scholarly journals Early Combination Therapy of Ketamine and Midazolam in Patients with Refractory Status Epilepticus in Hemodynamic Unstable State

2021 ◽  
Vol 11 (2) ◽  
pp. 150-153
Author(s):  
Jung-Won Choi ◽  
Jung-Won Shin
Keyword(s):  
Status Epilepticus ◽  
Low Dose ◽  
Hemodynamic Instability ◽  
Systemic Circulation ◽  
Refractory Status Epilepticus ◽  
Unstable State ◽  
Concomitant Treatment ◽  
Refractory Status ◽  
Vasopressor Agents ◽  
Third Line

The use of anesthetics is inevitable to suppress seizure activity in refractory status epilepticus (RSE). Hypotension, which is a critical side effect observed when treating RSE using a higher dosage of anesthetics that enhance γ-aminobutyric acid (GABA) activity, often requires vasopressor agents. Concomitant treatment with N-methyl-D-aspartate (NMDA) receptor antagonists, such as ketamine, could be effective in prolonged refractory SE, while maintaining stable blood pressure owing to the blockage of catecholamine reuptake in the systemic circulation. We report two cases of patients who had RSE with hemodynamic instability treated promptly with an early combination of ketamine and low-dose midazolam. The combination treatment effectively suppressed epileptic discharge with less hemodynamic side effects; moreover, a low dose of midazolam was required when combined with ketamine therapy. The initial combination of a third-line therapy that blocks NMDA receptors with enhanced GABAergic activity could be useful in RSE. Further studies are necessary in many variable etiologies of SE.

scholarly journals Anesthetic Use In Status Epilepticus: A Concise Review

2020 ◽  
pp. 20-36
Author(s):  
Furkan M. Yilmaz ◽  
Lauren A. Igneri ◽  
Yasir A. Yilmaz ◽  
Evren Burakgazi-Dalkilic
Keyword(s):  
Status Epilepticus ◽  
Recent Literature ◽  
Refractory Status Epilepticus ◽  
Clinical Use ◽  
Concise Review ◽  
Refractory Status ◽  
Line Therapy ◽  
Agent Selection ◽  
Third Line Therapy ◽  
Third Line

The purpose of this review is to summarize the recent literature focusing on intravenous (IV) administration of commonly used anesthetics, including midazolam, pentobarbital/ thiopental, propofol, and ketamine in the treatment of status epilepticus (SE). Anesthetics should be reserved as third-line therapy for the treatment of SE when benzodiazepines and other second-line agents fail to terminate the seizure. We have reviewed the literature related to the treatment of status epilepticus, refractory status epilepticus, super-refractory status epilepticus, anesthetics, midazolam, pentobarbital/thiopental, propofol, and ketamine. This paper focuses on the pharmacology, dosages, major side effects, and clinical use of IV anesthetics in the treatment of SE with an emphasis on the developing literature supporting the use of ketamine for this indication. Based on the available literature, we propose recommendations for third-line agent selection in the management of SE.

scholarly journals Use of continuous ketamine infusion as an adjunctive agent in neonates and infants with refractory and super refractory status epilepticus

2021 ◽  
Author(s):  
Mackenzie N. DeVine ◽  
Sharon E. Gordon ◽  
Craig A. Press
Keyword(s):  
Status Epilepticus ◽  
Infusion Rate ◽  
Hemodynamic Instability ◽  
Refractory Status Epilepticus ◽  
Older Children ◽  
Safe Alternative ◽  
Ketamine Infusion ◽  
Young Infants ◽  
Refractory Status ◽  
Neonates And Infants

Abstract Background Continuous ketamine infusions have been studied as an adjunctive agent for refractory status epilepticus (RSE) and super refractory status epilepticus (SRSE) in older children and adults. However, minimal information exists on the efficacy, safety, and dosing for continuous ketamine in neonates and young infants. The purpose of our study was to review the safety and efficacy of continuous ketamine infusions in neonates and infants with RSE and super refractory status epilepticus (SRSE) at our institution. Methods Safety and clinical outcomes for neonates and infants who received continuous ketamine for RSE or SRSE at Children’s Hospital Colorado between June 2019 and June 2020 were retrospectively reviewed. Patients were included if they were less than or equal to 3 months of age and received continuous ketamine infusion for RSE defined as unresolved seizures despite administration of at least one first- and at least one second-line rescue medication or SRSE defined as unresolved seizures despite administration of third-line agents. Results We identified three patients who met inclusion criteria and received continuous ketamine infusion for RSE or SRSE during our study period. Patients included were refractory to an average of six anti-seizure medications prior to initiation of continuous ketamine infusion. Each patient was initiated on a continuous ketamine infusion rate of 1 mg/kg/hr with one patient requiring titration to a maximum of 6 mg/kg/hr. In one case, the concomitant use of continuous ketamine allowed for a reduction in benzodiazepine continuous infusion rate. In all cases, ketamine was well tolerated especially in the setting of hemodynamic instability. Conclusion Ketamine may provide a safe alternative in the acute setting in severe RSE and SRSE, especially in the setting of hemodynamic instability. This is the first small retrospective study to document the use of continuous ketamine as a treatment modality in neonates and infants with RSE or SRSE secondary to various underlying etiologies without adverse events.

scholarly journals Ketamine Infusion for Super Refractory Status Epilepticus in Alternating Hemiplegia of Childhood

2020 ◽  
Vol 51 (03) ◽  
pp. 225-228 ◽  
Author(s):  
Debopam Samanta
Keyword(s):  
Status Epilepticus ◽  
Neurodevelopmental Disorder ◽  
Refractory Status Epilepticus ◽  
Human Case ◽  
The Body ◽  
Gabaergic Interneuron ◽  
Ketamine Infusion ◽  
Alternating Hemiplegia Of Childhood ◽  
Refractory Status ◽  
Third Line

AbstractAlternating hemiplegia of childhood (AHC) is a rare neurodevelopmental disorder and characterized by infantile onset hemiplegia involving either side of the body and other paroxysmal spells, including epilepsy. The N-methyl-D-aspartate (NMDA) receptor noncompetitive antagonist ketamine has been proved to be effective terminating status epilepticus (SE) in animal models and human case studies. Less than 50 cases, those use ketamine, have been reported in the management of pediatric SE, but its effectiveness is unknown in patients with AHC. The author reported two patients with molecularly confirmed AHC who presented with super refractory status epilepticus. These two patients failed multiple antiepileptic drugs, including midazolam infusion and propofol but responded promptly to ketamine infusion. This is the first description of the effectiveness of ketamine as an effective third-line agent for super refractory SE associated with AHC. Increased glutamate-mediated neurotoxicity can be present in AHC, not only due to overexpression of glutamate receptors during status epilepticus but also due to unique characteristics of AHC-preferential inactivity of GABAergic interneuron and impaired action of glutamate transporters (EAAT-1). Moreover, as neuroregression is possible after SE in AHC, earlier termination of SE by using ketamine can be an effective option in this population. Further prospective, controlled studies are needed to confirm the finding of this study.

scholarly journals New-Onset Refractory Status Epilepticus: More Investigations, More Questions

2016 ◽  
Vol 8 (2) ◽  
pp. 127-133 ◽  
Author(s):  
Philippe Dillien ◽  
Susana Ferrao Santos ◽  
Vincent van Pesch ◽  
Vanessa Suin ◽  
Sophie Lamoral ◽  
...  
Keyword(s):  
Status Epilepticus ◽  
Immune Therapy ◽  
Healthy Woman ◽  
Refractory Status Epilepticus ◽  
Refractory Status ◽  
The Status ◽  
Third Line Therapy ◽  
High Doses ◽  
Third Line ◽  
New Onset

A 27-year-old previously healthy woman was admitted to the hospital with recurrent seizures. Status epilepticus developed that became refractory to third-line therapy with propofol and barbiturates. The patient had a very extensive diagnostic workup including autoimmune, viral and genetic investigations. A tentative immune therapy was proposed with high doses of steroids and plasma exchanges. Our patient had an inherited heterozygous single nucleotide variant in the sequence c.1280A>G [p.Lys427Arg] of the SMC3 gene that was insufficient to explain the seizures. Surprisingly, IgM antibodies against Japanese encephalitis virus were positive on the serum drawn 11 days after symptom onset, as detected by ELISA and the immunofluorescence antibody (IFA) technique. IgG antibodies were also positive using the IFA technique, but not with ELISA. The same investigations as well as the detection of the viral genome by the q-RT-PCR technique were negative on cerebrospinal fluid. Despite the suspicion of a viral infection, we concluded that our patient had a new-onset refractory status epilepticus of cryptogenic origin. Termination of the status epilepticus was obtained after 47 days, with a possible benefit from the introduction of ketamine.

scholarly journals How to Help Your Patients Enroll in the New-Onset Refractory Status Epilepticus (NORSE) and Febrile Infection-Related Epilepsy Syndrome (FIRES) Family Registry, and Other Rare Epilepsy Registries

2021 ◽  
pp. 153575972199832
Author(s):  
Karnig Kazazian ◽  
Marissa Kellogg ◽  
Nora Wong ◽  
Krista Eschbach ◽  
Raquel Farias Moeller ◽  
...  
Keyword(s):  
Status Epilepticus ◽  
Refractory Status Epilepticus ◽  
Epilepsy Syndrome ◽  
Neurologic Disorder ◽  
Mortality And Morbidity ◽  
Refractory Status ◽  
Rigorous Research ◽  
Active Epilepsy ◽  
New Onset

New-onset refractory status epilepticus (NORSE) is a rare clinical presentation of refractory status epilepticus (RSE) that occurs in people without active epilepsy or preexisting neurologic disorder. Febrile infection-related epilepsy syndrome (FIRES) is a subcategory of NORSE. New-onset refractory status epilepticus/FIRES are becoming increasingly recognized; however, information pertaining to disease course, clinical outcomes, and survivorship remains limited, and mortality and morbidity are variable, but often high. The objective of the NORSE/FIRES Family Registry is to (1) provide an easily accessible and internationally available multilingual registry into which survivors or NORSE/FIRES surrogates or family members of people affected by NORSE/FIRES or their physicians can enter data in a systematic and rigorous research study from anywhere in the world where internet is available; and (2) to examine past medical history, outcomes, and quality of life for people affected by NORSE/FIRES.

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