Abstract

IntroductionSeizures refractory to third-line therapy are also labeled super-refractory status epilepticus (SRSE). These seizures are extremely difficult to control and associated with poor outcome. We aimed to characterize efficacy and side-effects of continuous infusions of pentobarbital (cIV-PTB) treating SRSE.MethodsWe retrospectively reviewed continuous electroencephalography (cEEG) reports for all adults with RSE treated with cIV-PTB between May 1997 and April 2010 at our institution. Patients with post-anoxic SE and those receiving cIV-PTB for reasons other than RSE were excluded. We collected baseline information, cEEG findings, side-effects and functional outcome at discharge and one year.ResultsThirty one SRSE patients treated with cIV-PTB for RSE were identified. Mean age was 48 years old (interquartile range (IQR) 28,63), 26% (N = 8) had a history of epilepsy. Median SE duration was 6.5 days (IQR 4,11) and the mean duration of cIV-PTB was 6 days (IQR 3,14). 74% (N = 23) presented with convulsive SE. Underlying etiology was acute symptomatic seizures in 52% (N = 16; 12/16 with encephalitis), remote 30% (N = 10), and unknown 16% (N = 5). cIV-PTB controlled seizures in 90% (N = 28) of patients but seizures recurred in 48% (N = 15) while weaning cIV-PTB, despite the fact that suppression-burst was attained in 90% (N = 28) of patients and persisted >72 hours in 56% (N = 17). Weaning was successful after adding phenobarbital in 80% (12/15 of the patients with withdrawal seizures). Complications during or after cIV-PTB included pneumonia (32%, N = 10), hypotension requiring pressors (29%, N = 9), urinary tract infection (13%, N = 4), and one patient each with propylene glycol toxicity and cardiac arrest. One-third (35%, N = 11) had no identified new complication after starting cIV-PTB. At one year after discharge, 74% (N = 23) were dead or in a state of unresponsive wakefulness, 16% (N = 5) severely disabled, and 10% (N = 3) had no or minimal disability. Death or unresponsive wakefulness was associated with catastrophic etiology (p = 0.03), but none of the other collected variables.ConclusionscIV-PTB effectively aborts SRSE and complications are infrequent; outcome in this highly refractory cohort of patients with devastating underlying etiologies remains poor. Phenobarbital may be particularly helpful when weaning cIV-PTB.

Highlights

  • Seizures refractory to third-line therapy are labeled super-refractory status epilepticus (SRSE)

  • Demographics During the study period, 147 patients presented with RSE, 21% (31/147) of whom fulfilled criteria for SRSE treated with cIV-PTB during continuous electroencephalography (cEEG)

  • Patients with RSE who did not progress to SRSE were older (odds ratio (OR) 0.96;CI 0.94-0.98), and more frequently had intracerebral hemorrhage

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Summary

Introduction

Seizures refractory to third-line therapy are labeled super-refractory status epilepticus (SRSE). Seizures do not respond to first- and second-line therapy in 9 to 40% [1,2,3,4] of patients with status epilepticus (SE) This condition, known as refractory status epilepticus (RSE), is associated with high morbidity [3,4,5,6] and is typically treated with anesthetic agents such as midazolam or propofol [7]. Among these patients, 10 to 15% [4] fail to respond to third-line therapy, and are considered to have super-refractory SE (SRSE) [8]. We aimed to assess the efficacy of cIV-PTB in terminating seizures, the occurrence of withdrawal seizures, and the safety of using cIV-PTB in the modern era of ICU care

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