of initiation of a ketamine infusion for refractory seizures. Seizure onset was determined to be the first clinical seizure or nonconvulsive seizure reported on electroencephalography (EEG) or the start time of EEG for patients with seizures at EEG initiation. Responders were defined as patients with resolution of seizures within 24 h of initiation without the need for intubation or an additional CIA. RESULTS A total of 28 patients were analyzed (median age 62 years, 64.3% female, 82.1% African American, 82.1% with structural seizure etiology, and 85.7% focal seizures). Of patients, 78.5% received an initial bolus averaging 0.9 mg/kg, and the majority (89.3%) were initiated on an infusion at 10 μg/kg/minute; median duration was 39.8 h. Maximum infusion rates were 10 μg/kg/minute in 16 patients, 20 μg/kg/minute in seven patients, and 30 μg/kg/minute in five patients. Of patients, 71.4% were assessed to be ketamine responders; six of the eight nonresponders required intubation and an additional CIA. Responders were 80% more likely to have received ketamine 5 or more hours earlier than nonresponders. Hypotension (systolic blood pressure < 90 mmHg) occurred in 31.8% of patients receiving only ketamine, which did not correlate with duration or maximum dose of ketamine; hypertension (systolic blood pressure > 180 mmHg) occurred in 39.3%. CONCLUSIONS Ketamine represents a safe and effective treatment option for refractory seizures and has potential to reduce morbidity associated with intubation in a carefully selected patient population. Early initiation may increase the likelihood of success.
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Affiliation(s)
- Lauren A Kimmons
- Methodist University Hospital, 1265 Union Avenue, Memphis, TN, 38104, USA.
- University of Tennessee Health Sciences Center, 910 Madison Avenue, Memphis, TN, 38163, USA.
| | - Mohammad Alzayadneh
- University of Tennessee Health Sciences Center, 910 Madison Avenue, Memphis, TN, 38163, USA
| | - E Jeffrey Metter
- University of Tennessee Health Sciences Center, 910 Madison Avenue, Memphis, TN, 38163, USA
| | - Khalid Alsherbini
- Methodist University Hospital, 1265 Union Avenue, Memphis, TN, 38104, USA
- University of Tennessee Health Sciences Center, 910 Madison Avenue, Memphis, TN, 38163, USA
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Heuser K, Horn M, Samsonsen C, Ulvin LB, Olsen KB, Power KN, Veiby G, Molteberg E, Engelsen B, Taubøll E. Treating status epilepticus in adults. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2024; 144:23-0782. [PMID: 38506004 DOI: 10.4045/tidsskr.23.0782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
This clinical review examines the treatment of status epilepticus, a condition in which epileptic seizures are prolonged and pose a significant risk of brain damage and death. International guidelines recommend the use of benzodiazepines as first-line treatment, and these should be administered promptly and in appropriate doses. Second-line treatment involves the use of high-dose anti-seizure medications to stop and prevent seizures. If seizure activity persists, general anaesthesia should be administered as soon as possible. All neurological hospital departments should have established and rehearsed protocols for treating status epilepticus.
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Affiliation(s)
| | - Morten Horn
- Nevrologisk avdeling, Oslo universitetssykehus
| | | | | | | | | | - Gyri Veiby
- Nevrologisk avdeling, Haukeland universitetssjukehus
| | | | | | - Erik Taubøll
- Nevrologisk avdeling, Oslo universitetssykehus, og, Universitetet i Oslo
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Rossetti AO, Claassen J, Gaspard N. Status epilepticus in the ICU. Intensive Care Med 2024; 50:1-16. [PMID: 38117319 DOI: 10.1007/s00134-023-07263-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
Status epilepticus (SE) is a common medical emergency associated with significant morbidity and mortality. Management that follows published guidelines is best suited to improve outcomes, with the most severe cases frequently being managed in the intensive care unit (ICU). Diagnosis of convulsive SE can be made without electroencephalography (EEG), but EEG is required to reliably diagnose nonconvulsive SE. Rapidly narrowing down underlying causes for SE is crucial, as this may guide additional management steps. Causes may range from underlying epilepsy to acute brain injuries such as trauma, cardiac arrest, stroke, and infections. Initial management consists of rapid administration of benzodiazepines and one of the following non-sedating intravenous antiseizure medications (ASM): (fos-)phenytoin, levetiracetam, or valproate; other ASM are increasingly used, such as lacosamide or brivaracetam. SE that continues despite these medications is called refractory, and most commonly treated with continuous infusions of midazolam or propofol. Alternatives include further non-sedating ASM and non-pharmacologic approaches. SE that reemerges after weaning or continues despite management with propofol or midazolam is labeled super-refractory SE. At this step, management may include non-sedating or sedating compounds including ketamine and barbiturates. Continuous video EEG is necessary for the management of refractory and super-refractory SE, as these are almost always nonconvulsive. If possible, management of the underlying cause of seizures is crucial particularly for patients with autoimmune encephalitis. Short-term mortality ranges from 10 to 15% after SE and is primarily related to increasing age, underlying etiology, and medical comorbidities. Refractoriness of treatment is clearly related to outcome with mortality rising from 10% in responsive cases, to 25% in refractory, and nearly 40% in super-refractory SE.
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Affiliation(s)
- Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
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Finsterer J, Press CA, DeVine MN, Gordon SE. Assessing the Effect of Ketamine on Suprarefractory Status Epilepticus Requires Appropriately Designed Cohort Studies. J Pediatr Pharmacol Ther 2023; 28:585-586. [PMID: 38130346 PMCID: PMC10731937 DOI: 10.5863/1551-6776-28.6.585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
| | - Craig A Press
- Department of Pediatrics and Neurology (CAP), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mackenzie N DeVine
- Department of Pharmacy (MND, SEG), Children's Hospital Colorado, Aurora, CO
| | - Sharon E Gordon
- Department of Pharmacy (MND, SEG), Children's Hospital Colorado, Aurora, CO
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Huang TH, Lai MC, Chen YS, Huang CW. The Roles of Glutamate Receptors and Their Antagonists in Status Epilepticus, Refractory Status Epilepticus, and Super-Refractory Status Epilepticus. Biomedicines 2023; 11:biomedicines11030686. [PMID: 36979664 PMCID: PMC10045490 DOI: 10.3390/biomedicines11030686] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 03/30/2023] Open
Abstract
Status epilepticus (SE) is a neurological emergency with a high mortality rate. When compared to chronic epilepsy, it is distinguished by the durability of seizures and frequent resistance to benzodiazepine (BZD). The Receptor Trafficking Hypothesis, which suggests that the downregulation of γ-Aminobutyric acid type A (GABAA) receptors, and upregulation of N-methyl-D-aspartate (NMDA) and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors play major roles in the establishment of SE is the most widely accepted hypothesis underlying BZD resistance. NMDA and AMPA are ionotropic glutamate receptor families that have important excitatory roles in the central nervous system (CNS). They are both essential in maintaining the normal function of the brain and are involved in a variety of neuropsychiatric diseases, including epilepsy. Based on animal and human studies, antagonists of NMDA and AMPA receptors have a significant impact in ending SE; albeit most of them are not yet approved to be in clinically therapeutic guidelines, due to their psychomimetic adverse effects. Although there is still a dearth of randomized, prospective research, NMDA antagonists such as ketamine, magnesium sulfate, and the AMPA antagonist, perampanel, are regarded to be reasonable optional adjuvant therapies in controlling SE, refractory SE (RSE) or super-refractory SE (SRSE), though there are still a lack of randomized, prospective studies. This review seeks to summarize and update knowledge on the SE development hypothesis, as well as clinical trials using NMDA and AMPA antagonists in animal and human studies of SE investigations.
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Affiliation(s)
- Tzu-Hsin Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
- Zhengxin Neurology & Rehabilitation Center, Tainan 70459, Taiwan
| | - Ming-Chi Lai
- Department of Pediatrics, Chi-Mei Medical Center, Tainan 71004, Taiwan
| | - Yu-Shiue Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
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Buratti S, Giacheri E, Palmieri A, Tibaldi J, Brisca G, Riva A, Striano P, Mancardi MM, Nobili L, Moscatelli A. Ketamine as advanced second-line treatment in benzodiazepine-refractory convulsive status epilepticus in children. Epilepsia 2023; 64:797-810. [PMID: 36792542 DOI: 10.1111/epi.17550] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
Status epilepticus (SE) is one of the most common neurological emergencies in children. To date, there is no definitive evidence to guide treatment of SE refractory to benzodiazepines. The main objectives of treatment protocols are to expedite therapeutic decisions and to use fast- and short-acting medications without significant adverse effects. Protocols differ among institutions, and most frequently valproate, phenytoin, and levetiracetam are used as second-line treatment. After failure of first- and second-line medications, admission to the intensive care unit and continuous infusion of anesthetics are usually indicated. Ketamine is a noncompetitive N-methyl-D-aspartate receptor antagonist that has been safely used for the treatment of refractory SE in adults and children. In animal models of SE, ketamine demonstrated antiepileptic and neuroprotective properties and synergistic effects with other antiseizure medications. We reviewed the literature to demonstrate the potential role of ketamine as an advanced second-line agent in the treatment of SE. Pharmacological targets, pathophysiology of SE, and the receptor trafficking hypothesis are reviewed and presented. The pharmacology of ketamine is outlined with related properties, advantages, and side effects. We summarize the most recent and relevant publications on experimental and clinical studies on ketamine in SE. Key expert opinion is also reported. Considering the current knowledge on SE pathophysiology, early sequential polytherapy should include ketamine for its wide range of positive assets. Future research and clinical trials on SE pharmacotherapy should focus on the role of ketamine as second-line medication.
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Affiliation(s)
- Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Emanuele Giacheri
- Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonella Palmieri
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Jessica Tibaldi
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giacomo Brisca
- Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonella Riva
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
| | - Pasquale Striano
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy.,Pediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Lino Nobili
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy.,Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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