Long‐term prognosis related to deep sedation in refractory status Epilepticus

ObjectiveTo better understand the heterogeneous population of patients with new-onset refractory status epilepticus (NORSE), we studied the most severe cases in patients who presented with new-onset super-refractory status epilepticus (NOSRSE).MethodsWe report a retrospective case series of 26 adults admitted to the Columbia University Irving Medical Center neurologic intensive care unit (NICU) from February 2009 to February 2016 with NOSRSE. We evaluated demographics, diagnostic studies, and treatment course. Outcomes were modified Rankin Scale score (mRS) at hospital discharge and most recent follow-up visit (minimum of 2 months post discharge), NICU and hospital length of stay, and long-term antiepileptic drug use.ResultsOf the 252 patients with refractory status epilepticus, 27/252 had NORSE and 26/27 of those had NOSRSE. Age was bimodally distributed with peaks at 27 and 63 years. The majority (96%) had an infectious or psychiatric prodrome. Etiology was cryptogenic in 73%, autoimmune in 19%, and infectious in 8%. Seven patients (27%) underwent brain biopsy, autopsy, or both; 3 (12%) were diagnostic (herpes simplex encephalitis, candida encephalitis, and acute demyelinating encephalomyelitis). On discharge, 6 patients (23%) had good or fair outcome (mRS 0–3). Of the patients with long-term follow-up data (median 9 months, interquartile range 2–22 months), 12 patients (71%) had mRS 0–3.ConclusionAmong our cohort, nearly all patients with NORSE had NOSRSE. The majority were cryptogenic with few antibody-positive cases identified. Neuropathology was diagnostic in 12% of cases. Although only 23% of patients had good or fair outcome on discharge, 71% met these criteria at follow-up.

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Determinants of mortality and long-term outcome in children with refractory and super refractory status epilepticus

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2021.12.030 ◽

2022 ◽

Vol 97 ◽

pp. 12-16

Author(s):

Sita Jayalakshmi ◽

Anuja Patil ◽

Anusha Challa ◽

Mihir Parekh ◽

Harsh Khandelia ◽

...

Keyword(s):

Status Epilepticus ◽

Refractory Status Epilepticus ◽

Term Outcome ◽

Long Term Outcome ◽

Refractory Status

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Long-term risk of chronic epilepsy in adults after post-anoxic coma and refractory status epilepticus: a retrospective cohort study

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2020-324767 ◽

2020 ◽

pp. jnnp-2020-324767

Author(s):

Lorenzo Tinti ◽

Simone Beretta ◽

Anna Coppo ◽

Elisa Bianchi ◽

Clara Zanchi ◽

...

Keyword(s):

Cohort Study ◽

Status Epilepticus ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Refractory Status Epilepticus ◽

Chronic Epilepsy ◽

Refractory Status ◽

Anoxic Coma

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Updates in Refractory Status Epilepticus

Critical Care Research and Practice ◽

10.1155/2018/9768949 ◽

2018 ◽

Vol 2018 ◽

pp. 1-19 ◽

Cited By ~ 4

Author(s):

Rohit Marawar ◽

Maysaa Basha ◽

Advait Mahulikar ◽

Aaron Desai ◽

Kushak Suchdev ◽

...

Keyword(s):

Status Epilepticus ◽

Treatment Options ◽

Neurological Status ◽

Refractory Status Epilepticus ◽

Focal Lesion ◽

Long Term Outcomes ◽

Refractory Status ◽

Autoimmune Etiology ◽

New Onset

Refractory status epilepticus is defined as persistent seizures despite appropriate use of two intravenous medications, one of which is a benzodiazepine. It can be seen in up to 40% of cases of status epilepticus with an acute symptomatic etiology as the most likely cause. New-onset refractory status epilepticus (NORSE) is a recently coined term for refractory status epilepticus where no apparent cause is found after initial testing. A large proportion of NORSE cases are eventually found to have an autoimmune etiology needing immunomodulatory treatment. Management of refractory status epilepticus involves treatment of an underlying etiology in addition to intravenous anesthetics and antiepileptic drugs. Alternative treatment options including diet therapies, electroconvulsive therapy, and surgical resection in case of a focal lesion should be considered. Short-term and long-term outcomes tend to be poor with significant morbidity and mortality with only one-third of patients reaching baseline neurological status.

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Potential Consequences of High-Dose Infusion of Ketamine for Refractory Status Epilepticus: Case Reports and Systematic Literature Review

Anaesthesia and Intensive Care ◽

10.1177/0310057x1804600514 ◽

2018 ◽

Vol 46 (5) ◽

pp. 516-528 ◽

Cited By ~ 5

Author(s):

D. Golub ◽

A. Yanai ◽

K. Darzi ◽

J. Papadopoulos ◽

B. Kaufman

Keyword(s):

Systematic Review ◽

Metabolic Acidosis ◽

Status Epilepticus ◽

Literature Review ◽

Dose Range ◽

Refractory Status Epilepticus ◽

High Dose ◽

Ketamine Infusion ◽

Refractory Status

Our goal was to provide comprehensive data on the effectiveness of ketamine in refractory status epilepticus (RSE) and to describe the potential consequences of long-term ketamine infusion. Ketamine, an N-methyl D-aspartate (NMDA) receptor antagonist, blocks excitatory pathways contributing to ongoing seizure. While ketamine use is standard in anaesthetic induction, no definitive protocol exists for its use in RSE, and little is known about its adverse effects in long-term, high-dose administration. We present two cases of RSE that responded rapidly to ketamine infusion, both with fatal outcomes secondary to metabolic acidosis and cardiovascular collapse. We performed a systematic review of the application and consequences of ketamine use in RSE. PubMed, Ovid, MEDLINE and PMC were searched for articles describing ketamine treatment for RSE according to a predetermined search strategy and inclusion criteria. The systematic review revealed wide discrepancies in ketamine dosing (infusion maintenance dose range 0.0075–10.5 mg/kg/hour), but good outcomes in medically managed RSE (75% of studies reported moderate or complete seizure control in adults, 62.5% in paediatrics). Additionally, literature review elucidated a potentially causal relationship between prolonged ketamine infusion and both cardiovascular and metabolic dysregulation. Ketamine is effective in RSE by antagonising excitotoxic NMDA receptors. However, there is high variability in ketamine dosing and scarce data on its safety in long-term infusion. Metabolic acidosis and haemodynamic instability associated with the use of long-term, high-dose ketamine infusions must be of concern to clinicians administering ketamine to critically ill patients.

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