Abstract
BackgroundThe general principles in the administration of anesthetic drugs entail not only the suppression of seizure activity but also the achievement of electroencephalography burst suppression (BS). However, previous studies have reported conflicting results, possibly owing to the inclusion of various anesthetic agents, not all patients undergoing continuous electroencephalography (cEEG), and the inclusion of anoxic encephalopathy. This study aimed to analyze the effects of midazolam-induced BS on the occurrence outcomes in refractory status epilepticus patients.MethodsBased on a prospective database of patients who had been diagnosed with status epilepticus via cEEG, multivariate Poisson regression modules were used to estimate the effect of midazolam-induced BS on breakthrough seizure, withdrawal seizure, intra-hospital complications, functional outcome at 3 months, and mortality. Modules were based on a pre-compiled directed acyclic graph (DAG).ResultsWe included 51 non-anoxic encephalopathy, refractory status epilepticus patients. Burst suppression was achieved in 26 patients (51%); 25 patients (49%) had non-burst suppression on their cEEG. Breakthrough seizure was less often seen in the burst suppression group than in the non-burst suppression group. The incidence risk ratio [IRR] was 0.30 (95% confidence interval = 0.13–0.74). There was weak evidence of an association between BS and increased withdrawal seizure, but no association between BS and intra-hospital complications, mortality or functional outcomes was observed.ConclusionThis study provides evidence that BS is safe and associated with less breakthrough seizures. Additionally, it was not associated with an increased rate of intra-hospital complications or long-term outcomes.
Highlights
The general principles in the administration of anesthetic drugs entail the suppression of seizure activity and the achievement of electroencephalography burst suppression (BS)
Midazolam is considered the first-line anesthetic drug for refractory status epilepticus as intensivists are familiar with its use in the management of agitated patients who are on a mechanical ventilator
We excluded 61 patients who responded to initial antiepileptic drugs, had Status epilepticus (SE) of an anoxic encephalopathy origin or received an anesthetic other than midazolam (Fig. 1)
Summary
The general principles in the administration of anesthetic drugs entail the suppression of seizure activity and the achievement of electroencephalography burst suppression (BS). Previous studies have reported conflicting results, possibly owing to the inclusion of various anesthetic agents, not all patients undergoing continuous electroencephalography (cEEG), and the inclusion of anoxic encephalopathy. This study aimed to analyze the effects of midazolam-induced BS on the occurrence outcomes in refractory status epilepticus patients. Refractory status epilepticus (RSE) is defined as status epilepticus that cannot be controlled with an adequate dose of first-line and second-line antiepileptic drugs [1]. Refractory status epilepticus develops in approximately 30–40% of patients with status epilepticus [1]. This condition is associated with progressively increasing intrahospital mortality ranging between 19 and 67% depending on the study [1, 2].
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