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Turcato G, Giovannini G, Lattanzi S, Orlandi N, Turchi G, Zaboli A, Brigo F, Meletti S. The Role of Early Intubation in Status Epilepticus with Out-of-Hospital Onset: A Large Prospective Observational Study. J Clin Med 2024; 13:936. [PMID: 38398250 PMCID: PMC10889680 DOI: 10.3390/jcm13040936] [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: 12/21/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Background: this study aimed to evaluate the role of early airway management and intubation in status epilepticus (SE) with out-of-hospital onset. Methods: We included all patients with out-of-hospital SE onset referred to the emergency department of the Academic Hospital of Modena between 2013 and 2021. Patients were compared according to out-of-hospital airway management (intubation versus non-intubation) and a propensity score was performed for clinical variables unevenly distributed between the two groups. Results: We evaluated 711 patients with SE. A total of 397 patients with out-of-hospital SE onset were eventually included; of these, 20.4% (81/397) were intubated before arrival at the hospital. No difference was found in the clinical characteristics of patients after propensity score matching. The 30-day mortality in the propensity group was 19.4% (14/72), and no difference was found between intubated (7/36, 19.4%) and non-intubated (7/36, 19.4%) patients. No difference was found in SE cessation. Compared to non-intubated patients, those who underwent out-of-hospital intubation had a higher risk of progression to refractory or super-refractory SE, greater worsening of mRS values between hospital discharge and admission, and lower probability of returning to baseline condition at 30 days after SE onset. Conclusions: Early intubation for out-of-hospital SE onset is not associated with improved patient survival even after balancing for possible confounders. Further studies should evaluate the timing of intubation and its association with first-line treatments for SE and their efficacy. In addition, they should focus on the settings and the exact reasons leading to intubation to better inform early management of SE with out-of-hospital onset.
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Affiliation(s)
- Gianni Turcato
- Department of Internal Medicine, Hospital of Santorso (AULSS-7), 36014 Santorso, Italy;
| | - Giada Giovannini
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, 41124 Modena, Italy; (G.G.); (G.T.); (S.M.)
- PhD Programm in Clinical and Experimental Medicine, University of Modena and Reggio-Emilia, 41121 Modena, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Niccolò Orlandi
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, 41124 Modena, Italy; (G.G.); (G.T.); (S.M.)
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia, 41121 Modena, Italy
| | - Giulia Turchi
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, 41124 Modena, Italy; (G.G.); (G.T.); (S.M.)
| | - Arian Zaboli
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), 39010 Bolzano, Italy
| | - Francesco Brigo
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), 39010 Bolzano, Italy
| | - Stefano Meletti
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, 41124 Modena, Italy; (G.G.); (G.T.); (S.M.)
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia, 41121 Modena, Italy
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Fisch U, Jünger AL, Baumann SM, Semmlack S, De Marchis GM, Rüegg SJ, Hunziker S, Marsch S, Sutter R. Association Between Dose Escalation of Anesthetics and Outcomes in Patients With Refractory Status Epilepticus. Neurology 2024; 102:e207995. [PMID: 38165316 DOI: 10.1212/wnl.0000000000207995] [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: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate the association between dose escalation of continuously administered IV anesthetics and its duration with short-term outcomes in adult patients treated for refractory status epilepticus (RSE). METHODS Clinical and electroencephalographic data of patients with RSE without hypoxic-ischemic encephalopathy who were treated with anesthetics at a Swiss academic medical center from 2011 to 2019 were assessed. The frequency of anesthetic dose escalation (i.e., dose increase) and its associations with in-hospital death or return to premorbid neurologic function were primary endpoints. Multivariable logistic regression analysis was performed to identify associations with endpoints. RESULTS Among 111 patients with RSE, doses of anesthetics were escalated in 57%. Despite patients with dose escalation having a higher morbidity (lower Glasgow Coma Scale [GCS] score at status epilepticus [SE] onset, more presumably fatal etiologies, longer duration of SE and intensive care, more infections, and arterial hypotension) as compared with patients without, the primary endpoints did not differ between these groups in univariable analyses. Multivariable analyses revealed decreased odds for death with dose escalation (odds ratio 0.09, 95% CI 0.01-0.86), independent of initial GCS score, presumably fatal etiology, SE severity score, SE duration, and nonconvulsive SE with coma, with similar functional outcome among survivors compared with patients without dose escalation. DISCUSSION Our study reveals that anesthetic dose escalation in adult patients with RSE is associated with decreased odds for death without increasing the proportion of surviving patients with worse neurofunctional state than before RSE. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that anesthetic dose escalation decreases the odds of death in patients with RSE.
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Affiliation(s)
- Urs Fisch
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Anja L Jünger
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sira M Baumann
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Saskia Semmlack
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Gian Marco De Marchis
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan J Rüegg
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sabina Hunziker
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Marsch
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Raoul Sutter
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
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Lattanzi S, Giovannini G, Orlandi N, Brigo F, Trinka E, Meletti S. How much refractory is 'refractory status epilepticus'? A retrospective study of treatment strategies and clinical outcomes. J Neurol 2023; 270:6133-6140. [PMID: 37587268 DOI: 10.1007/s00415-023-11929-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/29/2023] [Accepted: 08/09/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND AND PURPOSE This study aimed to evaluate whether differences in clinical outcomes exist according to treatments received and seizure activity resolution in patients with refractory status epilepticus (RSE). METHODS Consecutive episodes of non-hypoxic status epilepticus (SE) in patients ≥ 14 years old were included. Episodes of RSE were stratified in: (i) SE persistent despite treatment with first-line therapy with benzodiazepines and one second-line treatment with antiseizure medications (ASMs), but responsive to successive treatments with ASMs (RSE-rASMs); (ii) SE persistent despite treatment with first-line therapy with benzodiazepines and successive treatment with one or more second-line ASMs, but responsive to anesthetic drugs [RSE-rGA (general anesthesia)]. Study endpoints were mortality during hospitalization and worsening of modified Rankin Scale (mRS) at discharge. RESULTS Status epilepticus was responsive in 298 (54.1%), RSE-rASMs in 152 (27.6%), RSE-rGA in 46 (8.3%), and super-refractory (SRSE) in 55 (10.0%) out of 551 included cases. Death during hospitalization occurred in 98 (17.8%) and worsening of mRS at discharge in 287 (52.1%) cases. Multivariable analyses revealed increased odds of in-hospital mortality with RSE-rGA (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.27-7.35) and SRSE (OR 3.83, 95%. CI 1.73-8.47), and increased odds of worsening of mRS with RSE-rASMs (OR 2.06, 95% CI 1.28-3.31), RSE-rGA (OR 4.44, 95% CI 1.97-10.00), and SRSE (OR 13.81, 95% CI 5.34-35.67). CONCLUSIONS In RSE, varying degrees of refractoriness may be defined and suit better the continuum spectrum of disease severity and the heterogeneity of SE burden and prognosis.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy.
| | | | - Niccolò Orlandi
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Via Giardini, 1355, Ospedale Civile S. Agostino Estense, 41126, Modena, Italy
| | - Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, BZ, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
- Center for Cognitive Neuroscience, Salzburg, Austria
- Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy.
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Via Giardini, 1355, Ospedale Civile S. Agostino Estense, 41126, Modena, Italy.
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Peng W, Lu L, Wang P, Zhou Y, Xiong W, Li J, Tian L, Liu J, Tang Y, Wei J, Zhu C, Trinka E, Zhou D. The initial treatment in convulsive status epilepticus in China: A multi-center observational study. Epilepsy Res 2023; 197:107245. [PMID: 37864968 DOI: 10.1016/j.eplepsyres.2023.107245] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE To investigate the initial treatment of patients with convulsive status epilepticus (CSE) in a resource-limited region of China, and to discuss the difference of in-hospital outcomes and economic costs between those with guideline-recommended initial treatment and those without. METHODS In this retrospective study, we screened adult patients discharged with the diagnosis of CSE in four centers in west China. Individuals with different exposure to the initial drug were divided into benzodiazepine (BDZ) and non-BDZ group for outcome comparison. The primary outcomes were seizure control, and the ratio of patients who developed refractory SE. The secondary outcomes included in-hospital mortality, the modified Rankin Scale (mRS) score at discharge, in-hospital respiratory support rate, length, and cost of the stay. RESULTS Three-hundred and thirteen patients (127, 40.6% were women) with CSE were included. The median age was 43 (range 16-92). There were 152 (48.6%) patients initially treated with BDZ. Among the 36 who received midazolam as initial treatment, twenty-six received an insufficient dose. The other 116 (76.3%) patients in the BDZ group chose diazepam as initial treatment. Fifteen of them (12.9%) were treated underdose. In the non-BDZ group (161, 51.4%), antiseizure medications (ASMs) and/or coma-induced drugs were used as initial treatment. Among those initially administrated ASMs, intramuscular phenobarbital (38,37.6%) and valproate (46, 52.3%) were most frequently seen. There was a significant difference in the time latency to initial treatment and etiology between BDZ and non-BDZ group. The non-BDZ group reported a higher cessation rate after initial treatment compared to the BDZ group (P = 0.012). No significant difference in other primary and secondary outcomes. SIGNIFICANCE Non-adherence and underdosing of the initial treatment of SE were common in China. However, the non-BDZ group showed a better seizure control rate. The effect came from early aggressive medication, that is, the combination of ASMs and anesthesia. Non-BDZ group was not inferior to BDZs in terms of seizure control, the occurrence of in-hospital death, and poor outcome at discharge. More robust evidence is needed in developing settings when choosing the initial treatment.
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Affiliation(s)
- Wei Peng
- Department of Neurology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan, China
| | - Lu Lu
- Department of Neurology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan, China
| | - Peiyu Wang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan, China
| | - Yu Zhou
- Department of Neurology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan, China
| | - Weixi Xiong
- Department of Neurology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan, China
| | - Jinmei Li
- Department of Neurology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan, China
| | - Linyu Tian
- Department of Neurology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan, China
| | - Jie Liu
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yufeng Tang
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang 621000, China
| | - Jun Wei
- Department of Neurology, Yibin No.4 People's Hospital, Yibin, China
| | - Cairong Zhu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Member of European Reference Network EpiCARE, Paracelsus Medical University, Centre for Cognitive Neuroscience, Salzburg, Austria; Institute of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, UMIT, Hall in Tyrol, Austria; Neuroscience Institute, Christian Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Dong Zhou
- Department of Neurology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan, China.
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De Stefano P, Sutter R. Response: Letter to the editor regarding "Early timing of anesthesia in status epilepticus is associated with complete recovery: A 7-year retrospective two-center study". Epilepsia 2023; 64:2532-2533. [PMID: 37381082 DOI: 10.1111/epi.17703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/21/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Pia De Stefano
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Raoul Sutter
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
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Cagnotti G, Ferrini S, Di Muro G, Avilii E, Favole A, D’Angelo A. Duration of constant rate infusion with diazepam or propofol for canine cluster seizures and status epilepticus. Front Vet Sci 2023; 10:1247100. [PMID: 37675074 PMCID: PMC10478093 DOI: 10.3389/fvets.2023.1247100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/10/2023] [Indexed: 09/08/2023] Open
Abstract
Introduction Constant rate infusion (CRI) of benzodiazepines or propofol (PPF) is a therapeutic option for cluster seizures (CS) and status epilepticus (SE) in canine patients non-responding to first-line benzodiazepines or non-anesthetics. However, specific indications for optimal duration of CRI are lacking. The aim of this study was to determine the effect of duration of anesthetic CRI on outcome and length of hospital stay in dogs with refractory seizure activity of different etiology. Study design Open-label non-randomized clinical trial. Materials and methods Seventy-three client-owned dogs were enrolled. Two groups [experimental (EXP) vs. control (CTRL)] were compared. The EXP group received diazepam (DZP) or PPF CRI for 12 h (±1 h) and the CTRL group received DZP or PPF CRI for 24 h (±1 h) in addition to a standardized emergency treatment protocol identical for both study groups. The historical control group was made up of a population of dogs already reported in a previously published paper by the same authors. Favorable outcome was defined as seizure cessation after CRI, no seizure recurrence, and clinical recovery. Poor outcome was defined as seizure recurrence, death in hospital or no return to acceptable clinical baseline. Univariate statistical analysis was performed. Results The study sample was 73 dogs: 45 (62%) received DZP CRI and 28 (38%) received PPF CRI. The EXP group was 39 dogs (25 DZP CRI and 14 PPF CRI) and the CTRL group 34 dogs (20 DZP CRI and 14 PPF CRI). We found no statistically significant difference in outcomes between the groups. The median length of stay was 56 h (IQR, 40-78) for the ALL EXP group and 58.5 h (IQR, 48-74.5) for the ALL CTRL group (p = 0.8). Conclusion Even though a shorter DZP or PPF CRI duration was not associated with a worse outcome, the study failed to identify a clear superiority of shorter CRI duration on outcome or length of hospital stay in dogs with refractory seizure activity of different etiology.
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Affiliation(s)
- Giulia Cagnotti
- Department of Veterinary Sciences, University of Turin, Turin, Italy
| | - Sara Ferrini
- Department of Veterinary Sciences, University of Turin, Turin, Italy
| | - Giorgia Di Muro
- Department of Veterinary Sciences, University of Turin, Turin, Italy
| | - Eleonora Avilii
- Department of Veterinary Sciences, University of Turin, Turin, Italy
| | - Alessandra Favole
- Istituto Zooprofilattico del Piemonte, Liguria e Valle d’Aosta, Turin, Italy
| | - Antonio D’Angelo
- Department of Veterinary Sciences, University of Turin, Turin, Italy
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Baumann SM, De Stefano P, Kliem PSC, Grzonka P, Gebhard CE, Sarbu OE, De Marchis GM, Hunziker S, Rüegg S, Kleinschmidt A, Pugin J, Quintard H, Marsch S, Seeck M, Sutter R. Sex-related differences in adult patients with status epilepticus: a seven-year two-center observation. Crit Care 2023; 27:308. [PMID: 37543625 PMCID: PMC10403848 DOI: 10.1186/s13054-023-04592-6] [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: 06/26/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Conflicting findings exist regarding the influence of sex on the development, treatment, course, and outcome of status epilepticus (SE). Our study aimed to investigate sex-related disparities in adult SE patients, focusing on treatment, disease course, and outcome at two Swiss academic medical centers. METHODS In this retrospective study, patients treated for SE at two Swiss academic care centers from Basel and Geneva from 2015 to 2021 were included. Primary outcomes were return to premorbid neurologic function, death during hospital stay and at 30 days. Secondary outcomes included characteristics of treatment and disease course. Associations with primary and secondary outcomes were assessed using multivariable logistic regression. Analysis using propensity score matching was performed to account for the imbalances regarding age between men and women. RESULTS Among 762 SE patients, 45.9% were women. No sex-related differences were found between men and women, except for older age and lower frequency of intracranial hemorrhages in women. Compared to men, women had a higher median age (70 vs. 66, p = 0.003), had focal nonconvulsive SE without coma more (34.9% vs. 25.5%; p = 0.005) and SE with motor symptoms less often (52.3% vs. 63.6%, p = 0.002). With longer SE duration (1 day vs. 0.5 days, p = 0.011) and a similar proportion of refractory SE compared to men (36.9% vs. 36.4%, p = 0.898), women were anesthetized and mechanically ventilated less often (30.6% vs. 42%, p = 0.001). Age was associated with all primary outcomes in the unmatched multivariable analyses, but not female sex. In contrast, propensity score-matched multivariable analyses revealed decreased odds for return to premorbid neurologic function for women independent of potential confounders. At hospital discharge, women were sent home less (29.7% vs. 43.7%, p < 0.001) and to nursing homes more often (17.1% vs. 10.0%, p = 0.004). CONCLUSIONS This study identified sex-related disparities in the clinical features, treatment modalities, and outcome of adult patients with SE with women being at a disadvantage, implying that sex-based factors must be considered when formulating strategies for managing SE and forecasting outcomes.
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Affiliation(s)
- Sira M Baumann
- Clinic for Intensive Care Medicine, Department of Acute Care, University Hospital Basel, Basel, Switzerland
| | - Pia De Stefano
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
| | - Paulina S C Kliem
- Clinic for Intensive Care Medicine, Department of Acute Care, University Hospital Basel, Basel, Switzerland
| | - Pascale Grzonka
- Clinic for Intensive Care Medicine, Department of Acute Care, University Hospital Basel, Basel, Switzerland
| | - Caroline E Gebhard
- Clinic for Intensive Care Medicine, Department of Acute Care, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Oana E Sarbu
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical Faculty of the University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- Clinic for Intensive Care Medicine, Department of Acute Care, University Hospital Basel, Basel, Switzerland
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical Faculty of the University of Basel, Basel, Switzerland
| | - Andreas Kleinschmidt
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Medical Faculty of the University of Geneva, Geneva, Switzerland
| | - Jérôme Pugin
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
- Medical Faculty of the University of Geneva, Geneva, Switzerland
| | - Hervé Quintard
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
- Medical Faculty of the University of Geneva, Geneva, Switzerland
| | - Stephan Marsch
- Clinic for Intensive Care Medicine, Department of Acute Care, University Hospital Basel, Basel, Switzerland
- Medical Faculty of the University of Basel, Basel, Switzerland
| | - Margitta Seeck
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Medical Faculty of the University of Geneva, Geneva, Switzerland
| | - Raoul Sutter
- Clinic for Intensive Care Medicine, Department of Acute Care, University Hospital Basel, Basel, Switzerland.
- Department of Neurology, University Hospital Basel, Basel, Switzerland.
- Medical Faculty of the University of Basel, Basel, Switzerland.
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland.
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D'Anto J, Beuchat I, Rossetti AO, Novy J. Clonazepam Loading Dose in Status Epilepticus: Is More Always Better? CNS Drugs 2023; 37:523-529. [PMID: 37291410 PMCID: PMC10276784 DOI: 10.1007/s40263-023-01012-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Benzodiazepines are the first treatment line in status epilepticus (SE). Despite their well-established benefit, benzodiazepines are frequently underdosed with potential detrimental consequences. In some European countries, clonazepam (CLZ) is commonly used as the first line treatment. The aim of this study was to explore the correlation between CLZ loading doses and SE outcome. METHODS This study included a retrospective analysis of a prospective registry in Lausanne, Switzerland (CHUV Lausanne University Hospital), including all SE episodes treated between February 2016 and February 2021. Only adults (> 16 years old) were included with CLZ used as the first treatment line. Post-anoxic SE were excluded because of significant differences in physiopathology and prognosis. Patient characteristics, SE features, the validated SE severity score (STESS), and treatment characteristics were prospectively recorded. We considered loading doses of 0.015 mg/kg or higher (following commonly recommended loading doses) as high doses. We analyzed outcome in terms of number of treatment lines after the CLZ, proportion of refractory episodes, intubation for airways protection, intubation for SE treatment, and mortality. We performed univariable analyses to investigate the association between loading doses and clinical response. A multivariable stepwise backward binary logistic regression was applied for adjusting for potential confounders. Multivariable linear regression was similarly used to analyze CLZ dose as a continuous variable. RESULTS We collected 251 SE episodes in 225 adult patients. Median CLZ loading dose was 0.010 mg/kg. CLZ high doses were used in 21.9% of SE episodes (in 43.8% for > 80% of the high dose). Thirteen percent of patients with SE were intubated for airways control, while intubation was needed in 12.7% for SE treatment. High CLZ loading doses were independently associated with younger age (median 62 versus 68 years old, p = 0.002), lesser weight (65 kg versus 75 kg, p = 0.001) and more frequent intubation for airways protection (23% vs 11%, p = 0.013), but differing CLZ dose was not associated with any outcome parameter. CONCLUSION CLZ high doses were more frequently used for SE treatment in younger patients with healthy weight and were more often associated with intubation for airways protection, probably as an adverse event. Varying CLZ dose did not alter outcome in SE, raising the possibility that commonly recommended doses are above what is needed, at least in some patients. Our results suggest that CLZ doses in SE may be individualized depending on the clinical setting.
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Affiliation(s)
- Jennifer D'Anto
- Department of Internal Medicine, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Isabelle Beuchat
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Andrea O Rossetti
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Jan Novy
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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De Stefano P, Baumann SM, Grzonka P, Sarbu OE, De Marchis GM, Hunziker S, Rüegg S, Kleinschmidt A, Quintard H, Marsch S, Seeck M, Sutter R. Early timing of anesthesia in status epilepticus is associated with complete recovery: A 7-year retrospective two-center study. Epilepsia 2023; 64:1493-1506. [PMID: 37032415 DOI: 10.1111/epi.17614] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/07/2023] [Accepted: 04/07/2023] [Indexed: 04/11/2023]
Abstract
OBJECTIVE This study was undertaken to investigate the efficacy, tolerability, and outcome of different timing of anesthesia in adult patients with status epilepticus (SE). METHODS Patients with anesthesia for SE from 2015 to 2021 at two Swiss academic medical centers were categorized as anesthetized as recommended third-line treatment, earlier (as first- or second-line treatment), and delayed (later as third-line treatment). Associations between timing of anesthesia and in-hospital outcomes were estimated by logistic regression. RESULTS Of 762 patients, 246 received anesthesia; 21% were anesthetized as recommended, 55% earlier, and 24% delayed. Propofol was preferably used for earlier (86% vs. 55.5% for recommended/delayed anesthesia) and midazolam for later anesthesia (17.2% vs. 15.9% for earlier anesthesia). Earlier anesthesia was statistically significantly associated with fewer infections (17% vs. 32.7%), shorter median SE duration (.5 vs. 1.5 days), and more returns to premorbid neurologic function (52.9% vs. 35.5%). Multivariable analyses revealed decreasing odds for return to premorbid function with every additional nonanesthetic antiseizure medication given prior to anesthesia (odds ratio [OR] = .71, 95% confidence interval [CI] = .53-.94) independent of confounders. Subgroup analyses revealed decreased odds for return to premorbid function with increasing delay of anesthesia independent of the Status Epilepticus Severity Score (STESS; STESS = 1-2: OR = .45, 95% CI = .27-.74; STESS > 2: OR = .53, 95% CI = .34-.85), especially in patients without potentially fatal etiology (OR = .5, 95% CI = .35-.73) and in patients experiencing motor symptoms (OR = .67, 95% CI = .48-.93). SIGNIFICANCE In this SE cohort, anesthetics were administered as recommended third-line therapy in only every fifth patient and earlier in every second. Increasing delay of anesthesia was associated with decreased odds for return to premorbid function, especially in patients with motor symptoms and no potentially fatal etiology.
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Affiliation(s)
- Pia De Stefano
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Sira M Baumann
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Pascale Grzonka
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Oana E Sarbu
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical faculty of the University of Basel, Basel, Switzerland
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
| | - Andreas Kleinschmidt
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Medical faculty of the University of Geneva, Geneva, Switzerland
| | - Hervé Quintard
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
- Medical faculty of the University of Geneva, Geneva, Switzerland
| | - Stephan Marsch
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
| | - Margitta Seeck
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Medical faculty of the University of Geneva, Geneva, Switzerland
| | - Raoul Sutter
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
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10
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Fisch U, Jünger AL, Baumann SM, Semmlack S, De Marchis GM, Hunziker S, Rüegg S, Marsch S, Sutter R. Association Between Induced Burst Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus: A 9-Year Cohort Study. Neurology 2023; 100:e1955-e1966. [PMID: 36889924 PMCID: PMC10186226 DOI: 10.1212/wnl.0000000000207129] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/17/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate the frequency of induced EEG burst suppression pattern during continuous IV anesthesia (IVAD) and associated outcomes in adult patients treated for refractory status epilepticus (RSE). METHODS Patients with RSE treated with anesthetics at a Swiss academic care center from 2011 to 2019 were included. Clinical data and semiquantitative EEG analyses were assessed. Burst suppression was categorized as incomplete burst suppression (with ≥20% and <50% suppression proportion) or complete burst suppression (with ≥50% suppression proportion). The frequency of induced burst suppression and association of burst suppression with outcomes (persistent seizure termination, in-hospital survival, and return to premorbid neurologic function) were the endpoints. RESULTS We identified 147 patients with RSE treated with IVAD. Among 102 patients without cerebral anoxia, incomplete burst suppression was achieved in 14 (14%) with a median of 23 hours (interquartile range [IQR] 1-29) and complete burst suppression was achieved in 21 (21%) with a median of 51 hours (IQR 16-104). Age, Charlson comorbidity index, RSE with motor symptoms, the Status Epilepticus Severity Score and arterial hypotension requiring vasopressors were identified as potential confounders in univariable comparisons between patients with and without any burst suppression. Multivariable analyses revealed no associations between any burst suppression and the predefined endpoints. However, among 45 patients with cerebral anoxia, induced burst suppression was associated with persistent seizure termination (72% without vs 29% with burst suppression, p = 0.004) and survival (50% vs 14% p = 0.005). DISCUSSION In adult patients with RSE treated with IVAD, burst suppression with ≥50% suppression proportion was achieved in every fifth patient and not associated with persistent seizure termination, in-hospital survival, or return to premorbid neurologic function.
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Affiliation(s)
- Urs Fisch
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Anja L Jünger
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sira M Baumann
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Saskia Semmlack
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Gian Marco De Marchis
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sabina Hunziker
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Rüegg
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Marsch
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Raoul Sutter
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland.
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11
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Wagner AS, Baumann SM, Semmlack S, Frei AI, Rüegg S, Hunziker S, Marsch S, Sutter R. Comparing Patients With Isolated Seizures and Status Epilepticus in Intensive Care Units: An Observational Cohort Study. Neurology 2023; 100:e1763-e1775. [PMID: 36878696 PMCID: PMC10136011 DOI: 10.1212/wnl.0000000000206838] [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: 06/07/2022] [Accepted: 12/06/2022] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To assess the frequency of status epilepticus (SE) among seizing critically ill adult patients and to determine clinical differences between patients with isolated seizures and patients with SE in the intensive care unit (ICU). METHODS From 2015 to 2020, all consecutive adult ICU patients at a Swiss tertiary care center with isolated seizures or SE as reported by intensivists and/or consulting neurologists were identified by screening of all digital medical, ICU, and EEG records. Patients aged <18 years and patients with myoclonus due to hypoxic-ischemic encephalopathy but without seizures on EEG were excluded. The frequency of isolated seizures, SE, and clinical characteristics at seizure onset associated with SE were the primary outcomes. Uni- and multivariable logistic regression was performed to identify associations with the emergence of SE. RESULTS Among 404 patients with seizures, 51% had SE. Compared with patients with isolated seizures, patients with SE had a lower median Charlson Comorbidity Index (CCI) (3 vs 5, p < 0.001), fewer fatal etiologies (43.6% vs 80.5%, p < 0.001), higher median Glasgow coma scores (7 vs 5, p < 0.001), fever more frequently (27.5% vs 7.5%, p < 0.001), shorter median ICU and hospital stay (ICU: 4 vs 5 days, p = 0.039; hospital stay: 13 vs 15 days, p = 0.045), and recovered to premorbid function more often (36.8% vs 17%, p < 0.001). Multivariable analyses revealed decreased odds ratios (ORs) for SE with increasing CCI (OR 0.91, 95% CI 0.83-0.99), fatal etiology (OR 0.15, 95% CI 0.08-0.29), and epilepsy (OR 0.32, 95% CI 0.16-0.63). Systemic inflammation was an additional association with SE after excluding patients with seizures as the reason for ICU admission (ORfor CRP 1.01, 95% CI 1.00-1.01; ORfor fever 7.35, 95% CI 2.84-19.0). Although fatal etiologies and increasing CCI remained associated with low odds for SE after excluding anesthetized patients and hypoxic-ischemic encephalopathy, inflammation remained associated in all subgroups except patients with epilepsy. DISCUSSION Among all ICU patients with seizures, SE emerged frequently and seen in every second patient. Besides the unexpected low odds for SE with higher CCI, fatal etiology, and epilepsy, the association of inflammation with SE in the critically ill without epilepsy represents a potential treatment target and deserves further attention.
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Affiliation(s)
- Anna S Wagner
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sira M Baumann
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Saskia Semmlack
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Anja I Frei
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Rüegg
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sabina Hunziker
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Marsch
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Raoul Sutter
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland.
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12
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Byun JI. Management of convulsive status epilepticus: recent updates. ENCEPHALITIS 2023; 3:39-43. [PMID: 37469676 PMCID: PMC10295829 DOI: 10.47936/encephalitis.2022.00087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 10/31/2022] [Accepted: 11/15/2022] [Indexed: 07/21/2023] Open
Abstract
Convulsive status epilepticus (SE) is a medical emergency associated with high morbidity and mortality. Recently, clinical trials and meta-analyses investigating medical treatment of SE have been published. Benzodiazepine is well known as the first-line treatment for SE. Recent evidence suggests the equivalence of intravenous fosphenytoin, valproate, and levetiracetam for treatment of established SE. There is lack of evidence regarding treatment for refractory SE. Intravenous midazolam is commonly used, and recent evidence supports the use of ketamine. Additional studies are needed to improve the management of convulsive SE.
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Affiliation(s)
- Jung-Ick Byun
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
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13
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Sutter R, Jünger AL, Baumann SM, Grzonka P, De Stefano P, Fisch U. Balancing the risks and benefits of anesthetics in status epilepticus. Epilepsy Behav 2023; 138:109027. [PMID: 36496337 DOI: 10.1016/j.yebeh.2022.109027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/23/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE According to international guidelines, status epilepticus refractory to first- and second-line antiseizure medication should be treated with anesthetics. Therefore, continuously delivered intravenous midazolam, propofol, or barbiturates are recommended as third-line therapy. While electroencephalographically (EEG)-controlled titration of anesthetics to seizure termination or to the emergence of an EEG burst-suppression pattern makes sense, evidence of the efficacy and tolerability of such third-line treatment is limited and concerns regarding the risks of anesthesia remain. The lack of treatment alternatives and persistent international discord reflecting contradictory results from some studies leave clinicians on their own when deciding to escalate treatment. In this conference-accompanying narrative review, we highlight the challenges of EEG-monitored third-line treatment and discuss recent studies that examined earlier administration of anesthetics. RESULTS Based on the literature, maintaining continuous burst suppression is difficult despite the constant administration of anesthetics, and the evidence for burst suppression as an adequate surrogate target is limited by methodological shortcomings as acknowledged by international guidelines. In our Swiss cohort including 102 patients with refractory status epilepticus, burst suppression as defined by the American Clinical Neurophysiology Society's Critical Care EEG Terminology 2021 was established in only 21%. Besides case reports suggesting that rapid but short-termed anesthesia can be sufficient to permanently stop seizures, a study including 205 patients revealed that anesthesia as second-line treatment was associated with a shorter median duration of status epilepticus (0.5 versus 12.5 days, p < 0.001), median ICU (2 versus 5.5 days, p < 0.001) and hospital stay (8 versus 17 days, p < 0.001) with equal rates of complications when compared to anesthesia as third-line treatment. CONCLUSIONS Recent investigations have led to important findings and new insights regarding the use of anesthetics in refractory status epilepticus. However, numerous methodological limitations and remaining questions need to be considered when it comes to the translation into clinical practice, and, in consequence, call for prospective randomized studies. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- Raoul Sutter
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland; Department of Neurology, University Hospital Basel, Basel, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland.
| | - Anja L Jünger
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland; Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Sira M Baumann
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
| | - Pascale Grzonka
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
| | - Pia De Stefano
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland; EEG and Epilepsy Unit, Department of Clinical Neurosciences and Faculty of Medicine of Geneva, University Hospital of Geneva, Geneva, Switzerland
| | - Urs Fisch
- Department of Neurology, University Hospital Basel, Basel, Switzerland
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14
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Fisch U, Jünger AL, Hert L, Rüegg S, Sutter R. Therapeutically induced EEG burst-suppression pattern to treat refractory status epilepticus—what is the evidence? ZEITSCHRIFT FÜR EPILEPTOLOGIE 2022. [DOI: 10.1007/s10309-022-00539-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractCurrent guidelines advocate to treat refractory status epilepticus (RSE) with continuously administered anesthetics to induce an artificial coma if first- and second-line antiseizure drugs have failed to stop seizure activity. A common surrogate for monitoring the depth of the artificial coma is the appearance of a burst-suppression pattern (BS) in the EEG. This review summarizes the current knowledge on the origin and neurophysiology of the BS phenomenon as well as the evidence from the literature for the presumed benefit of BS as therapy in adult patients with RSE.
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15
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Jacq G, Chelly J, Quenot JP, Soulier P, Lesieur O, Beuret P, Holleville M, Bruel C, Bailly P, Sauneuf B, Sejourne C, Rigaud JP, Galbois A, Arrayago M, Plantefeve G, Stoclin A, Schnell D, Fontaine C, Perier F, Bougouin W, Pichon N, Mongardon N, Ledoux D, Lascarrou JB, Legriel S. Multicentre observational status-epilepticus registry: protocol for ICTAL. BMJ Open 2022; 12:e059675. [PMID: 35168989 PMCID: PMC8852755 DOI: 10.1136/bmjopen-2021-059675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Status epilepticus (SE) is a common life-threatening neurological emergency that can cause long-term impairments. Overall outcomes remain poor. Major efforts are required to clarify the epidemiology of SE and the determinants of outcomes, thereby identifying targets for improved management. METHODS AND ANALYSIS ICTAL Registry is a multicentre open cohort of critically ill patients with convulsive, non-convulsive or psychogenic non-epileptic SE. Observational methods are applied to collect uniform data. The goal of the ICTAL Registry is to collect high-quality information on a large number of patients, thereby allowing elucidation of the pathophysiological mechanisms involved in mortality and morbidity. The registry structure is modular, with a large core data set and the opportunity for research teams to create satellite data sets for observational or interventional studies (eg, cohort multiple randomised controlled trials, cross-sectional studies and short-term and long-term longitudinal outcome studies). The availability of core data will hasten patient recruitment to studies, while also decreasing costs. Importantly, the vast amount of data from a large number of patients will allow valid subgroup analyses, which are expected to identify patient populations requiring specific treatment strategies. The results of the studies will have a broad spectrum of application, particularly given the multidisciplinary approach used by the IctalGroup research network. ETHICS AND DISSEMINATION The ICTAL Registry protocol was approved by the ethics committee of the French Intensive Care Society (#CE_SRLF 19-68 and 19-68a). Patients or their relatives/proxies received written information to the use of the retrospectively collected and pseudonymised data, in compliance with French law. Prospectively included patients receive written consent form as soon as they recover decision-making competency; if they refuse consent, they are excluded from the registry. Data from the registry will be disseminated via conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT03457831.
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Affiliation(s)
- Gwenaelle Jacq
- Service de réanimation et unité de soins continus, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Jonathan Chelly
- Service de réanimation, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Toulon, France
| | | | - Pauline Soulier
- Service de réanimation, Groupe Hospitalier Sud Ile-de-France, Melun, France
| | - Olivier Lesieur
- Service de réanimation, Centre hospitalier de la Rochelle, La Rochelle, Nouvelle-Aquitaine, France
| | - Pascal Beuret
- Service de Réanimation et Soins Continus, Centre Hospitalier de Roanne, Roanne, Rhône-Alpes, France
| | | | - Cedric Bruel
- Service de réanimation, Groupe hospitalier Paris Saint Joseph, Paris, France
| | - Pierre Bailly
- Médecine Intensive Réanimation, CHU de Brest, Brest, France
| | - Bertrand Sauneuf
- Service de réanimation, Centre Hospitalier Louis Pasteur de Cherbourg, Cherbourg-Octeville, Basse-Normandie, France
| | | | - Jean Philippe Rigaud
- Service de réanimation, Centre Hospitalier de Dieppe, Dieppe, Haute-Normandie, France
| | - Arnaud Galbois
- Intensive Care Unit, Claude Galien Private Hospital, Quincy-sous-Senart, Île-de-France, France
| | - Marine Arrayago
- Department of Intensive Care, Cannes Hospital, Cannes, France
| | - Gaetan Plantefeve
- Service de Médecine Intensive Réanimation, Centre Hospitalier d'Argenteuil, Argenteuil, Île-de-France, France
| | | | - David Schnell
- Service de réanimation, Hospital Centre Angouleme, Angouleme, Poitou-Charentes, France
| | - Candice Fontaine
- Service de réanimation et unité de soins continus, Centre Hospitalier de Versailles, Le Chesnay, France
| | - François Perier
- Service de réanimation et unité de soins continus, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Wulfran Bougouin
- Intensive Care Unit, Jacques Cartier Private Hospital, Massy, France
| | - Nicolas Pichon
- Service de réanimation, Centre Hospitalier de Brive, Brive-la-Gaillarde, France
| | - Nicolas Mongardon
- Service de Médecine Intensive-Réanimation, Hôpital Henri Mondor, Creteil, Île-de-France, France
| | - Didier Ledoux
- Department of Intensive Care, University Hospital of Liege, Sart, Belgium
| | | | - Stephane Legriel
- Service de réanimation et unité de soins continus, Centre Hospitalier de Versailles, Le Chesnay, France
- University Paris-Saclay, UVSQ, INSERM, Team « PsyDev », CESP, Villejuif, France
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Lee JW. Only a Fine Line Separates Genius, Insanity, and Anesthetic Medication for Coma Induction in Status Epilepticus. Epilepsy Curr 2021; 21:424-426. [PMID: 34924848 PMCID: PMC8652327 DOI: 10.1177/15357597211041829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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