Severity scores for status epilepticus in the ICU: systemic illness also matters

BACKGROUND

Current prognostic scores for status epilepticus (SE) may not be adequate for patients in ICU who usually have more severe systemic conditions or more refractory episodes of SE. We aimed to compare the prognostic performance of two SE scores, Status Epilepticus Severity Score (STESS) and Epidemiology-Based Mortality Score in Status Epilepticus (EMSE) score, with four systemic severity scores, Acute Physiology and Chronic Health Evaluation 2 (APACHE-2), Simplified Acute Physiology Score 2 (SAPS-2), Sequential Organ Failure Assessment (SOFA) score, and Inflammation, Nutrition, Consciousness, Neurologic function and Systemic condition (INCNS) score in critically ill patients with SE.

METHODS

This retrospective observational study of a prospectively identified SE cohort was conducted in the ICU at a tertiary-care center. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and associations with outcomes of STESS, EMSE, INCNS, APACHE-2, SAPS-2, and SOFA score for the prediction of in-hospital mortality and no return to baseline condition were assessed.

RESULTS

Between January 2015 and December 2020, 166 patients with SE in ICU were included in the study. In predicting in-hospital death, APACHE-2 (0.72), SAPS-2 (0.73), and SOFA score (0.71) had higher AUCs than STESS (0.58) and EMSE (0.69). In predicting no return to baseline condition, the AUC of APACHE-2 (0.75) was the highest, and the AUC of INCNS (0.55) was the lowest. When the specificity approached 90%, the sensitivity values of these scores were not quite acceptable (< 40%). Neither SE scores nor systemic severity scores had desirable prognostic power. In the multivariate logistic regression analyses, the best combinations of scores always included at least one or more systemic severity scores.

CONCLUSIONS

STESS and EMSE were insufficient in outcome prediction for SE patients in ICU, and EMSE was marginally better than STESS. Systemic illness matters in ICU patients with SE, and SE scores should be modified to achieve better accuracy in this severely ill population. This study mostly refers to severely ill patients in the ICU.

Frequency and Types of Complications Encountered in Patients With Nonconvulsive Status Epilepticus in the Neurological ICU: Impact on Outcome

Objectives. The frequency and types of complications in patients with nonconvulsive status epilepticus (NCSE) who are followed up in the intensive care unit (ICU), and the impact of these complications on outcome are not well-known. We investigated the complications and their effects on prognosis in NCSE patients. Methods. After reviewing the video-EEG monitoring (VEEGM) reports of all the consecutive patients who were followed up in our ICU between 2009 and 2019, we identified two groups of patients: 1-patients with NCSE (study group) and 2-patients who underwent VEEGM for possible NCSE but did not have ictal recordings (no-NCSE group). Electronic health records were reviewed to identify demographic and clinical data, duration of ICU care, medical and surgical complications, pharmacologic treatment, and outcome. These parameters were compared statistically between the groups. We also investigated the parameters affecting prognosis at discharge. Results. Thirty-two patients with NCSE comprised the study group. Infection developed in 84%. More than half were intubated, had tracheostomy or percutaneous endoscopic gastrostomy application. Refractory NCSE was associated with significantly more frequent complications and worse outcome. There was a higher tendency of infections in the study group (P = .059). Higher organ failure scores and prolonged stay in ICU predicted worse outcome (P < .05). Conclusion. The frequency of complications in patients with NCSE who are cared for in the ICU is considerable. Most of the complications are similar to the other patients in ICU, except for the higher frequency of infections. Increased physician awareness about modifiable parameters and timely interventions might help improve prognosis.

Long-term prognosis related to deep sedation in refractory status Epilepticus

OBJECTIVE

To evaluate long-term prognosis in patients with refractory status epilepticus according to the level of sedation reached during drug-induced coma.

MATERIALS AND METHODS

Longitudinal study of patients with status epilepticus who received anesthetics to induce therapeutic coma. Demographic data, clinical, and electroencephalographic characteristics were collected, as well as variables related to sedation. We considered as deep sedation the EEG burst-suppression patterns (suppression ratio > 50%). A GOSE (Glasgow Outcome Scale Extended) score of 7 or 8 was considered as good prognosis. A comparative study was carried out to identify predictors of good or poor prognosis at discharge, at 1 and 2 years of follow-up.

RESULTS

We included 61 patients: 63.9% were men; mean age 53.5 ± 16.8 years (range 16-86 years), 39.3% reached deep sedation; 62.3% had > 48 h induced coma. The median hospital stay was 21 days, while 10 days in the intensive care unit (ICU). In the multiple regression analysis, an ICU length of stay ≥ 7 days was associated with poor prognosis at discharge and at long-term (P < .05), while deep sedation was associated only with poor long-term prognosis (1 and 2 years, P < .05). The Kaplan-Meier curve showed higher survival in the group that did not undergo deep sedation (P < .05).

CONCLUSIONS

In refractory status epilepticus, deep sedation is associated with poor prognosis at long-term.

Predictors of mortality at one year after generalized convulsive status epilepticus

BACKGROUND

Status epilepticus (SE) is a life-threatening neurologic emergency, which requires prompt medical treatment. Little is known of the long-term survival of SE. The aim of this study was to investigate which factors influence 90 days and 1-year mortality after SE.

MATERIALS AND METHODS

This retrospective study includes all consecutive adult (>16 years) patients (N = 70) diagnosed with generalized convulsive SE (GCSE) in Helsinki University Central Hospital (HUCH) emergency department (ED) over 2 years. We defined specific factors including patient demographics, GCSE characteristics, treatment, complications, delays in treatment, and outcome at hospital discharge and determined their relation to 90 days and 1-year mortality after GCSE by using logistic regression models. Survival analyses at 1 year after GCSE were performed with Cox proportional hazards regression analysis.

RESULTS

In-hospital mortality was 7.1%. Mortality rate was 14.3% at 90 days and 24.3% at 1 year after GCSE. In the univariate logistic regression analysis, Status Epilepticus Severity Score > 4 (STESS) (ODDS = 7.30, p = 0.012), worse-than-baseline condition at hospital discharge (ODDS = 3.5, p = 0.006), long delays in attaining seizure freedom (ODDS = 2.2, p = 0.041), and consciousness (ODDS = 3.4, p = 0.014) were risk factors for mortality at 90 days whereas epilepsy (ODDS = 0.2, p = 0.014) and Glasgow Outcome Scale (GOS) >3 at hospital discharge (ODDS = 0.05, p = 0.006) were protective factors. Risk factors for mortality at 1 year were STESS >4 (ODDS = 5.1, p = 0.028), use of vasopressors (ODDS = 8.2, p = 0.049), and worse-than-baseline condition at discharge (ODDS = 7.8, p = 0.010) while GOS >3 (ODDS = 0.2, p = 0.005) was protective. The univariate survival analysis at 1 year confirmed the significant findings regarding parameters STESS >4 (Hazard ratio (HR) = 4.1, p = 0.009), worse-than-baseline condition (HR = 6.2, p = 0.015), GOS >3 (HR = 0.2, p = 0.004) at hospital discharge and epilepsy (HR = 0.4, p = 0.044). Additionally, diagnostic delay over 6 h (HR = 3.8, p = 0.022) and Complication Burden Index (CBI) as an ordinal variable (0-2, 3-6, >6) (HR = 2.7, p = 0.027) were predictive for mortality. In the multivariate survival analysis, STESS > 4 (HR = 5.1, p = 0.007), CBI (HR = 3.2, p = 0.025, ordinal variable), diagnostic delay over 6 h (HR = 7.2, p = 0.003), and worse-than-baseline condition at hospital discharge (HR = 5.8, p = 0.027) were all independent risk factors for mortality at 1 year.

CONCLUSIONS

Severe form of SE, delayed recognition of GCSE, high number of complications during treatment period, and poor condition at hospital discharge are all independent predictors of long-term mortality. Most of these factors are also associated with mortality at 90 days, though at that point, delays in treatment seem to have a greater impact on prognosis than at 1 year. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures.