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Chiriboga N, Spentzas T, Abu-Sawwa R. A systematic review and meta-analysis of ketamine in pediatric status epilepticus. Epilepsia 2024; 65:2200-2212. [PMID: 38881333 DOI: 10.1111/epi.18035] [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: 12/01/2023] [Revised: 05/22/2024] [Accepted: 05/22/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE Status epilepticus (SE) is a common neurological medical emergency in the pediatric population, with 10%-40% of cases progressing to refractory SE (RSE), requiring treatment with anesthetic infusions. We present a systematic review and meta-analysis of the use of ketamine for the treatment of pediatric SE and its potential advantages over other anesthetic infusions. METHODS This review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Electronic databases, including PubMed, Cochrane Library, Ovid, Embase, and Google Scholar, were searched with the keywords "pediatrics," "status epilepticus," and "ketamine treatment." Randomized trials, prospective and retrospective cohort studies, and case reports were considered for inclusion. RESULTS Eighteen publications met the initial inclusion criteria. The 18 publications comprise 11 case reports, one nonconclusive clinical trial, two case series, and four retrospective cohorts. After excluding the case reports because of reporting bias, only the six case series and cohorts were included in the final analysis. There were 172 patients in the six included studies. The weighted age was 9.93 (SD = 10.29) years. The weighted maximum dose was 7.44 (SD = 9.39) mg/kg/h. SE cessation was attained in 51% (95% confidence interval = 43-59) of cases with the addition of ketamine. The heterogeneity was I2 = 0%, t2 = 0, χ2 (5) = 3.39 (p = .64). SIGNIFICANCE Pediatric RSE is difficult to treat, resulting in increased morbidity and mortality. Without strong recommendations and evidence regarding preferred agents, this review provides evidence that ketamine may be considered in managing SE in the pediatric population.
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Affiliation(s)
- Nicolas Chiriboga
- Pediatric Intensive Care Unit Le Bonheur Children's Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Thomas Spentzas
- Pediatric Intensive Care Unit Le Bonheur Children's Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Renad Abu-Sawwa
- Department of Anatomy and Cell Biology, Rush Medical College, Chicago, Illinois, USA
- Department of Pediatric Neurology, Rush University Children's Hospital, Chicago, Illinois, USA
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2
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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 2024:1-8. [PMID: 39058382 DOI: 10.1080/10903127.2024.2382367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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 to 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.
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Affiliation(s)
- Joseph Daniel Finney
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, Missouri
| | - Paul D Schuler
- Department of Emergency Medicine, School of Medicine, University of Missouri, Columbia, Missouri
| | - James R Rudloff
- Department of Pediatrics, Institute for Informatics Data Science and Biostatistics, Washington University in Saint Louis, St. Louis, Missouri
| | - Nicholas Agostin
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, Missouri
| | - Oleg V Lobanov
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Jeffrey Siegler
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Manish I Shah
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Elan L Guterman
- Philip R. Lee Institute for Health Policy Studies and Department of Neurology, University of California, San Francisco, California
| | - James M Chamberlain
- Pediatrics and Emergency Medicine, George Washington University, Washington, District of Columbia
| | - Fahd A Ahmad
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, Missouri
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Rubinos C. Emergent Management of Status Epilepticus. Continuum (Minneap Minn) 2024; 30:682-720. [PMID: 38830068 DOI: 10.1212/con.0000000000001445] [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: 06/05/2024]
Abstract
OBJECTIVE Status epilepticus is a neurologic emergency that can be life- threatening. The key to effective management is recognition and prompt initiation of treatment. Management of status epilepticus requires a patient-specific-approach framework, consisting of four axes: (1) semiology, (2) etiology, (3) EEG correlate, and (4) age. This article provides a comprehensive overview of status epilepticus, highlighting the current treatment approaches and strategies for management and control. LATEST DEVELOPMENTS Administering appropriate doses of antiseizure medication in a timely manner is vital for halting seizure activity. Benzodiazepines are the first-line treatment, as demonstrated by three randomized controlled trials in the hospital and prehospital settings. Benzodiazepines can be administered through IV, intramuscular, rectal, or intranasal routes. If seizures persist, second-line treatments such as phenytoin and fosphenytoin, valproate, or levetiracetam are warranted. The recently published Established Status Epilepticus Treatment Trial found that all three of these drugs are similarly effective in achieving seizure cessation in approximately half of patients. For cases of refractory and super-refractory status epilepticus, IV anesthetics, including ketamine and γ-aminobutyric acid-mediated (GABA-ergic) medications, are necessary. There is an increasing body of evidence supporting the use of ketamine, not only in the early phases of stage 3 status epilepticus but also as a second-line treatment option. ESSENTIAL POINTS As with other neurologic emergencies, "time is brain" when treating status epilepticus. Antiseizure medication should be initiated quickly to achieve seizure cessation. There is a need to explore newer generations of antiseizure medications and nonpharmacologic modalities to treat status epilepticus.
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Bode CM, Kristensen SB, Olsen HT, Cornwall CD, Roberg L, Monsson O, Krøigård T, Toft P, Beier CP. Postictal Encephalopathy After Status Epilepticus: Outcome and Risk Factors. Neurocrit Care 2024; 40:1025-1035. [PMID: 37940836 PMCID: PMC11147838 DOI: 10.1007/s12028-023-01868-1] [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] [Received: 06/21/2023] [Accepted: 09/22/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Postictal encephalopathy is well known after status epilepticus (SE), but its prognostic impact and triggers are unknown. Here, we aimed to establish risk factors for the development of postictal encephalopathy and to study its impact on survival after discharge. METHODS This retrospective cohort study comprised adult patients diagnosed with first nonanoxic SE at Odense University Hospital between January 2008 and December 2017. Patients with ongoing SE at discharge or unknown treatment success were excluded. Postictal symptoms of encephalopathy were estimated retrospectively using the West Haven Criteria (WHC). WHC grade was determined for postictal day 1 to 14 or until the patient died or was discharged from the hospital. Cumulative postictal WHC during 14 days after SE-cessation was used to quantify postictal encephalopathy. Clinical characteristics, patient demographics, electroencephalographic and imaging features, and details on intensive care treatment were assessed from medical records. RESULTS Of all eligible patients (n = 232), 198 (85.3%) had at least WHC grade 2 postictal encephalopathy that lasted for > 14 days in 24.5% of the surviving patients. WHC grade at discharge was strongly associated with poor long-term survival (p < 0.001). Postictal encephalopathy was not associated with nonconvulsive SE, postictal changes on magnetic resonance imaging, or distinct ictal patterns on electroencephalography. Although duration of SE and treatment in the intensive care unit showed an association with cumulative postictal WHC grade, they were not independently associated with the degree of encephalopathy when controlling for confounders. In a linear regression model, etiology, duration of sedation, age, and premorbid modified Rankin Scale were significant and consistent predictors for higher cumulative postictal WHC grade. Exploratory analyses showed an association of a cumulative midazolam dosage (mg/kg/h) with higher cumulative postictal WHC grade. DISCUSSION In this cohort, postictal encephalopathy after SE was common and associated with poor long-term survival. Seizure characteristics were not independently associated with postictal encephalopathy; the underlying etiology, long (high-dose midazolam) sedation, high age, and poor premorbid condition were the major risk factors for its development.
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Affiliation(s)
- Clara Marie Bode
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | - Simon Bruun Kristensen
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | | | - Camilla Dyremose Cornwall
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Lars Roberg
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | - Olav Monsson
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | - Thomas Krøigård
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Neurophysiology, Odense University Hospital, Odense, Denmark
| | - Palle Toft
- Department of Anesthesiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christoph P Beier
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.
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Jacobwitz M, Mulvihill C, Kaufman MC, Gonzalez AK, Resendiz K, Francoeur C, Helbig I, Topjian AA, Abend NS. A Comparison of Ketamine and Midazolam as First-Line Anesthetic Infusions for Pediatric Status Epilepticus. Neurocrit Care 2024; 40:984-995. [PMID: 37783824 DOI: 10.1007/s12028-023-01859-2] [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: 07/07/2023] [Accepted: 09/08/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Pediatric refractory status epilepticus (RSE) often requires management with anesthetic infusions, but few data compare first-line anesthetics. This study aimed to compare the efficacy and adverse effects of midazolam and ketamine infusions as first-line anesthetics for pediatric RSE. METHODS Retrospective single-center study of consecutive study participants treated with ketamine or midazolam as the first-line anesthetic infusions for RSE at a quaternary care children's hospital from December 1, 2017, until September 15, 2021. RESULTS We identified 117 study participants (28 neonates), including 79 (68%) who received midazolam and 38 (32%) who received ketamine as the first-line anesthetic infusions. Seizures terminated more often in study participants administered ketamine (61%, 23/38) than midazolam (28%, 22/79; odds ratio [OR] 3.97, 95% confidence interval [CI] 1.76-8.98; P < 0.01). Adverse effects occurred more often in study participants administered midazolam (24%, 20/79) than ketamine (3%, 1/38; OR 12.54, 95% CI 1.61-97.43; P = 0.016). Study participants administered ketamine were younger, ketamine was used more often for children with acute symptomatic seizures, and midazolam was used more often for children with epilepsy. Multivariable logistic regression of seizure termination by first-line anesthetic infusion (ketamine or midazolam) including age at SE onset, SE etiology category, and individual seizure duration at anesthetic infusion initiation indicated seizures were more likely to terminate following ketamine than midazolam (OR 4.00, 95% CI 1.69-9.49; P = 0.002) and adverse effects were more likely following midazolam than ketamine (OR 13.41, 95% CI 1.61-111.04; P = 0.016). Survival to discharge was higher among study participants who received midazolam (82%, 65/79) than ketamine (55%, 21/38; P = 0.002), although treating clinicians did not attribute any deaths to ketamine or midazolam. CONCLUSIONS Among children and neonates with RSE, ketamine was more often followed by seizure termination and less often associated with adverse effects than midazolam when administered as the first-line anesthetic infusion. Further prospective data are needed to compare first-line anesthetics for RSE.
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Affiliation(s)
- Marin Jacobwitz
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Caitlyn Mulvihill
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Michael C Kaufman
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
- The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexander K Gonzalez
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
- The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Karla Resendiz
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Conall Francoeur
- Division of Critical Care, Québec, QC, Canada
- Department of Pediatrics, Centre Hospitalier Universitaire de Québec-University of Laval Research Center, Québec, QC, Canada
| | - Ingo Helbig
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
- The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nicholas S Abend
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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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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Williams NC, Morgan LA, Friedman J, Siegler J. Ketamine Efficacy for Management of Status Epilepticus: Considerations for Prehospital Clinicians. Air Med J 2024; 43:84-89. [PMID: 38490790 DOI: 10.1016/j.amj.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/10/2023] [Accepted: 09/21/2023] [Indexed: 03/17/2024]
Abstract
Current first-line therapies for seizure management recommend benzodiazepines, which target gamma-aminobutyric acid type A channels to stop the seizure activity. However, seizures may be refractory to traditional first-line therapies, transitioning into status epilepticus and becoming resistant to gamma-aminobutyric acid type A augmenting drugs. Although there are other antiseizure medications available for clinicians to use in the intensive care unit, these options can be less readily available outside of the intensive care unit and entirely absent in the prehospital setting. Instead, patients frequently receive multiple doses of first-line agents with increased risk of hemodynamic or airway collapse. Ketamine is readily available in the prehospital setting and emergency department, has well-established antiseizure effects with a favorable safety profile, and is a drug often used for several other indications. This article aimed to explore the utilization of ketamine for seizure management in the prehospital setting, reviewing seizure pathophysiology, established treatment mechanisms of action and pharmacokinetics, and potential benefits of early ketamine use in status epilepticus.
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Affiliation(s)
| | - Lindsey A Morgan
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle, WA; Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA
| | | | - Jeffrey Siegler
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, MO
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Roberti R, Riva A, D'Onofrio G, Giacheri E, Amadori E, Vari MS, La Neve A, Vigevano F, Verrotti A, Cordelli DM, Romeo A, Palmieri A, Mancardi MM, Caglieris S, Varone A, Minetti C, Russo E, Buratti S, Striano P. A proposal for a shared therapeutic algorithm in children with prolonged convulsive seizures and status epilepticus. Expert Rev Neurother 2024; 24:133-138. [PMID: 38230547 DOI: 10.1080/14737175.2024.2305813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/11/2024] [Indexed: 01/18/2024]
Affiliation(s)
- Roberta Roberti
- Science of Health Department, School of Medicine, Magna Græcia University, Catanzaro, Italy
| | - Antonella Riva
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Gianluca D'Onofrio
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Emanuele Giacheri
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Elisabetta Amadori
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Maria Stella Vari
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Angela La Neve
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Federico Vigevano
- Neurology Unit, Department of Neuroscience, Bambino Gesù, IRCCS Children's Hospital, Full member of European Reference Network EpiCARE, Rome, Italy
| | - Alberto Verrotti
- Department of Medical, Oral and Biotechnological Sciences, University "G. D'Annunzio"of Chieti-Pescara, Chieti, Italy
| | - Duccio Maria Cordelli
- UOC Neuropsychiatry of the Pediatric Age, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Antonino Romeo
- Pediatric Neurology Unit and Epilepsy Center, Department of Neuroscience, "Fatebenefratelli e Oftalmico" Hospital, Milano, Italy
| | - Antonella Palmieri
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maria Margherita Mancardi
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
- Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Sergio Caglieris
- Health System of Liguria, Territorial Emergency Liguria, Genoa, Italy
| | - Antonio Varone
- Department of Neuroscience, Pediatric Neurology, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Carlo Minetti
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, Magna Græcia University, Catanzaro, Italy
| | - Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
- Pediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Shehata IM, Kohaf NA, ElSayed MW, Latifi K, Aboutaleb AM, Kaye AD. Ketamine: Pro or antiepileptic agent? A systematic review. Heliyon 2024; 10:e24433. [PMID: 38293492 PMCID: PMC10826813 DOI: 10.1016/j.heliyon.2024.e24433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/01/2024] Open
Abstract
Purpose of Review: This evidence-based systematic review evaluated the safety of ketamine as regard the potential to provoke epilepsy to help better guide anesthesiologists in their practice. Recent findings Ketamine, originally developed as a dissociative anesthetic, has gained attention for its potential therapeutic applications in various medical conditions, including epilepsy. Ketamine is generally well-tolerated and widely used in anesthesia, however, conflicting data are confusing the anesthesiologists regarding the potential risk of seizures associated with its use. The literature that claimed the proepileeptic property are inconsistent and the mechanism of action is unclear. Moreover, the case reports had been in same certain contexts, such as procedural sedation where ketamine was used as a single agent. On the other hand, the retrospective data analysis confirmed the positive role ketamine plays as antiepileptic agent. Summary Many studies have shown promising results for the use of ketamine as antiepileptic agent. In case of epileptic patients, there is no contraindication for using ketamine, however, combining with benzodiazepine or propofol may enhance the safety.
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Affiliation(s)
| | - Neveen A. Kohaf
- Department of Clinical Pharmacy, Alazhar, University, Cairo, 11651, Egypt
| | - Mohamed W. ElSayed
- Geisel School of Medicine at Dartmouth, New Hampshire Hospital, SUNY School of Graduate Studies, USA
| | - Kaveh Latifi
- Department of Anesthesiology and Pain Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Alan David Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
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Colman R, Pierre P, Adriansjach J, Crosno K, Noguchi KK, Ikonomidou C. Behavioral and Cognitive Outcomes of Rhesus Macaques Following Neonatal Exposure to Antiseizure Medications. Ann Neurol 2023; 95:10.1002/ana.26794. [PMID: 37706347 PMCID: PMC10937326 DOI: 10.1002/ana.26794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/20/2023] [Accepted: 09/11/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVE Exposure of neonatal macaques to the antiseizure medications phenobarbital and midazolam (PbM) causes widespread apoptotic death of neurons and oligodendrocytes. We studied behavior and neurocognitive performance in 12 to 24 month-old macaques treated as neonates with PbM. METHODS A total of 14 monkeys received phenobarbital and midazolam over 24 hours under normothermia (n = 8) or mild hypothermia (n = 6). Controls (n = 8) received no treatment. Animals underwent testing in the human intruder paradigm at ages 12 and 18 months, and a 3-step stimulus discrimination task at ages 12, 18, and 24 months. RESULTS Animals treated with PbM displayed lower scores for environmental exploration, and higher scores for locomotion and vocalizations compared with controls. Combined PbM and hypothermia resulted in lower scores for aggression and vigilance at 12 months compared with controls and normothermic PbM animals. A mixed-effects generalized linear model was used to test for differences in neurocognitive performance between the control and PbM groups in the first step of the stimulus discrimination task battery (shape center baited to shape center non-baited). The odds of passing this step differed by group (p = 0.044). At any given age, the odds of passing for a control animal were 9.53-fold (95% CI 1.06-85) the odds for a PbM animal. There was also evidence suggesting a higher learning rate in the shape center non-baited for the control relative to the PbM group (Cox model HR 2.13, 95% CI 1.02-4.43; p = 0.044). INTERPRETATION These findings demonstrate that a 24-hour-long neonatal treatment with a clinically relevant combination of antiseizure medications can have long-lasting effects on behavior and cognition in nonhuman primates. ANN NEUROL 2023.
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Affiliation(s)
- Ricki Colman
- Wisconsin National Primate Research Center, Madison WI, USA
- Department of Cell and Regenerative Biology, University of Wisconsin, School of Medicine, Madison WI USA
| | - Peter Pierre
- Wisconsin National Primate Research Center, Madison WI, USA
| | | | - Kristin Crosno
- Wisconsin National Primate Research Center, Madison WI, USA
| | - Kevin K. Noguchi
- Department of Psychiatry, Washington University, School of Medicine, St Louis, USA
| | - Chrysanthy Ikonomidou
- Department of Neurology, University of Wisconsin, School of Medicine, Madison WI USA
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Vossler DG. Midazolam, Ketamine, and Propofol: While We Slept, Others Worked on Anesthetizing Infusions for Refractory Status Epilepticus. Epilepsy Curr 2023; 23:230-232. [PMID: 37662457 PMCID: PMC10470094 DOI: 10.1177/15357597231171240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
Management of Refractory Status Epilepticus: An International Cohort Study (MORSE CODe) Analysis of Patients Managed in the ICU Chiu WT, Campozano V, Schiefecker A, Rodriguez DR, Ferreira D, Headlee A, Zeidan S, Grinea A, Huang YH, Doyle K, Shen Q, Gómez D, Hocker SE, Rohaut B, Sonneville R, Hong C-T, Demeret S, Kurtz P, Maldonado N, Helbok R, Fernandez T, Claassen J. Neurology . 2022;99(11):e1191-e1201. doi:10.1212/WNL.0000000000200818 Background and Objectives: Status epilepticus that continues after the initial benzodiazepine and a second anticonvulsant medication is known as refractory status epilepticus (RSE). Management is highly variable because adequately powered clinical trials are missing. We aimed to determine whether propofol and midazolam were equally effective in controlling RSE in the intensive care unit, focusing on management in resource-limited settings. Methods: Patients with RSE treated with midazolam or propofol between January 2015 and December 2018 were retrospectively identified among 9 centers across 4 continents from upper-middle-income economies in Latin America and high-income economies in North America, Europe, and Asia. Demographics, Status Epilepticus Severity Score, etiology, treatment details, and discharge modified Rankin Scale (mRS) were collected. The primary outcome measure was good functional outcome defined as a mRS score of 0-2 at hospital discharge. Results: Three hundred eighty-seven episodes of RSE (386 patients) were included, with 162 (42%) from upper-middle-income and 225 (58%) from high-income economies. Three hundred six (79%) had acute and 79 (21%) remote etiologies. Initial RSE management included midazolam in 266 (69%) and propofol in 121 episodes (31%). Seventy episodes (26%) that were initially treated with midazolam and 42 (35%) with propofol required the addition of a second anesthetic to treat RSE. Baseline characteristics and outcomes of patients treated with midazolam or propofol were similar. Breakthrough (odds ratio [OR] 1.6, 95% CI 1.3-2.0) and withdrawal seizures (OR 2.0, 95% CI 1.7-2.5) were associated with an increased number of days requiring continuous intravenous anticonvulsant medications (cIV-ACMs). Prolonged EEG monitoring was associated with fewer days of cIV-ACMs (1-24 hours OR 0.5, 95% CI 0.2-0.9, and >24 hours OR 0.7, 95% CI 0.5-1.0; reference EEG <1 hour). This association was seen in both, high-income and upper-middle-income economies, but was particularly prominent in high-income countries. One hundred ten patients (28%) were dead, and 80 (21%) had good functional outcomes at hospital discharge. Discussion: Outcomes of patients with RSE managed in the intensive care unit with propofol or midazolam infusions are comparable. Prolonged EEG monitoring may allow physicians to decrease the duration of anesthetic infusions safely, but this will depend on the implementation of RSE management protocols. Goal-directed management approaches including EEG targets may hold promise for patients with RSE. Ketamine for Management of Neonatal and Pediatric Refractory Status Epilepticus Jacobwitz M, Mulvihill C, Kaufman MC, Gonzalez AK, Resendiz K, MacDonald JM, Francoeur C, Helbig I, Topjian AA, Abend NS. Neurology . 2022;99(12):e1227-e1238. doi:10.1212/WNL.0000000000200889 Background and Objectives: Few data are available regarding the use of anesthetic infusions for refractory status epilepticus (RSE) in children and neonates, and ketamine use is increasing despite limited data. We aimed to describe the impact of ketamine for RSE in children and neonates. Methods: Retrospective single-center cohort study of consecutive patients admitted to the intensive care units of a quaternary care children’s hospital treated with ketamine infusion for RSE. Results: Sixty-nine patients were treated with a ketamine infusion for RSE. The median age at onset of RSE was 0.7 years (interquartile range 0.15-7.2), and the cohort included 13 (19%) neonates. Three patients (4%) had adverse events requiring intervention during or within 12 hours of ketamine administration, including hypertension in 2 patients and delirium in 1 patient. Ketamine infusion was followed by seizure termination in 32 patients (46%), seizure reduction in 19 patients (28%), and no change in 18 patients (26%). Discussion: Ketamine administration was associated with few adverse events, and seizures often terminated or improved after ketamine administration. Further data are needed comparing first-line and subsequent anesthetic medications for treatment of pediatric and neonatal RSE.
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