Abstract
Status Epilepticus (SE) is a medical emergency, due to significant morbidity and mortality. In the Intensive Care Unit (ICU) there are two groups of patients with SE: patients with multiple episodes of seizures that are non-responsive to initial management and there are individuals admitted for other reasons who developed non convulsive status epilepticus (NCSE) subclinical ictal episodes in their ICU permanence.
It is estimated NCSE represents between 25-50% of the SE, but in the critically-ill patient this entity could have a greater incidence. 10 to 40% of all patients with SE evolve to a refractory status epilepticus (RSE).
Refractory status epilepticus (RSE) is defined as the absence of response to a first-line antiepileptic drug (benzodiazepines) and to one or two second-line drugs. Control of RSE demands the use of multiple anticonvulsant drugs (AED), high-dose sedatives, and sometimes vasopressive or mechanical ventilatory support.
RSE management is based on case reports and experience from referral centers. It is recommended that the elimination of electrographic ictal activity is conducted through sedation, reaching a pharmacological burst-suppression pattern; a less aggressive alternative is suggested, without sedation, using antiepileptic medication in high-doses, in a step-up approach, guided by the improvement observed through cVEEG monitoring.
The purpose of this study is to present recommendations for management of RSE in critically ill patients based on current literature and experience in the ICU of the Neurological Institute of Antioquia (INDEA).
References
Abou Khaled KJ, Hirsch LJ. Updates in the management of seizures and status epilepticus in critically ill patients. Neurol Clin. 2008;26:385-408.
Arif H, Hirsch LJ. Treatment of status epilepticus. Semin Neurol. 2008;28:342-54.
Chen JW, Wasterlain CG. Status epilepticus: pathophysiology and management in adults. Lancet Neurol 2006;5:246-56.
Mirski MA, Varelas PN. Seizures and status epilepticus in the critically ill. Crit Care Clin. 2008;24:115-47, ix.
DeLorenzo RJ, Waterhouse EJ, Towne AR, Boggs JG, Ko D, DeLorenzo GA, Brown A, Garnett L. Persistent Nonconvulsive Status Epilepticus After the Control of Convulsive Status Epilepticus. Epilepsia 1998;39:833-840.
Towne AR, Waterhouse EJ, Boggs JG, Garnett LK, Brown AJ, Smith JR Jr, DeLorenzo RJ. Prevalence of nonconvulsive status epilepticus in comatose patients. Neurology 2000;54:340-345.
Claassen J, Mayer SA, Kowalski RG, et al. Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology 2004;62:1743-1748.
Jordan KG. Continuous EEG and evoked potential monitoring in the neuroscience intensive care unit. J Clin Neurophysiol. 1993;10:445-475.
Maganti R, Gerber P, Drees C, Chung S. Nonconvulsive status epilepticus. Epilepsy Behav. 2008;12:572-586.
Fernández-Torre JL. Estado epiléptico no convulsivo en adultos en coma. Rev Neurol 2010;50:300-308.
Bauer G, Trinka E. Nonconvulsive status epilepticus and coma. Epilepsia 2010;51:177-90.
Friedman D, Claassen J, Hirsch LJ. Continuous electroencephalogram monitoring in the intensive care unit. Anesth Analg. 2009;109:506-523.
Abend NS, Dlugos DJ, Hahn CD, Hirsch LJ, Herman ST. Use of EEG Monitoring and Management of Non-Convulsive Seizures in Critically Ill Patients: A Survey of Neurologists. Neurocrit Care. 2010;12:382-389.
Mark L. Scheuer, Continuous EEG Monitoring in the Intensive Care Unit. Epilepsia 2002;43:114-127.
Claassen J, Hirsch LJ, Emerson RG, Mayer SA. Treatment of Refractory Status Epilepticus with Pentobarbital, Propofol or Midazolam: A Systematic Review. Epilepsia 2002;43:146-153.
Lowenstein D. The Management of Refractory Status Epilepticus: An Update. Epilepsia 2006;47(Suppl 1):35-40.
Holtkamp M, Masuhr F, Harms L, Einhäupl KM, Meierkord H, Buchheim K. The management of refractory generalised convulsive and complex partial status epilepticus in three European countries: a survey among epileptologists and critical care neurologists. J Neurol Neurosurg Psychiatry 2003;74:1095-1099.
Kälviäinen R, Eriksson K, Parviainen I. Refractory Generalised Convulsive Status Epilepticus. A Guide to Treatment. CNS Drugs 2005; 19: 759-768.
Kelso ARC, Cock HR. Status epilepticus. Pract Neurol 2005;5:322-333.
Meierkord H, Boon P, Engelsen B, Göcke K, Shorvon S, Tinuper P, Holtkamp M. EFNS guideline on the management of status epilepticus in adults. Eur J Neurol 2010;17:348-355.
Jordan KG, Hirsch LJ. In Nonconvulsive Status Epilepticus (NCSE), Treat to Burst-Suppression: Pro and Con. Epilepsia 2006; 47(Suppl 1):41-5.
Rossetti AO, Reichhart MD, Schaller MD, Despland PA, Bogousslavsky J. Propofol treatment of refractory status epilepticus: a study of 31 episodes. Epilepsia. 2004;45:757-763.
Mayer SA, Claassen J, Lokin J, Mendelsohn F, Dennis LJ, Fitzsimmons BF. Refractory Status Epilepticus. Frequency, Risk Factors, and Impact on Outcome. Arch Neurol. 2002;59:205-210.
Rossetti AO, Logroscino G, Bromfield EB. Refractory Status Epilepticus Effect of Treatment Aggressiveness on Prognosis. Arch Neurol. 2005;62:1698-1702.
Drislane FW, Lopez MR, Blum AS, Schomer DL. Detection and Treatment of Refractory Status Epilepticus in the Intensive Care Unit. J Clin Neurophysiol 2008;25:181-186.
Abend NS, Dlugos DJ. Treatment of Refractory Status Epilepticus: Literature Review and a Proposed Protocol. Pediatr Neurol 2008;38:377-390.
Varelas PN. How I Treat Status Epilepticus in the Neuro-ICU. Neurocrit Care 2008;9:153-157.
Novy J, Logroscino G, Rossetti AO. Refractory status epilepticus: A prospective observational study. Epilepsia. 2010;51:251-256.
Tripathi M, Vibha D, Choudhary N, Prasad K, Srivastava MV, Bhatia R, Chandra SP. Management of refractory status epilepticus at a tertiary care centre in a developing country. Seizure 2010;19:109-111.
Sinha S, Prashantha DK, Thennarasu K, Umamaheshwara Rao GS, Satishchandra P. Refractory status epilepticus: a developing country perspective. J Neurol Sci. 2010;15(290):60-65.
Young GB, Jordan KG, Doig GS. An assessment of nonconvulsive seizures in the intensive care unit using continuous EEG monitoring: an investigation of variables associated with mortality. Neurology 1996;47:83-89.
Chong DJ, Hirsch LJ. Which EEG patterns warrant treatment in the critically ill? Reviewing the evidence for treatment of periodic epileptiform discharges and related patterns. J Clin Neurophysiol 2005;22:79-91.
Vincent JL. Intensive Care Medicine. Annual update. Managing Critically Ill Patients with Status Epilepticus. 2008:822-836.
Rossetti AO, Logroscino G, Milligan TA, Michaelides C, Ruffieux C, Bromfield EB. Status Epilepticus Severity Score (STESS): a tool to orient early treatment strategy. J Neurol. 2008;255:1561-1566.
Patel NC, Landan IR, Levin J, Szaflarski J, Wilner AN. The use of levetiracetam in refractory status epilepticus. Seizure 2006;15:137-141.
Möddel G, Bunten S, Dobis C, Kovac S, Dogan M, Fischera M, Dziewas R, Schäbitz WR, Evers S, Happe S. Intravenous levetiracetam: a new treatment alternative for refractory status epilepticus. J Neurol. Neurosurg. Psychiatry 2009;80:689-692.
Knake S, Gruener J, Hattemer K, Klein KM, Bauer S, Oertel WH, Hamer HM, Rosenow F. Intravenous levetiracetam in the treatment of benzodiazepine refractory status epilepticus. J. Neurol. Neurosurg. Psychiatry 2008;79:588-589.
Towne AR, Garnett LK, Waterhouse EJ, Morton LD, DeLorenzo RJ. The use of topiramate in refractory status epilepticus. Neurology, 2003; 60:332-334.
Bensalem MK, Fakhoury TA. Topiramate and status epilepticus: report of three cases. Epilepsy Behav. 2003;4:757-760.
Soler B, Godoy J, Mellado Talesnik P. Treatment of refractory status epilepticus with topiramate. Report of three cases. Rev Med Chil. 2009;137:936-1139.
Koubeissi MZ, Amina S, Pita I, Bergey GK, Werz MA. Tolerability and efficacy of oral loading of levetiracetam. Neurology 2008;70:2166-2170.
Drislane FW, Blum AS, Lopez MR, Gautam S, Schomer DL. Duration of refractory status epilepticus and outcome: Loss of prognostic utility after several hours. Epilepsia 2009;50:1566-1571.
Cooper AD, Britton JW, Rabinstein AA. Functional and cognitive outcome in prolonged refractory status epilepticus. Arch Neurol. 2009;66:1505-1509.
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