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

Michael A Pizzi,William D Freeman,William O Tatum,Prasuna Kamireddi,Jerry J Shih,Daniel A Jackson

doi:10.1186/s40560-017-0248-6

Abstract

BackgroundNonconvulsive 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 presentationA 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.ConclusionThis 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.

Highlights

Nonconvulsive status epilepticus (NCSE) is a diagnosis that is often challenging and one that may progress to refractory NCSE
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

Summary

Conclusion

ASD medication management of refractory NCSE is debatable and should be tailored based on the condition of the patient at the time of presentation. Ketamine could be a better choice in refractory NCSE or subtle focal SE than other anesthetic agents, and its early initiation in the course of management may be considered with additional validation from a larger population. Though not currently indicated for NCSE, was beneficial as a maintenance therapy in our patient after controlling electrographic seizures with IV ketamine. This case and successful transitional regimen requires further support from prospective, controlled studies

Background

Discussion

Generalized slowing mixed delta and theta frequencies

Findings

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