Propofol and barbiturates for the anesthesia of refractory convulsive status epilepticus: pros and cons

Propofol-Related Infusion Syndrome: A Bibliometric Analysis of the 100 Most-Cited Articles

Propofol-related infusion syndrome (PRIS) is a rare, yet life-threatening sequelae to prolonged administration of the anesthetic propofol in mechanically intubated patients. The condition is characterized by progressive multi-system organ failure and eventual mortality; of note, the predominant characteristics of PRIS involve but are not limited to cardiovascular impairment and collapse, metabolic and lactic acidosis, rhabdomyolysis, hyperkalemia, and acute renal failure. While potent or extended doses of propofol have been found to be the primary precipitating factor of this condition, others such as age, critical illness, steroid therapy, and hyperlipidemia have been discovered to play a role as well. This bibliometric analysis was done to reflect the current relevance and understanding of PRIS in recent literature. The SCOPUS database was utilized to conduct a search for articles with keywords "propofol infusion syndrome" and "propofol syndrome" from February 24, 2001, until April 16, 2023, with parameters for article title, citation number, citation per year, author, institution, publishing journal, and country of origin. PRIS was first defined in 1990, just a year after its approval by the Food and Drug Administration for use as a sedative-hypnotic. Since then, interest in PRIS slowly rose up to 13 publications per year in 2013. Seven papers on the topic were published in Critical Care Medicine, six in Neurocritical Care, and four in Anesthesia. The most common institutions were Mayo Clinic, Northeastern University, and Tufts Medical Center. To our knowledge, this is the first bibliometric analysis to evaluate the most influential publications about PRIS. A majority of the research is case-based, possibly owing to the rarity of the condition. Our research suggests that confounding factors outside the precipitating dosage of propofol may be implicated in the onset and progression of PRIS. This study could therefore bring renewed interest to the topic and lead to additional research focused on fully understanding the pathophysiology of PRIS in order to promote the development of novel diagnostics and treatment.

Behavioral Pharmacology of Five Uncommon Passiflora Species Indicates Sedative and Anxiolytic-like Potential

BACKGROUND

There are over 500 species in the Passiflora genus, and while some of them are very well known in folk medicine for their anxiolytic effects, very little is known for the other genus representants, which could also present medicinal effects.

OBJECTIVE

In this study, we performed an interspecific pharmacological comparison of five little investigated Passiflora species, all native to Brazil: P. bahiensis, P. coccinea, P. quadrangularis, P. sidaefolia, and P. vitifolia.

METHOD

Extracts were administered to mice before behavioral testing, which included a general pharmacological screening and anxiolytic-like effect investigation.

RESULTS

Three of the species [P. coccinea, P. quadrangularis, and P. sidaefolia] induced a decrease in locomotor activity of mice; P. coccinea also reduced the latency to sleep. Importantly, none of the species interfered with motor coordination. Oral administration evoked no severe signs of toxicity even at higher doses. Regarding the anxiolytic-like profile, P. sidaefolia reduced the anxious-like behavior in the Holeboard test in a similar way to the positive control, Passiflora incarnata, while not affecting total motricity.

CONCLUSION

These results indicate that P. coccinea, P. quadrangularis, and P. sidaefolia reduced the general activity of mice and confer a calmative/sedative potential to these three species, which must be further elucidated by future investigations.

Treatment of Refractory Convulsive Status Epilepticus: A Comprehensive Review by the American Epilepsy Society Treatments Committee

Purpose:

Established tonic–clonic status epilepticus (SE) does not stop in one-third of patients when treated with an intravenous (IV) benzodiazepine bolus followed by a loading dose of a second antiseizure medication (ASM). These patients have refractory status epilepticus (RSE) and a high risk of morbidity and death. For patients with convulsive refractory status epilepticus (CRSE), we sought to determine the strength of evidence for 8 parenteral ASMs used as third-line treatment in stopping clinical CRSE.

Methods:

A structured literature search (MEDLINE, Embase, CENTRAL, CINAHL) was performed to identify original studies on the treatment of CRSE in children and adults using IV brivaracetam, ketamine, lacosamide, levetiracetam (LEV), midazolam (MDZ), pentobarbital (PTB; and thiopental), propofol (PRO), and valproic acid (VPA). Adrenocorticotropic hormone (ACTH), corticosteroids, intravenous immunoglobulin (IVIg), magnesium sulfate, and pyridoxine were added to determine the effectiveness in treating hard-to-control seizures in special circumstances. Studies were evaluated by predefined criteria and were classified by strength of evidence in stopping clinical CRSE (either as the last ASM added or compared to another ASM) according to the 2017 American Academy of Neurology process.

Results:

No studies exist on the use of ACTH, corticosteroids, or IVIg for the treatment of CRSE. Small series and case reports exist on the use of these agents in the treatment of RSE of suspected immune etiology, severe epileptic encephalopathies, and rare epilepsy syndromes. For adults with CRSE, insufficient evidence exists on the effectiveness of brivaracetam (level U; 4 class IV studies). For children and adults with CRSE, insufficient evidence exists on the effectiveness of ketamine (level U; 25 class IV studies). For children and adults with CRSE, it is possible that lacosamide is effective at stopping RSE (level C; 2 class III, 14 class IV studies). For children with CRSE, insufficient evidence exists that LEV and VPA are equally effective (level U, 1 class III study). For adults with CRSE, insufficient evidence exists to support the effectiveness of LEV (level U; 2 class IV studies). Magnesium sulfate may be effective in the treatment of eclampsia, but there are only case reports of its use for CRSE. For children with CRSE, insufficient evidence exists to support either that MDZ and diazepam infusions are equally effective (level U; 1 class III study) or that MDZ infusion and PTB are equally effective (level U; 1 class III study). For adults with CRSE, insufficient evidence exists to support either that MDZ infusion and PRO are equally effective (level U; 1 class III study) or that low-dose and high-dose MDZ infusions are equally effective (level U; 1 class III study). For children and adults with CRSE, insufficient evidence exists to support that MDZ is effective as the last drug added (level U; 29 class IV studies). For adults with CRSE, insufficient evidence exists to support that PTB and PRO are equally effective (level U; 1 class III study). For adults and children with CRSE, insufficient evidence exists to support that PTB is effective as the last ASM added (level U; 42 class IV studies). For CRSE, insufficient evidence exists to support that PRO is effective as the last ASM used (level U; 26 class IV studies). No pediatric-only studies exist on the use of PRO for CRSE, and many guidelines do not recommend its use in children aged <16 years. Pyridoxine-dependent and pyridoxine-responsive epilepsies should be considered in children presenting between birth and age 3 years with refractory seizures and no imaging lesion or other acquired cause of seizures. For children with CRSE, insufficient evidence exists that VPA and diazepam infusion are equally effective (level U, 1 class III study). No class I to III studies have been reported in adults treated with VPA for CRSE. In comparison, for children and adults with established convulsive SE (ie, not RSE), after an initial benzodiazepine, it is likely that loading doses of LEV 60 mg/kg, VPA 40 mg/kg, and fosphenytoin 20 mg PE/kg are equally effective at stopping SE (level B, 1 class I study).

Conclusions:

Mostly insufficient evidence exists on the efficacy of stopping clinical CRSE using brivaracetam, lacosamide, LEV, valproate, ketamine, MDZ, PTB, and PRO either as the last ASM or compared to others of these drugs. Adrenocorticotropic hormone, IVIg, corticosteroids, magnesium sulfate, and pyridoxine have been used in special situations but have not been studied for CRSE. For the treatment of established convulsive SE (ie, not RSE), LEV, VPA, and fosphenytoin are likely equally effective, but whether this is also true for CRSE is unknown. Triple-masked, randomized controlled trials are needed to compare the effectiveness of parenteral anesthetizing and nonanesthetizing ASMs in the treatment of CRSE.

Recommandations Formalisées d’Experts SRLF/SFMU : Prise en charge des états de mal épileptiques en préhospitalier, en structure d’urgence et en réanimation dans les 48 premières heures (A l’exclusion du nouveau-né et du nourrisson)

La Société de réanimation de langue française et la Société française de médecine d’urgence ont décidé d’élaborer de nouvelles recommandations sur la prise en charge de l’état mal épileptique (EME) avec l’ambition de répondre le plus possible aux nombreuses questions pratiques que soulèvent les EME : diagnostic, enquête étiologique, traitement non spécifique et spécifique. Vingt-cinq experts ont analysé la littérature scientifique et formulé des recommandations selon la méthodologie GRADE. Les experts se sont accordés sur 96 recommandations. Les recommandations avec le niveau de preuve le plus fort ne concernent que l’EME tonico-clonique généralisé (EMTCG) : l’usage des benzodiazépines en première ligne (clonazépam en intraveineux direct ou midazolam en intramusculaire) est recommandé, répété 5 min après la première injection (à l’exception du midazolam) en cas de persistance clinique. En cas de persistance 5 min après cette seconde injection, il est proposé d’administrer la seconde ligne thérapeutique : valproate de sodium, (fos-)phénytoïne, phénobarbital ou lévétiracétam. La persistance avérée de convulsions 30 min après le début de l’administration du traitement de deuxième ligne signe l’EMETCG réfractaire. Il est alors proposé de recourir à un coma thérapeutique au moyen d’un agent anesthésique intraveineux de type midazolam ou propofol. Des recommandations spécifiques à l’enfant et aux autres EME sont aussi énoncées.

Evaluation of fosphenytoin, levetiracetam, and propofol as treatments for nerve agent-induced seizures in pediatric and adult rats

Multiple recent instances of nerve agent (NA) exposure in civilian populations have occurred, resulting in a variety of negative effects and lethality in both adult and pediatric populations. Seizures are a prominent effect of NAs that can result in neurological damage and contribute to their lethality. Current anticonvulsant treatments for NAs are approved for adults, but no approved pediatric treatments exist. Further, the vast majority of NA-related research in animals has been conducted in adult male subjects. There is a need for research that includes female and pediatric populations in testing. In this project, adult and pediatric male and female rats were challenged with sarin or VX and then treated with fosphenytoin, levetiracetam, or propofol. In this study, fosphenytoin and levetiracetam failed to terminate seizure activity when animals were treated 5 min after seizure onset. Propofol was effective, exhibiting high efficacy and potency for terminating seizure activity quickly in pediatric and adult animals, suggesting it may be an effective anticonvulsant for NA-induced seizures in pediatric populations.

[Drugs for intravenous induction of anesthesia: propofol]

In a series of articles dealing with hypnotics for induction of anesthesia, this article describes the development and current value of propofol. Its significance far exceeds that of a pure induction hypnotic (sedation in diagnostic and therapeutic procedures and on the intensive care unit). Propofol is also used for sedation in diagnostic and therapeutic procedures and on the intensive care unit. In the field of induction of anesthesia, the alternatives are barely used. Some contraindications are still controversial whereas others are no longer sufficiently anchored in the users' awareness (widespread off-label use). Adverse effects, such as injection pain, infection risk and propofol-related infusion syndrome (PRIS) could be significantly reduced by pharmacovigilance. With appropriate caution nearly the whole spectrum of anesthesiology patients can be treated using propofol. The hemodynamic side effects and the rare but potentially fatal PRIS are limitations. Further developments address the water solubility and the solubilizing agents of propofol.

Systematic review and meta-analysis of propofol versus barbiturates for controlling refractory status epilepticus

Background

Several studies have compared the efficacy and safety of propofol and barbiturates in the treatment of refractory status epilepticus (RSE). This study aims to quantitatively assess the advantages and disadvantages of propofol and barbiturates in controlling RSE.

Methods

We searched for studies with relevant data from the PubMed, Embase, Ovid, Cochrane Library, Springer Link, Web of Science, and China National Knowledge Infrastructure databases. By calculating odds ratios and standardized mean differences with 95% confidence intervals, we assessed the disease control rate (DCR), case fatality rate (CFR), average control time (ACT), average tracheal intubation placement time (ATIPT), and incidence of hypotension between propofol and barbiturates in treating RSE.

Results

Seven studies with 261 patients were included in this analysis. Meta-analysis revealed that the DCR of propofol was higher than that of barbiturates (p < 0.001) and that the CFR (p = 0.382) between the two treatment did not significantly differ in controlling RSE. Propofol shortened the ACT (p < 0.001) of RSE and reduced the ATIPT (p < 0.001) of patients with RSE more extensively than did barbiturates and did not increase the incidence of hypotension (p = 0.737).

Conclusions

In comparison with barbiturates, propofol can control RSE and shorten ATIPT in a more efficient and timely manner. Moreover, the drug does not increase the incidence of hypotension and CFR.

Developing a personalized closed-loop controller of medically-induced coma in a rodent model

OBJECTIVE

Personalized automatic control of medically-induced coma, a critical multi-day therapy in the intensive care unit, could greatly benefit clinical care and further provide a novel scientific tool for investigating how the brain response to anesthetic infusion rate changes during therapy. Personalized control would require real-time tracking of inter- and intra-subject variabilities in the brain response to anesthetic infusion rate while simultaneously delivering the therapy, which has not been achieved. Current control systems for medically-induced coma require a separate offline model fitting experiment to deal with inter-subject variabilities, which would lead to therapy interruption. Removing the need for these offline interruptions could help facilitate clinical feasbility. In addition, current systems do not track intra-subject variabilities. Tracking intra-subject variabilities is essential for studying whether or how the brain response to anesthetic infusion rate changes during therapy. Further, such tracking could enhance control precison and thus help facilitate clinical feasibility.

APPROACH

Here we develop a personalized closed-loop anesthetic delivery (CLAD) system in a rodent model that tracks both inter- and intra-subject variabilities in real time while simultaneously controlling the anesthetic in closed loop. We tested the CLAD in rats by administrating propofol to control the electroencephalogram (EEG) burst suppression. We first examined whether the CLAD can remove the need for offline model fitting interruption. We then used the CLAD as a tool to study whether and how the brain response to anesthetic infusion rate changes as a function of changes in the depth of medically-induced coma. Finally, we studied whether the CLAD can enhance control compared with prior systems by tracking intra-subject variabilities.

MAIN RESULTS

The CLAD precisely controlled the EEG burst suppression in each rat without performing offline model fitting experiments. Further, using the CLAD, we discovered that the brain response to anesthetic infusion rate varied during control, and that these variations correlated with the depth of medically-induced coma in a consistent manner across individual rats. Finally, tracking these variations reduced control bias and error by more than 70% compared with prior systems.

SIGNIFICANCE

This personalized CLAD provides a new tool to study the dynamics of brain response to anesthetic infusion rate and has significant implications for enabling clinically-feasible automatic control of medically-induced coma.

Transition from intravenous to enteral ketamine for treatment of nonconvulsive status epilepticus

Background

Nonconvulsive status epilepticus (NCSE) is a diagnosis that is often challenging and one that may progress to refractory NCSE. Ketamine is a noncompetitive N-methyl-d-aspartate antagonist that increasingly has been used to treat refractory status epilepticus. Current Neurocritical Care Society guidelines recommend intravenous (IV) ketamine infusion as an alternative treatment for refractory status epilepticus in adults. On the other hand, enteral ketamine use in NCSE has been reported in only 6 cases (1 adult and 5 pediatric) in the literature to date.

Case presentation

A 33-year-old woman with a history of poorly controlled epilepsy presented with generalized tonic-clonic seizures, followed by recurrent focal seizures that evolved into NCSE. This immediately recurred within 24 h of a prior episode of NCSE that was treated with IV ketamine. Considering her previous response, she was started again on an IV ketamine infusion, which successfully terminated NCSE. This time, enteral ketamine was gradually introduced while weaning off the IV formulation. Treatment with enteral ketamine was continued for 6 months and then tapered off. There was no recurrence of NCSE or seizures and no adverse events noted during the course of treatment.

Conclusion

This case supports the use of enteral ketamine as a potential adjunct to IV ketamine in the treatment of NCSE, especially in cases without coma. Introduction of enteral ketamine may reduce seizure recurrence, duration of stay in ICU, and morbidity associated with intubation.

Anesthetics and Outcome in Status Epilepticus: A Matched Two-Center Cohort Study

BACKGROUND

The use of anesthetics has been linked to poor outcome in patients with status epilepticus (SE). This association, however, may be confounded, as anesthetics are mostly administered in patients with more severe SE and critical illnesses.

OBJECTIVE

To minimize treatment-selection bias, we assessed the association between continuously administered intravenous anesthetic drugs (IVADs) and outcome in SE patients by a matched two-center study design.

METHODS

This cohort study was performed at the Johns Hopkins Bayview Medical Center, Baltimore, MD, USA and the University Hospital Basel, Basel, Switzerland. All consecutive adult SE patients from 2005 to 2013 were included. Odds ratios (ORs) for death and unfavorable outcome (Glasgow Outcome Score [GOS] 1-3) associated with administration of IVADs were calculated. To account for confounding by known outcome determinants (age, level of consciousness, worst seizure type, acute/fatal etiology, mechanical ventilation, and SE duration), propensity score matching and coarsened exact matching were performed in addition to multivariable regression models.

RESULTS

Among 406 consecutive patients, 139 (34.2%) were treated with IVADs. Logistic regression analyses of the unmatched and matched cohorts revealed increased odds for death and unfavorable outcome in survivors who had received IVADs (unmatched: OR_death = 3.13, 95% confidence interval [CI] 1.47-6.60 and OR_GOS1-3 = 2.51, 95% CI 1.37-4.60; propensity score matched: OR_death = 3.29, 95% CI 1.35-8.05 and OR_GOS1-3 = 2.27, 95% CI 1.02-5.06; coarsened exact matched: OR_death = 2.19, 95% CI 1.27-3.78 and OR_GOS1-3 = 3.94, 95% CI 2.12-7.32).

CONCLUSION

The use of IVADs in SE is associated with death and unfavorable outcome in survivors independent of known confounders and using different statistical approaches. Randomized trials are needed to determine if these associations are biased by outcome predictors not yet identified and hence not accounted for in this study.

Observed medical and surgical complications of prolonged barbiturate coma for refractory status epilepticus

BACKGROUND

Refractory status epilepticus is often treated with third-line therapy, such as pentobarbital coma. However, its use is limited by side effects. Recognizing and preventing major and minor adverse effects of prolonged pentobarbital coma may increase good outcomes. This study retrospectively reviewed direct and indirect medical and surgical pentobarbital coma.

METHODS

Retrospective chart review of all patients with refractory status epilepticus treated with pentobarbital over a 1 year period at a large tertiary care center. We collected baseline data, EEG data, and complications that were observed.

RESULTS

Overall, nine patients [median age 46.4 (IQR 21.7, 75.5) years] were induced with pentobarbital coma median 11 (IQR 3, 33) days after seizure onset for a median of 9 (IQR 3.5, 45.4) days. A total of four to eight concurrent antiepileptics were tried prior to the pentobarbital coma. Phenobarbital, due to recurrence of seizures on weaning pentobarbital coma, was required in seven patients. Observed complications included peripheral neuropathy (77.8%), cerebral atrophy (33.3%), volume overload (44.4%), renal/metabolic (77.8%), gastrointestinal (66.6%), endocrine (55.6%), cardiac/hemodynamic/vascular (77.8%), respiratory (100%), and infectious (77.8%). The number of complications trended with duration of induced coma but was nonsignificant. Median ICU length of stay was 40 (IQR 28, 97.5) days. Overall, five patients were able to follow commands after a median 37 (IQR 25.5, 90) days from coma onset. There were eight patients that were discharged from hospital with three remaining in a prolonged unresponsive state. There was one patient that died prior to discharge.

CONCLUSIONS

This study highlights the high morbidity in patients with refractory status epilepticus requiring pentobarbital coma. Anticipating and addressing the indirect and direct complications in prolonged pentobarbital coma may improve survival and functional outcomes in patients with refractory status epilepticus.

Nonconvulsive status epilepticus in adults - insights into the invisible

Nonconvulsive status epilepticus (NCSE) is a state of continuous or repetitive seizures without convulsions. Owing to the nonspecific symptoms and considerable morbidity and mortality associated with NCSE, clinical research has focused on early diagnosis, risk stratification and seizure termination. The subtle symptoms and the necessity for electroencephalographic confirmation of seizures result in under-diagnosis with deleterious consequences. The introduction of continuous EEG to clinical practice, and the characterization of electrographic criteria have delineated a number of NCSE types that are associated with different prognoses in several clinical settings. Epidemiological studies have uncovered risk factors for NCSE; knowledge of these factors, together with particular clinical characteristics and EEG observations, enables tailored treatment. Despite these advances, NCSE can be refractory to antiepileptic drugs, necessitating further escalation of treatment. The presumptive escalation to anaesthetics, however, has recently been questioned owing to an association with increased mortality. This Review compiles epidemiological, clinical and diagnostic aspects of NCSE, and considers current treatment options and prognosis.

Delays and Factors Related to Cessation of Generalized Convulsive Status Epilepticus

Introduction. This study was designed to identify the delays and factors related to and predicting the cessation of generalized convulsive SE (GCSE). Methods. This retrospective study includes 70 consecutive patients (>16 years) diagnosed with GCSE and treated in the emergency department of a tertiary hospital over 2 years. We defined cessation of SE stepwise using clinical seizure freedom, achievement of burst-suppression, and return of consciousness as endpoints and calculated delays for these cessation markers. In addition 10 treatment delay parameters and 7 prognostic and GCSE episode related factors were defined. Multiple statistical analyses were performed on their relation to cessation markers. Results. Onset-to-second-stage-medication (p = 0.027), onset-to-burst-suppression (p = 0.005), and onset-to-clinical-seizure-freedom (p = 0.035) delays correlated with the onset-to-consciousness delay. We detected no correlation between age, epilepsy, STESS, prestatus period, type of SE onset, effect of the first medication, and cessation of SE. Conclusion. Our study demonstrates that rapid administration of second-stage medication and early obtainment of clinical seizure freedom and burst-suppression predict early return of consciousness, an unambiguous marker for the end of SE. We propose that delays in treatment chain may be more significant determinants of SE cessation than the previously established outcome predictors. Thus, streamlining the treatment chain is advocated.

Can anesthetic treatment worsen outcome in status epilepticus?

Status epilepticus refractory to first-line and second-line antiepileptic treatments challenges neurologists and intensivists as mortality increases with treatment refractoriness and seizure duration. International guidelines advocate anesthetic drugs, such as continuously administered high-dose midazolam, propofol, and barbiturates, for the induction of therapeutic coma in patients with treatment-refractory status epilepticus. The seizure-suppressing effect of anesthetic drugs is believed to be so strong that some experts recommend using them after benzodiazepines have failed. Although the rationale for the use of anesthetic drugs in patients with treatment-refractory status epilepticus seems clear, the recommendation of their use in treating status epilepticus is based on expert opinions rather than on strong evidence. Randomized trials in this context are lacking, and recent studies provide disturbing results, as the administration of anesthetics was associated with poor outcome independent of possible confounders. This calls for caution in the straightforward use of anesthetics in treating status epilepticus. However, there are still more questions than answers, and current evidence for the adverse effects of anesthetic drugs in patients with status epilepticus remains too limited to advocate a change of treatment algorithms. In this overview, the rationale and the conflicting clinical implications of anesthetic drugs in patients with treatment-refractory status epilepticus are discussed, and remaining questions are elaborated. This article is part of a Special Issue entitled "Status Epilepticus".

Anesthetic drugs in status epilepticus: risk or rescue? A 6-year cohort study

OBJECTIVE

To evaluate the risks of continuously administered IV anesthetic drugs (IVADs) on the outcome of adult patients with status epilepticus (SE).

METHODS

All intensive care unit patients with SE from 2005 to 2011 at a tertiary academic medical care center were included. Relative risks were calculated for the primary outcome measures of seizure control, Glasgow Outcome Scale score at discharge, and death. Poisson regression models were used to control for possible confounders and to assess effect modification.

RESULTS

Of 171 patients, 37% were treated with IVADs. Mortality was 18%. Patients with anesthetic drugs had more infections during SE (43% vs 11%; p < 0.0001) and a 2.9-fold relative risk for death (2.88; 95% confidence interval 1.45-5.73), independent of possible confounders (i.e., duration and severity of SE, nonanesthetic third-line antiepileptic drugs, and critical medical conditions) and without significant effect modification by different grades of SE severity and etiologies. As IVADs were used after first- and second-line drugs failed, there was a correlation between treatment-refractory SE and the use of IVADs, leading to insignificant results regarding the risk of IVADs and outcome after additional adjustment for refractory SE.

CONCLUSION

Our findings heighten awareness regarding adverse effects of IVADs. Randomized controlled trials are needed to further clarify the association of IVADs with outcome in patients with SE.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that patients with SE receiving IVADs have a higher proportion of infection and an increased risk of death as compared to patients not receiving IVADs.

Outcome predictors for status epilepticus--what really counts

In adult patients with status epilepticus (SE)-a life-threatening state of ongoing or repetitive seizures--the current evidence regarding outcome prediction is based on clinical, biochemical and EEG determinants. These predictors of outcome involve clinical features such as age, history of prior seizures or epilepsy, SE aetiology, level of consciousness, and seizure type at SE onset. The clinical risk-benefit calculation between the danger of undertreated persistent seizure activity and, conversely, the potential damage from unwarranted aggressive treatments remains a constant challenge. Improved knowledge of outcome determinants, as well as increased availability of reliable outcome prediction models early in the course of SE, is paramount for optimization of treatment of patients who develop this disorder. In this Review, we discuss the major prognostic determinants of outcome in SE. Through consideration of studies that provide measures of association between predictors of SE outcome and death, we propose a detailed--but as yet unvalidated--paradigm for assessment of these predictors during the course of SE. Such an algorithm could guide the organization of results from existing trials and provide direction with regard to the parameters that should be monitored in future studies of SE.

Propofol infusion syndrome in refractory status epilepticus

BACKGROUND AND PURPOSE

Propofol is used for treating refractory status epilepticus, which has high rate of mortality. Propofol infusion syndrome is a rare but often fatal syndrome, characterized by lactic acidosis, lipidemia, and cardiac failure, associated with propofol infusion over prolonged periods of time. We investigated the clinical factors that characterize propofol infusion syndrome to know the risk of them in refractory status epilepticus.

METHODS

This retrospective observation study was conducted in Samsung medical center from Jan. 2005 to Dec. 2009. Thirty two patients (19 males, 13 females, aged between 16 and 64 years), with refractory status epilepsy were included. Their clinical findings and treatment outcomes were evaluated retrospectively. We divided our patients into established status epilepticus (ESE) and refractory status epilepticus (RSE). And then the patients with RSE was further subdivided into propofol treatment group (RSE-P) and the other anesthetics treatment group (RSE-O). We analyzed the clinical characteristics by comparison of the groups.

RESULTS

There were significant differences of hypotension and lipid change between ESE and RSE (p<0.05). However, there was no significant difference between RSE-P and RSE-O groups. The hospital days were longer in RSE than in ESE (p=0.012) and treatment outcome was also worse in RSE than in ESE (p=0.007) but there were no significant differences of hospital stays and treatment outcome between RSE-P and RSE-O.

CONCLUSIONS

RSE is very critical disease with high mortality, which may show as many clinical changes as propofol infusion syndrome. Therefore propofol infusion syndrome might be considered as one of the clinical manifestations of RSE.

Anesthetic management of a patient with Lennox-Gastaut syndrome with intractable epilepsy -a case report-

A 34-month-old female patient who had a prior history of generalized tonic-clonic seizures had been diagnosed with the Lennox-Gastuat syndrome. She was scheduled for epiblepharon repairs in both lower lids under general anesthesia. Preoperatively, her tonic seizure was poorly controlled with antiepileptic drugs. General anesthesia with thiopental and isoflurane was provided and the intraoperative course and the emergence of anesthesia were uneventful and smooth.

Third-line antiepileptic therapy and outcome in status epilepticus: the impact of vasopressor use and prolonged mechanical ventilation

OBJECTIVES

To characterize associations between antiepileptic drugs with sedating or anesthetic effects (third-line antiepileptic drugs) vs. other antiepileptic agents, and short-term outcomes, in status epilepticus. Furthermore, to evaluate the role of adverse hemodynamic and respiratory effects of these agents in status epilepticus treatment.

DESIGN

Retrospective comparative analysis.

SETTING

Tertiary academic medical center with two emergency departments and two neurologic intensive care units.

PATIENTS

Adults admitted with a diagnosis of status epilepticus defined as seizures lasting continuously >5 mins, or for discrete periods in succession.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 126 patients with 144 separate status epilepticus admissions, 57 were female (45%) with mean age 54.7 ± 15.7 yrs. Status epilepticus was convulsive in 132 cases (92%). Status epilepticus etiologies included subtherapeutic antiepileptic drugs (43%), alcohol or other nonantiepileptic drug (13%), and acute central nervous system disease (12%). Third-line antiepileptic drugs were administered in 47 cases (33%). Seventy-eight status epilepticus episodes (54%) had good outcomes (Glasgow Outcome Score = 1, 2) at the time of hospital discharge. On univariate analysis, poor outcome (Glasgow Outcome Score > 2) was associated with older age (mean 59.8 ± 15.5 vs. 50.5 ± 13.8 yrs, p < .001), acute central nervous system disease (21% vs. 4%, p = .001), mechanical ventilation (76% vs. 53%, p = .004), longer duration of ventilation (median 10 days [range 1-56] vs. 2 days [range 1-10], p < .001), treatment with vasopressors (35% vs. 5%, p < .001), and treatment with third-line antiepileptic drugs (51% vs. 17%, p < .001). Death was associated with acute central nervous system disease, prolonged ventilation, treatment with vasopressors, and treatment with third-line antiepileptic drugs. Predictors of poor outcome among all status epilepticus episodes were older age (odds ratio 1.06; 95% confidence interval 1.03-1.09; p < .001), treatment with third-line antiepileptic therapy (odds ratio 5.64; 95% confidence interval 2.31-13.75; p < .001), and first episode of status epilepticus (odds ratio 3.73; 95% confidence interval 1.38-10.10; p = .010). Among status epilepticus episodes treated by third-line antiepileptic drugs, predictors of poor outcome were older age (odds ratio, 1.09; 95% confidence interval 1.01-1.18; p = .038) and longer ventilation (odds ratio, 1.47; 95% confidence interval 1.08-2.00; p = .015). Predictors of mortality among all status epilepticus episodes were treatment with third-line antiepileptic drugs (odds ratio, 12.08; 95% confidence interval 2.30-63.39; p = .003) and older age (odds ratio, 1.06; 95% confidence interval 1.00-1.12; p = .045).

CONCLUSIONS

Third-line antiepileptic drug therapies with sedating or anesthetic effects predicted poor outcome and death in status epilepticus. Hypotension requiring vasopressor therapy and duration of mechanical ventilation induced by these agents may be contributing factors, especially when pentobarbital is used. These findings may inform decision making on drug therapy in status epilepticus and help develop safer and more effective treatment strategies to improve outcome.

Anaesthesia and epilepsy

Epilepsy is the most common serious neurological disorder, with a prevalence of 0.5-1% of the population. While the traditional antiepileptic drugs (AEDs) still play a significant role in treatment of seizures, there has been an influx of newer agents over the last 20 yr, which are now in common usage. Anaesthetists are frequently faced with patients with epilepsy undergoing emergency or elective surgery and patients suffering seizures and status epilepticus in the intensive care unit (ICU). This review examines perioperative epilepsy management, the mode of action of AEDs and their interaction with anaesthetic agents, potential adverse effects of anaesthetic agents, and the acute management of seizures and refractory status epilepticus on the ICU. Relevant literature was identified by a Pubmed search of epilepsy and status epilepticus in conjunction with individual anaesthetic agents.

Epilepsy and anesthesia

BACKGROUND AND OBJECTIVES

Epilepsy is one of the most frequent chronic neurological diseases. Although anesthesia for epilepsy patients is more common in neurosurgery, this group of patients needs, just as the general population, anesthesia for different diagnostic and therapeutic procedures. This article aims to address the issues of greatest interest to the anesthesiologist in the perioperative management of epileptic patients undergoing anesthesia for non-neurosurgical procedures.

CONTENT

We discuss relevant aspects of pathophysiology, classification and diagnosis of epilepsy; anticonvulsant therapy and interactions with anesthetic drugs; surgery and the ketogenic diet; pro-and anticonvulsant effects of drugs used in anesthesia; preoperative evaluation, intra- and postoperative conduct in epileptic patients, as well as the diagnosis and treatment of perioperative seizures.

CONCLUSIONS

In the perioperative management of epileptic patients is important for anesthesiologists to identify the type of epilepsy, the frequency, severity and the factors triggering the epileptogenic crises; the use of anticonvulsant drugs and possible interactions with drugs used in anesthesia; the presence of ketogenic diet and stimulatory of the vagus nerve, and its implications in anesthetic techniques. It is essential the understanding of pro- and anticonvulsant properties of drugs used in anesthesia, minimizing the risk of seizure activity in the intra- and postoperative. Finally, it is important to outline the diagnosis and initiate treatment of seizures, perioperative, which offers lower both morbidity and mortality.

Medical management of refractory status epilepticus

This review discusses the medical management of pediatric refractory status epilepticus, defined here as persistent seizures of any type after the administration of 2 appropriate anticonvulsants. The use of both nonanesthetic and anesthetic anticonvulsants is discussed along with the relative strengths and weaknesses of each agent. Appropriate treatment goals and the use of electroencephalographic monitoring are described as are reasonable treatment algorithms. Finally, ethical considerations are briefly discussed in the context of available outcome data.

Propofol for terminal sedation in palliative care: a systematic review

INTRODUCTION

We undertook a systematic review of published evidence of the effectiveness of propofol for terminal sedation. INCLUSIONS: Prospective or retrospective trials (controlled or uncontrolled) or case series of propofol for sedation in advanced incurable disease in either generalist setting or specialist palliative care units.

EXCLUSIONS

Use in anesthetic or intensivist settings (e.g., intensive care units); pediatric use. Identification of relevant studies: Using the search terms: [Hospice Care/OR Terminal Care/OR Palliative Care/OR palliative.mp] AND [Propofol/]. Studies were identified using a detailed search strategy from a number of electronic databases: Embase (1988-2005); MEDLINE (1966-2005) Cinahl (1982-2005), Cancerlit (1962-2005) The Cochrane Database of Systematic Reviews 2005 Issue 4. Hand searches of a number of palliative care journals were also undertaken (Palliative Medicine, Journal of Pain and Symptom Management, Progress in Palliative Care, Journal of Palliative Care, Journal of Palliative Medicine). No restriction was placed on the language of the original article.

RESULTS

Four articles--all case series or case reports--reporting generally favorable reports of the use of propofol as sedation for intractable symptoms in the last days of life especially when one or more other drugs have failed. Since these four articles are essentially hypothesis-generating, the article also discusses the possibility of the design of a clinical trial to compare propofol with other drugs used in this situation.

Propofol infusion syndrome in patients with refractory status epilepticus: an 11-year clinical experience

OBJECTIVES

Propofol is a sedative, anesthetic, and antiepileptic agent that is frequently used in patients with refractory status epilepticus. Propofol infusion syndrome is a feared complication of propofol use, especially at high infusion rates for prolonged periods. The present study describes the use of propofol and its associated complications in patients with refractory status epilepticus.

DESIGN

: Retrospective study with outcome assessment.

SETTING

Intensive care units at Mayo Clinic.

PATIENTS

Intensive care unit admissions with refractory status epilepticus.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A computer-assisted search identified 41 consecutive patients from January 1997 to September 2008 admitted to our intensive care unit with refractory status epilepticus, defined by the need for continuous intravenous infusion of anesthetic agents to control seizures. Propofol infusion syndrome was defined per previously published criteria. The study population consisted of 24 males and 17 females with a median age of 51 yrs (range, 0.25- 80). Propofol was used in 31 (76%) of these patients (propofol group), and other agents like midazolam, lorazepam, and pentobarbital were used in the other ten (24%) patients (nonpropofol group). Median hospital (12 days; range, 2-112) and intensive care unit length of stay (9 days; range, 2-95) did not differ among the two groups. Propofol was used for a median of 63 hrs (range, 2-391) with a median cumulative dosage of 12,750 mg (range, 336-57,545). The median peak infusion rate was 67 microg/kg/min (range, 19-200). There were three sudden unexplained cardiorespiratory arrests in the propofol group (3 of 31, 10%), of which two were fatal. These three patients were aged 37, 46, and 55 yrs and had no prior cardiopulmonary disease. Eleven additional patients (11 of 31, 35%) had non-life-threatening features of propofol infusion syndrome. There were no such events noted in the nonpropofol group.

CONCLUSIONS

The prolonged use of large doses of propofol to treat refractory status epilepticus was associated with significant mortality and morbidity.

[Anesthesia for procedures other than neurosurgery in the adult with epilepsy]

Epilepsy is a common disease affecting between 1% and 2% of the general population. The incidence increases with age. Given the complicated etiology and pathogenesis of this disease, epileptic patients of all ages may require anesthesia. The perioperative care of these patients involves a number of special considerations, although the main issues to deal with are pharmacologic. This review gives an overview of the etiopathogenesis and pathophysiology of epilepsy and describes the general characteristics of antiepileptic drug therapy. The anesthetic implications of chronic treatment with antiepileptic agents and the interactions between these drugs and common anesthetics are discussed in more detail.