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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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Waris A, Asim M, Ullah A, Alhumaydhi FA. Various pharmacological agents in the pipeline against intractable epilepsy. Arch Pharm (Weinheim) 2024:e2400229. [PMID: 38767508 DOI: 10.1002/ardp.202400229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
Epilepsy is a noncommunicable chronic neurological disorder affecting people of all ages, with the highest prevalence in low and middle-income countries. Despite the pharmacological armamentarium, the plethora of drugs in the market, and other treatment options, 30%-35% of individuals still show resistance to the current medication, termed intractable epilepsy/drug resistance epilepsy, which contributes to 50% of the mortalities due to epilepsy. Therefore, the development of new drugs and agents is needed to manage this devastating epilepsy. We reviewed the pipeline of drugs in "ClinicalTrials. gov," which is the federal registry of clinical trials to identify drugs and other treatment options in various phases against intractable epilepsy. A total of 31 clinical trials were found regarding intractable epilepsy. Among them, 48.4% (15) are about pharmacological agents, of which 26.6% are in Phase 1, 60% are in Phase 2, and 13.3% are in Phase 3. The mechanism of action or targets of the majority of these agents are different and are more diversified than those of the approved drugs. In this article, we summarized various pharmacological agents in clinical trials, their backgrounds, targets, and mechanisms of action for the treatment of intractable epilepsy. Treatment options other than pharmacological ones, such as devices for brain stimulation, ketogenic diets, gene therapy, and others, are also summarized.
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Affiliation(s)
- Abdul Waris
- Department of Biomedical Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong
| | - Muhammad Asim
- Department of Neurosciences, City University of Hong Kong, Kowloon Tong, Hong Kong
- Centre for Regenerative Medicine and Health (CRMH), Hong Kong SAR
| | - Ata Ullah
- Department of Biomedical Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong
| | - Fahad A Alhumaydhi
- Department of Medical Laboratories, College of Applied Medical Sciences, Qassim University, Buraydah, Saudi Arabia
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Kuki I, Inoue T, Fukuoka M, Nukui M, Okuno H, Amo K, Otsuka Y, Ishikawa J, Rinka H, Ujiro A, Togawa M, Shiomi M, Okazaki S. Efficacy and safety of ketamine for pediatric and adolescent super-refractory status epilepticus and the effect of cerebral inflammatory conditions. J Neurol Sci 2024; 459:122950. [PMID: 38461760 DOI: 10.1016/j.jns.2024.122950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 02/22/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE To investigate the short-term benefits and adverse effects of ketamine in the treatment of pediatric and adolescent super-refractory status epilepticus (SRSE), with a focus on the inflammatory etiology. METHODS This retrospective observational cohort study included a consecutive series of 18 pediatric to adolescent patients with SRSE admitted between 2008 and 2023 and treated with ketamine. Seizure frequency per hour before and after ketamine administration and response rate were calculated. Neurological decline, catecholamine administration, and adverse effects were also assessed. The patients were divided into inflammatory and non-inflammatory etiology groups. RESULTS The median age at SRSE onset was 1 year 5 months (range: 11 days-24 years), and 78% of the patients were male individuals. The median duration of treatment was 7.5 days (interquartile range: 2.8-15.5 days). Fifteen (83%) patients achieved >50% seizure reduction. The median seizure frequency before and after ketamine treatment was 5.9 and 0.9, respectively, showing a significant reduction in seizure frequency (p < 0.0001). Ten patients had inflammatory etiologies including bacterial meningitis (n = 2), viral encephalitis (n = 3), and febrile infection related epilepsy syndrome (n = 5). The inflammatory etiology group required a longer treatment duration (p = 0.0453) and showed lower seizure reduction (p = 0.0264), lower response rate (p = 0.0044), and higher neurological decline (p = 0.0003) than the non-inflammatory etiology group. Three (17%) patients experienced transient adverse events requiring intervention within 24 h of initiating ketamine administration. CONCLUSIONS Ketamine administration was associated with fewer serious adverse events and a reduced seizure frequency. Additionally, inflammatory conditions may weaken the efficacy of ketamine in patients with SRSE.
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Affiliation(s)
- Ichiro Kuki
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan.
| | - Takeshi Inoue
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Masataka Fukuoka
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Megumi Nukui
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Hideo Okuno
- Department of Pediatric Emergency Medicine, Osaka City General Hospital, Osaka, Japan
| | - Kiyoko Amo
- Department of Pediatric Emergency Medicine, Osaka City General Hospital, Osaka, Japan
| | - Yasunori Otsuka
- Department of Intensive Care Medicine, Osaka City General Hospital, Osaka, Japan
| | - Junichi Ishikawa
- Department of Pediatric Emergency Medicine, Osaka City General Hospital, Osaka, Japan; Department of Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Hiroshi Rinka
- Department of Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Atushi Ujiro
- Department of Pediatrics, Medical Corporation ISEIKAI, ISEIKAI International General Hospital
| | - Masao Togawa
- Department of Pediatrics, Medical Corporation ISEIKAI, ISEIKAI International General Hospital
| | - Masashi Shiomi
- Department of Pediatrics, Aizenbashi Hospital, Osaka, Japan
| | - Shin Okazaki
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
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Almohaish S, Tesoro EP, Brophy GM. Status Epilepticus: An Update on Pharmacological Management. Semin Neurol 2024. [PMID: 38580318 DOI: 10.1055/s-0044-1785503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Status epilepticus (SE) is a neurological emergency that requires timely pharmacological therapy to cease seizure activity. The treatment approach varies based on the time and the treatment stage of SE. Benzodiazepines are considered the first-line therapy during the emergent treatment phase of SE. Antiseizure medicines such as phenytoin, valproic acid, and levetiracetam are recommended during the urgent treatment phase. These drugs appear to have a similar safety and efficacy profile, and individualized therapy should be chosen based on patient characteristics. Midazolam, propofol, pentobarbital, and ketamine are continuous intravenous infusions of anesthetic medications utilized in the refractory SE (RSE) period. The most efficacious pharmacotherapeutic treatments for RSE and superrefractory status epilepticus are not clearly defined.
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Affiliation(s)
- Sulaiman Almohaish
- Department of Pharmacy Practice, Clinical Pharmacy College, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Eljim P Tesoro
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
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Williams NC, Morgan LA, Friedman J, Siegler J. Ketamine Efficacy for Management of Status Epilepticus: Considerations for Prehospital Clinicians. Air Med J 2024; 43:84-89. [PMID: 38490790 DOI: 10.1016/j.amj.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/10/2023] [Accepted: 09/21/2023] [Indexed: 03/17/2024]
Abstract
Current first-line therapies for seizure management recommend benzodiazepines, which target gamma-aminobutyric acid type A channels to stop the seizure activity. However, seizures may be refractory to traditional first-line therapies, transitioning into status epilepticus and becoming resistant to gamma-aminobutyric acid type A augmenting drugs. Although there are other antiseizure medications available for clinicians to use in the intensive care unit, these options can be less readily available outside of the intensive care unit and entirely absent in the prehospital setting. Instead, patients frequently receive multiple doses of first-line agents with increased risk of hemodynamic or airway collapse. Ketamine is readily available in the prehospital setting and emergency department, has well-established antiseizure effects with a favorable safety profile, and is a drug often used for several other indications. This article aimed to explore the utilization of ketamine for seizure management in the prehospital setting, reviewing seizure pathophysiology, established treatment mechanisms of action and pharmacokinetics, and potential benefits of early ketamine use in status epilepticus.
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Affiliation(s)
| | - Lindsey A Morgan
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle, WA; Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA
| | | | - Jeffrey Siegler
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, MO
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Edelson JC, Edelson CV, Rockey DC, Morales AL, Chung KK, Robles MJ, Marowske JH, Patel AA, Edelson SFD, Subramanian SR, Gancayco JG. Randomized Controlled Trial of Ketamine and Moderate Sedation for Outpatient Endoscopy in Adults. Mil Med 2024; 189:313-320. [PMID: 35796486 DOI: 10.1093/milmed/usac183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/20/2022] [Accepted: 06/16/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Ketamine is an effective sedative agent in a variety of settings due to its desirable properties including preservation of laryngeal reflexes and lack of cardiovascular depression. We hypothesized that ketamine is an effective alternative to standard moderate sedation (SMS) regimens for patients undergoing endoscopy. MATERIALS AND METHODS We conducted a randomized controlled trial comparing ketamine to SMS for outpatient colonoscopy or esophagogastroduodenoscopy at Brooke Army Medical Center. The ketamine group received a 1-mg dose of midazolam along with ketamine, whereas the SMS group received midazolam/fentanyl. The primary outcome was patient satisfaction measured using the Patient Satisfaction in Sedation Instrument, and secondary outcomes included changes in hemodynamics, time to sedation onset and recovery, and total medication doses. RESULTS Thirty-three subjects were enrolled in each group. Baseline characteristics were similar. Endoscopies were performed for both diagnostic and screening purposes. Ketamine was superior in the overall sedation experience and in all analyzed categories compared to the SMS group (P = .0096). Sedation onset times and procedure times were similar among groups. The median ketamine dose was 75 mg. The median fentanyl and midazolam doses were 150 mcg and 5 mg, respectively, in SMS. Vital signs remained significantly closer to the physiological baseline in the ketamine group (P = .004). Recovery times were no different between the groups, and no adverse reactions were encountered. CONCLUSIONS Ketamine is preferred by patients, preserves hemodynamics better than SMS, and can be safely administered by endoscopists. Data suggest that ketamine is a safe and effective sedation option for patients undergoing esophagogastroduodenoscopy or colonoscopy (clinicaltrials.gov NCT03461718).
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Affiliation(s)
- Jerome C Edelson
- Department of Gastroenterology and Hepatology, Brooke Army Medical Center, Ft. Sam Houston, TX 78824, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Cyrus V Edelson
- Department of Gastroenterology and Hepatology, Brooke Army Medical Center, Ft. Sam Houston, TX 78824, USA
| | - Don C Rockey
- Digestive Disease Research Center, Uniformed Services University of the Health Sciences, SC 20814, USA
| | - Amilcar L Morales
- Department of Gastroenterology and Hepatology, Brooke Army Medical Center, Ft. Sam Houston, TX 78824, USA
| | - Kevin K Chung
- Digestive Disease Research Center, Uniformed Services University of the Health Sciences, SC 20814, USA
| | - Matthew J Robles
- Department of Gastroenterology and Hepatology, Brooke Army Medical Center, Ft. Sam Houston, TX 78824, USA
| | - Johanna H Marowske
- Department of Gastroenterology and Hepatology, Brooke Army Medical Center, Ft. Sam Houston, TX 78824, USA
| | - Anish A Patel
- Department of Gastroenterology and Hepatology, Brooke Army Medical Center, Ft. Sam Houston, TX 78824, USA
| | - Scott F D Edelson
- Digestive Disease Research Center, Uniformed Services University of the Health Sciences, SC 20814, USA
- Department of Medicine, Brooke Army Medical Center, Ft. Sam Houston, TX 78824, USA
| | - Stalin R Subramanian
- Department of Gastroenterology and Hepatology, Brooke Army Medical Center, Ft. Sam Houston, TX 78824, USA
| | - John G Gancayco
- Department of Gastroenterology and Hepatology, Brooke Army Medical Center, Ft. Sam Houston, TX 78824, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Qing K, Alkhachroum A, Claassen J, Forgacs P, Schiff N. The Electrographic Effects of Ketamine on Patients With Refractory Status Epilepticus After Cardiac Arrest: A Single-Center Retrospective Cohort. J Clin Neurophysiol 2024:00004691-990000000-00119. [PMID: 38194637 DOI: 10.1097/wnp.0000000000001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
PURPOSE To investigate the effects of ketamine on patients with refractory status epilepticus after cardiac arrest. METHODS In this retrospective cohort, selected EEG segments from patients after cardiac arrest were classified into different EEG patterns (based on background continuity and burden of epileptiform discharges) and spectral profiles (based on the presence of frequency components). For patients who received ketamine, EEG data were compared before, during, and after ketamine infusion; for the no-ketamine group, EEG data were compared at three separated time points during recording. Ketamine usage was determined by clinical providers. Electrographic improvement in epileptiform activity was scored, and the odds ratio was calculated using the Fisher exact test. Functional outcome measures at time of discharge were also examined. RESULTS Of a total of 38 patients with postcardiac arrest refractory status epilepticus, 13 received ketamine and 25 did not. All patients were on ≥2 antiseizure medications including at least one sedative infusion (midazolam). For the ketamine group, eight patients had electrographic improvement, compared with only two patients in the no-ketamine group, with an odds ratio of 7.19 (95% confidence interval 1.16-44.65, P value of 0.0341) for ketamine versus no ketamine. Most of the patients who received ketamine had myoclonic status epilepticus, and overall neurologic outcomes were poor with no patients having a favorable outcome. CONCLUSIONS For postarrest refractory status epilepticus, ketamine use was associated with electrographic improvement, but with the available data, it is unclear whether ketamine use or EEG improvement can be linked to better functional recovery.
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Affiliation(s)
- Kurt Qing
- Department of Neurology, New York-Presbyterian Hospital Weill Cornell, New York, New York, U.S.A
| | - Ayham Alkhachroum
- Department of Neurology, University of Miami, Miami, Florida, U.S.A.; and
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York, New York, U.S.A
| | - Peter Forgacs
- Department of Neurology, New York-Presbyterian Hospital Weill Cornell, New York, New York, U.S.A
| | - Nicholas Schiff
- Department of Neurology, New York-Presbyterian Hospital Weill Cornell, New York, New York, U.S.A
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Dunn EJ, Willis DD. Ketamine for Super-Refractory Status Epilepticus in Palliative Care. A Case Report and Review of the Literature. Am J Hosp Palliat Care 2023:10499091231215491. [PMID: 37982530 DOI: 10.1177/10499091231215491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023] Open
Abstract
We report a case of super refractory status epilepticus uncontrolled by multiple anti-seizure medications in an individual with acute liver failure due to hepatic cirrhosis and an obstructive ileocecal mass plus multiple bilateral lung lesions presumed to be metastatic. A ketamine infusion was initiated late in his hospitalization which eliminated the convulsive seizures in less than an hour. The abatement of convulsive seizures allowed his grieving wife to return to her husband's bedside to witness the withdrawal of life sustaining treatment and be present during the final 24 hours of his life. We review the medical literature on the role of Intravenous (IV) Ketamine in the treatment of super refractory status epilepticus.
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Affiliation(s)
- Edward J Dunn
- U of L Health - Jewish Hospital Palliative Care, Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA
- U of L Health - Jewish Hospital, University of Louisville School of Medicine, Louisville, KY, USA
| | - David D Willis
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Ommati MM, Mobasheri A, Niknahad H, Rezaei M, Alidaee S, Arjmand A, Mazloomi S, Abdoli N, Sadeghian I, Sabouri S, Saeed M, Mousavi K, Najibi A, Heidari R. Low-dose ketamine improves animals' locomotor activity and decreases brain oxidative stress and inflammation in ammonia-induced neurotoxicity. J Biochem Mol Toxicol 2023; 37:e23468. [PMID: 37491939 DOI: 10.1002/jbt.23468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 06/10/2023] [Accepted: 07/08/2023] [Indexed: 07/27/2023]
Abstract
Ammonium ion (NH4 + ) is the major suspected molecule responsible for neurological complications of hepatic encephalopathy (HE). No specific pharmacological action for NH4 + -induced brain injury exists so far. Excitotoxicity is a well-known phenomenon in the brain of hyperammonemic cases. The hyperactivation of the N-Methyl- d-aspartate (NMDA) receptors by agents such as glutamate, an NH4 + metabolite, could cause excitotoxicity. Excitotoxicity is connected with events such as oxidative stress and neuroinflammation. Hence, utilizing NMDA receptor antagonists could prevent neurological complications of NH4 + neurotoxicity. In the current study, C57BL6/J mice received acetaminophen (APAP; 800 mg/kg, i.p) to induce HE. Hyperammonemic animals were treated with ketamine (0.25, 0.5, and 1 mg/kg, s.c) as an NMDA receptor antagonist. Animals' brain and plasma levels of NH4 + were dramatically high, and animals' locomotor activities were disturbed. Moreover, several markers of oxidative stress were significantly increased in the brain. A significant increase in brain tissue levels of TNF-α, IL-6, and IL-1β was also detected in hyperammonemic animals. It was found that ketamine significantly normalized animals' locomotor activity, improved biomarkers of oxidative stress, and decreased proinflammatory cytokines. The effects of ketamine on oxidative stress biomarkers and inflammation seem to play a key role in its neuroprotective mechanisms in the current study.
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Affiliation(s)
- Mohammad Mehdi Ommati
- College of Life Sciences, Shanxi Agricultural University, Taigu, Shanxi, China
- Henan Key Laboratory of Environmental and Animal Product Safety, College of Animal Science and Technology, Henan University of Science and Technology, Luoyang, Henan, China
| | - Ali Mobasheri
- Research Unit of Medical Imaging, Physics, and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland
- Departments of Orthopedics, Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Regenerative Medicine, State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
| | - Hossein Niknahad
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Rezaei
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sepideh Alidaee
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abdollah Arjmand
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sahra Mazloomi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Narges Abdoli
- Food and Drug Administration, Iran Ministry of Health and Medical Education, Tehran, Iran
| | - Issa Sadeghian
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Biotechnology Incubator, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Samira Sabouri
- Henan Key Laboratory of Environmental and Animal Product Safety, College of Animal Science and Technology, Henan University of Science and Technology, Luoyang, Henan, China
| | - Mohsen Saeed
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Khadijeh Mousavi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Asma Najibi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Heidari
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Syed MJ, Zutshi D, Muzammil SM, Mohamed W. Ketamine to Prevent Endotracheal Intubation in Adults with Refractory Non-convulsive Status Epilepticus: A Case Series. Neurocrit Care 2023:10.1007/s12028-023-01853-8. [PMID: 37783825 DOI: 10.1007/s12028-023-01853-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/01/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Non-convulsive status epilepticus (NCSE) is defined as status epilepticus (SE) with no obvious motor phenomenon and is diagnosed based on electroencephalogram (EEG). Refractory SE (RSE) is the persistence of seizures despite treatment with an adequately dosed first-line and second-line agents. Although guidelines for convulsive RSE include third-line agents such as intravenous anesthetic drugs (midazolam, propofol, or barbiturates), the therapeutic approach to NCSE is not well outlined. Treatment with traditional anesthetics invariably includes endotracheal intubation, which is associated with significant adverse events. Comparatively, ketamine, a non-competitive N-methyl-D-aspartate receptor antagonist is not associated with significant cardiorespiratory depression and may help in avoiding intubation. OBJECTIVE In this case series, we describe our experience with the early use of intravenous ketamine as the first anesthetic agent in patients with refractory NCSE to avoid endotracheal intubation. METHODS We present a case series of nine patients managed in the Neurointensive Care Unit at a university-affiliated tertiary care hospital. The study was approved by the hospital and university institutional review boards and the requirement for informed consent was waived for retrospective analysis of existing data, per institutional policy. All cases of SE were identified from a prospective database, and a subsequent retrospective chart review identified all patients with a diagnosis of refractory NCSE in whom ketamine was used as the first anesthetic agent. The primary endpoint was the avoidance of endotracheal intubation while on ketamine infusion. The secondary endpoint was defined as cessation of both clinical and electrographic seizures recorded on continuous EEG within 24 h of ketamine administration. RESULTS A total of nine patients experiencing refractory NCSE were included in this case series, with a median age of 61 (range 26-72) years and seven patients were male. The primary endpoint, avoiding intubation, was achieved in five out of nine (55%) cases. Six patients experienced resolution of refractory NCSE with ketamine administration as the sole anesthetic agent. Four patients required endotracheal intubation and three patients had a failure of seizure cessation with ketamine. Hypersalivation and pneumonia were the most common ketamine associated adverse events. In non-intubated patients, no deaths occurred. One patient was discharged home, four to subacute rehabilitation, one to a long term acute care hospital, and one patient to hospice. CONCLUSION The use of ketamine as the primary anesthetic agent may be a reasonable option to avoid endotracheal intubation in a subset of patients with refractory NCSE. This study is limited by its small sample size, retrospective design, and reliance on information obtained from chart review.
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Affiliation(s)
- Maryam J Syed
- Wayne State University School of Medicine, Detroit Medical Center, 4201 St Antoine, Detroit, MI, 48201, USA
| | - Deepti Zutshi
- Wayne State University School of Medicine, Detroit Medical Center, 4201 St Antoine, Detroit, MI, 48201, USA
| | - Syeda Maria Muzammil
- Wayne State University School of Medicine, Detroit Medical Center, 4201 St Antoine, Detroit, MI, 48201, USA
| | - Wazim Mohamed
- Wayne State University School of Medicine, Detroit Medical Center, 4201 St Antoine, Detroit, MI, 48201, USA.
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Jacobwitz M, Mulvihill C, Kaufman MC, Gonzalez AK, Resendiz K, Francoeur C, Helbig I, Topjian AA, Abend NS. A Comparison of Ketamine and Midazolam as First-Line Anesthetic Infusions for Pediatric Status Epilepticus. Neurocrit Care 2023:10.1007/s12028-023-01859-2. [PMID: 37783824 DOI: 10.1007/s12028-023-01859-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/08/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Pediatric refractory status epilepticus (RSE) often requires management with anesthetic infusions, but few data compare first-line anesthetics. This study aimed to compare the efficacy and adverse effects of midazolam and ketamine infusions as first-line anesthetics for pediatric RSE. METHODS Retrospective single-center study of consecutive study participants treated with ketamine or midazolam as the first-line anesthetic infusions for RSE at a quaternary care children's hospital from December 1, 2017, until September 15, 2021. RESULTS We identified 117 study participants (28 neonates), including 79 (68%) who received midazolam and 38 (32%) who received ketamine as the first-line anesthetic infusions. Seizures terminated more often in study participants administered ketamine (61%, 23/38) than midazolam (28%, 22/79; odds ratio [OR] 3.97, 95% confidence interval [CI] 1.76-8.98; P < 0.01). Adverse effects occurred more often in study participants administered midazolam (24%, 20/79) than ketamine (3%, 1/38; OR 12.54, 95% CI 1.61-97.43; P = 0.016). Study participants administered ketamine were younger, ketamine was used more often for children with acute symptomatic seizures, and midazolam was used more often for children with epilepsy. Multivariable logistic regression of seizure termination by first-line anesthetic infusion (ketamine or midazolam) including age at SE onset, SE etiology category, and individual seizure duration at anesthetic infusion initiation indicated seizures were more likely to terminate following ketamine than midazolam (OR 4.00, 95% CI 1.69-9.49; P = 0.002) and adverse effects were more likely following midazolam than ketamine (OR 13.41, 95% CI 1.61-111.04; P = 0.016). Survival to discharge was higher among study participants who received midazolam (82%, 65/79) than ketamine (55%, 21/38; P = 0.002), although treating clinicians did not attribute any deaths to ketamine or midazolam. CONCLUSIONS Among children and neonates with RSE, ketamine was more often followed by seizure termination and less often associated with adverse effects than midazolam when administered as the first-line anesthetic infusion. Further prospective data are needed to compare first-line anesthetics for RSE.
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Affiliation(s)
- Marin Jacobwitz
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Caitlyn Mulvihill
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Michael C Kaufman
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
- The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexander K Gonzalez
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
- The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Karla Resendiz
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Conall Francoeur
- Division of Critical Care, Québec, QC, Canada
- Department of Pediatrics, Centre Hospitalier Universitaire de Québec-University of Laval Research Center, Québec, QC, Canada
| | - Ingo Helbig
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
- The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nicholas S Abend
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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12
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Buratti S, Giacheri E, Palmieri A, Tibaldi J, Brisca G, Riva A, Striano P, Mancardi MM, Nobili L, Moscatelli A. Ketamine as advanced second-line treatment in benzodiazepine-refractory convulsive status epilepticus in children. Epilepsia 2023; 64:797-810. [PMID: 36792542 DOI: 10.1111/epi.17550] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
Status epilepticus (SE) is one of the most common neurological emergencies in children. To date, there is no definitive evidence to guide treatment of SE refractory to benzodiazepines. The main objectives of treatment protocols are to expedite therapeutic decisions and to use fast- and short-acting medications without significant adverse effects. Protocols differ among institutions, and most frequently valproate, phenytoin, and levetiracetam are used as second-line treatment. After failure of first- and second-line medications, admission to the intensive care unit and continuous infusion of anesthetics are usually indicated. Ketamine is a noncompetitive N-methyl-D-aspartate receptor antagonist that has been safely used for the treatment of refractory SE in adults and children. In animal models of SE, ketamine demonstrated antiepileptic and neuroprotective properties and synergistic effects with other antiseizure medications. We reviewed the literature to demonstrate the potential role of ketamine as an advanced second-line agent in the treatment of SE. Pharmacological targets, pathophysiology of SE, and the receptor trafficking hypothesis are reviewed and presented. The pharmacology of ketamine is outlined with related properties, advantages, and side effects. We summarize the most recent and relevant publications on experimental and clinical studies on ketamine in SE. Key expert opinion is also reported. Considering the current knowledge on SE pathophysiology, early sequential polytherapy should include ketamine for its wide range of positive assets. Future research and clinical trials on SE pharmacotherapy should focus on the role of ketamine as second-line medication.
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Affiliation(s)
- Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Emanuele Giacheri
- Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonella Palmieri
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Jessica Tibaldi
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giacomo Brisca
- Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonella Riva
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
| | - Pasquale Striano
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy.,Pediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Lino Nobili
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy.,Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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13
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Osman GM, Hocker SE. Status Epilepticus in Older Adults: Diagnostic and Treatment Considerations. Drugs Aging 2023; 40:91-103. [PMID: 36745320 DOI: 10.1007/s40266-022-00998-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 02/07/2023]
Abstract
Status epilepticus (SE) is one of the leading life-threatening neurological emergencies in the elderly population, with significant morbidity and mortality. SE presents unique diagnostic and therapeutic challenges in the older population given overlap with other causes of encephalopathy, complicating diagnosis, and the common occurrence of multiple comorbid diseases complicates treatment. First-line therapy involves the use of rescue benzodiazepine in the form of intravenous lorazepam or diazepam, intramuscular or intranasal midazolam and rectal diazepam. Second-line therapies include parenteral levetiracetam, fosphenytoin, valproate and lacosamide, and underlying comorbidities guide the choice of appropriate medication, while third-line therapies may be influenced by the patient's code status as well as the cause and type of SE. The standard of care for convulsive SE is treatment with an intravenous anesthetic, including midazolam, propofol, ketamine and pentobarbital. There is currently limited evidence guiding appropriate therapy in patients failing third-line therapies. Adjunctive strategies may include immunomodulatory treatments, non-pharmacological strategies such as ketogenic diet, neuromodulation therapies and surgery in select cases. Surrogate decision makers should be updated early and often in refractory episodes of SE and informed of the high morbidity and mortality associated with the disease as well as the high probability of subsequent epilepsy among survivors.
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Affiliation(s)
- Gamaleldin M Osman
- Department of Neurology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN, 55905, USA.
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14
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Insight into Drug Resistance in Status Epilepticus: Evidence from Animal Models. Int J Mol Sci 2023; 24:ijms24032039. [PMID: 36768361 PMCID: PMC9917109 DOI: 10.3390/ijms24032039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/11/2023] [Accepted: 01/15/2023] [Indexed: 01/22/2023] Open
Abstract
Status epilepticus (SE), a condition with abnormally prolonged seizures, is a severe type of epilepsy. At present, SE is not well controlled by clinical treatments. Antiepileptic drugs (AEDs) are the main therapeutic approaches, but they are effective for SE only with a narrow intervening window, and they easily induce resistance. Thus, in this review, we provide an updated summary for an insight into drug-resistant SE, hoping to add to the understanding of the mechanism of refractory SE and the development of active compounds. Firstly, we briefly outline the limitations of current drug treatments for SE by summarizing the extensive experimental literature and clinical data through a search of the PubMed database, and then summarize the common animal models of refractory SE with their advantages and disadvantages. Notably, we also briefly review some of the hypotheses about drug resistance in SE that are well accepted in the field, and furthermore, put forward future perspectives for follow-up research on SE.
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15
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Neurotoxicity evoked by organophosphates and available countermeasures. Arch Toxicol 2023; 97:39-72. [PMID: 36335468 DOI: 10.1007/s00204-022-03397-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022]
Abstract
Organophosphorus compounds (OP) are a constant problem, both in the military and in the civilian field, not only in the form of acute poisoning but also for their long-lasting consequences. No antidote has been found that satisfactorily protects against the toxic effects of organophosphates. Likewise, there is no universal cure to avert damage after poisoning. The key mechanism of organophosphate toxicity is the inhibition of acetylcholinesterase. The overstimulation of nicotinic or muscarinic receptors by accumulated acetylcholine on a synaptic cleft leads to activation of the glutamatergic system and the development of seizures. Further consequences include generation of reactive oxygen species (ROS), neuroinflammation, and the formation of various other neuropathologists. In this review, we present neuroprotection strategies which can slow down the secondary nerve cell damage and alleviate neurological and neuropsychiatric disturbance. In our opinion, there is no unequivocal approach to ensure neuroprotection, however, sooner the neurotoxicity pathway is targeted, the better the results which can be expected. It seems crucial to target the key propagation pathways, i.e., to block cholinergic and, foremostly, glutamatergic cascades. Currently, the privileged approach oriented to stimulating GABAAR by benzodiazepines is of limited efficacy, so that antagonizing the hyperactivity of the glutamatergic system could provide an even more efficacious approach for terminating OP-induced seizures and protecting the brain from permanent damage. Encouraging results have been reported for tezampanel, an antagonist of GluK1 kainate and AMPA receptors, especially in combination with caramiphen, an anticholinergic and anti-glutamatergic agent. On the other hand, targeting ROS by antioxidants cannot or already developed neuroinflammation does not seem to be very productive as other processes are also involved.
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16
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Awasthi N, Yadav R, Kumar D. Revealing metabolic path of Ketamine catalyzed by CYP450 via quantum mechanical approach. J Mol Struct 2023. [DOI: 10.1016/j.molstruc.2022.134126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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17
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Löscher W, Trinka E. The potential of intravenous topiramate for the treatment of status epilepticus. Epilepsy Behav 2023; 138:109032. [PMID: 36528009 DOI: 10.1016/j.yebeh.2022.109032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
There is considerable clinical evidence that topiramate (TPM) has a high potential in the treatment of refractory and super-refractory status epilepticus (RSE, SRSE). Because TPM is only approved for oral administration, it is applied as suspension via a nasogastric tube for SE treatment. However, this route of administration is impractical in an emergency setting and leads to variable absorption with unpredictable plasma levels and time to peak concentration. Thus, the development of an intravenous (i.v.) solution for TPM is highly desirable. Here we present data on two parenteral formulations of TPM that are currently being developed. One of these solutions is using sulfobutylether-β-cyclodextrin (SBE-β-CD; Captisol®) as an excipient. A 1% solution of TPM in 10% Captisol® has been reported to be well tolerated in safety studies in healthy volunteers and patients with epilepsy or migraine, but efficacy data are not available. The other solution uses the FDA- and EMA-approved excipient amino sugar meglumine. Meglumine is much more effective to dissolve TPM in water than Captisol®. A 1% solution of TPM can be achieved with 0.5-1% of meglumine. While the use of Captisol®-containing solutions is restricted in children and patients with renal impairment, such restrictions do not apply to meglumine. Recently, first-in-human data were reported for a meglumine-based solution of TPM, indicating safety and efficacy when used as a replacement for oral administration in a woman with epilepsy. Based on the multiple mechanisms of action of TPM that directly target the molecular neuronal alterations that are thought to underlie the loss of efficacy of benzodiazepines and other anti-seizure medications during prolonged SE and its rapid brain penetration after i.v. administration, we suggest that parenteral (i.v.) TPM is ideally suited for the treatment of RSE and SRSE. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, 30559 Hannover, Germany; Center for Systems Neuroscience, 30559 Hannover, Germany.
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria; Center for Cognitive Neuroscience, Salzburg, Austria
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18
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Double antiglutamatergic treatment in patients with status epilepticus: A case series. Epilepsy Behav 2022; 137:108954. [PMID: 36375305 DOI: 10.1016/j.yebeh.2022.108954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 10/10/2022] [Accepted: 10/10/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Status epilepticus (SE) continues to be a challenging neurological emergency with high morbidity and mortality. During treatment, different regimens are practiced encompassing all known seizure termination mechanisms. To our knowledge, this is the first case series report describing EEG patterns and clinical outcomes in patients treated with ketamine and perampanel (PER) concomitantly. OBJECTIVE To assess clinical and electrographic outcomes in patients receiving dual antiglutamatergic therapy in SE. RESULTS Twenty-one out of twenty five patients were treated with ketamine, and four patients with ketamine were associated with PER. In the ketamine plus PER group, three out of four patients had convulsive SE, and one had non-convulsive status epilepticus (NCSE), whereas eight patients in the ketamine group had NCSE. The incidence of beta pattern appearance on EEG after starting patients on ketamine and PER was achieved in all four patients (100%) compared to (61.9%) in the other group. A burst suppression pattern was recorded in 75% of patients treated with ketamine and PER, in comparison to 28.5% of patients in patients treated with a different regimen. The time to resolution of SE was significantly shorter in the ketamine group (median 24 (24-64) h vs. 6 (05-144) h p > 0.05). Moreover, the average number of days on IV anesthetic was slightly lower in a patient treated with PER concomitantly. In terms of morbidity, the average increase in mRS was also lower in the ketamine and PER group, although it was not statistically significant. CONCLUSIONS Dual anti-glutamatergic therapy could provide a favorable approach to treating SE, which yet needs to be further investigated through larger randomized control studies.
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19
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Jacobwitz M, Mulvihill C, Kaufman MC, Gonzalez AK, Resendiz K, MacDonald JM, Francoeur C, Helbig I, Topjian AA, Abend NS. Ketamine for Management of Neonatal and Pediatric Refractory Status Epilepticus. Neurology 2022; 99:e1227-e1238. [PMID: 35817569 PMCID: PMC10499431 DOI: 10.1212/wnl.0000000000200889] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/11/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Few data are available regarding the use of anesthetic infusions for refractory status epilepticus (RSE) in children and neonates, and ketamine use is increasing despite limited data. We aimed to describe the impact of ketamine for RSE in children and neonates. METHODS Retrospective single-center cohort study of consecutive patients admitted to the intensive care units of a quaternary care children's hospital treated with ketamine infusion for RSE. RESULTS Sixty-nine patients were treated with a ketamine infusion for RSE. The median age at onset of RSE was 0.7 years (interquartile range 0.15-7.2), and the cohort included 13 (19%) neonates. Three patients (4%) had adverse events requiring intervention during or within 12 hours of ketamine administration, including hypertension in 2 patients and delirium in 1 patient. Ketamine infusion was followed by seizure termination in 32 patients (46%), seizure reduction in 19 patients (28%), and no change in 18 patients (26%). DISCUSSION Ketamine administration was associated with few adverse events, and seizures often terminated or improved after ketamine administration. Further data are needed comparing first-line and subsequent anesthetic medications for treatment of pediatric and neonatal RSE. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence on the therapeutic utility of ketamine for treatment of RSE in children and neonates.
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Affiliation(s)
- Marin Jacobwitz
- From the Department of Pediatrics (Division of Neurology) (M.J., C.M., M.C.K., A.K.G., I.H., N.S.A.), Children's Hospital of Philadelphia; The Epilepsy NeuroGenetics Initiative (ENGIN) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia; Department of Biomedical and Health Informatics (DBHi) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia, PA; Department of Anesthesia and Critical Care Medicine (K.R., A.A.T., N.S.A.), Children's Hospital of Philadelphia; Department of Pharmacy Services (K.R.), Children's Hospital of Philadelphia, PA; Division of Critical Care (J.M.M.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Critical Care (C.F.), Quebec, Department of Pediatrics, CHU de Québec-University of Laval Research Center; Departments of Neurology and Pediatrics (I.H., N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Anesthesia & Critical Care (A.A.T.), University of Pennsylvania Perelman School of Medicine.
| | - Caitlyn Mulvihill
- From the Department of Pediatrics (Division of Neurology) (M.J., C.M., M.C.K., A.K.G., I.H., N.S.A.), Children's Hospital of Philadelphia; The Epilepsy NeuroGenetics Initiative (ENGIN) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia; Department of Biomedical and Health Informatics (DBHi) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia, PA; Department of Anesthesia and Critical Care Medicine (K.R., A.A.T., N.S.A.), Children's Hospital of Philadelphia; Department of Pharmacy Services (K.R.), Children's Hospital of Philadelphia, PA; Division of Critical Care (J.M.M.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Critical Care (C.F.), Quebec, Department of Pediatrics, CHU de Québec-University of Laval Research Center; Departments of Neurology and Pediatrics (I.H., N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Anesthesia & Critical Care (A.A.T.), University of Pennsylvania Perelman School of Medicine
| | - Michael C Kaufman
- From the Department of Pediatrics (Division of Neurology) (M.J., C.M., M.C.K., A.K.G., I.H., N.S.A.), Children's Hospital of Philadelphia; The Epilepsy NeuroGenetics Initiative (ENGIN) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia; Department of Biomedical and Health Informatics (DBHi) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia, PA; Department of Anesthesia and Critical Care Medicine (K.R., A.A.T., N.S.A.), Children's Hospital of Philadelphia; Department of Pharmacy Services (K.R.), Children's Hospital of Philadelphia, PA; Division of Critical Care (J.M.M.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Critical Care (C.F.), Quebec, Department of Pediatrics, CHU de Québec-University of Laval Research Center; Departments of Neurology and Pediatrics (I.H., N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Anesthesia & Critical Care (A.A.T.), University of Pennsylvania Perelman School of Medicine
| | - Alexander K Gonzalez
- From the Department of Pediatrics (Division of Neurology) (M.J., C.M., M.C.K., A.K.G., I.H., N.S.A.), Children's Hospital of Philadelphia; The Epilepsy NeuroGenetics Initiative (ENGIN) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia; Department of Biomedical and Health Informatics (DBHi) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia, PA; Department of Anesthesia and Critical Care Medicine (K.R., A.A.T., N.S.A.), Children's Hospital of Philadelphia; Department of Pharmacy Services (K.R.), Children's Hospital of Philadelphia, PA; Division of Critical Care (J.M.M.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Critical Care (C.F.), Quebec, Department of Pediatrics, CHU de Québec-University of Laval Research Center; Departments of Neurology and Pediatrics (I.H., N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Anesthesia & Critical Care (A.A.T.), University of Pennsylvania Perelman School of Medicine
| | - Karla Resendiz
- From the Department of Pediatrics (Division of Neurology) (M.J., C.M., M.C.K., A.K.G., I.H., N.S.A.), Children's Hospital of Philadelphia; The Epilepsy NeuroGenetics Initiative (ENGIN) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia; Department of Biomedical and Health Informatics (DBHi) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia, PA; Department of Anesthesia and Critical Care Medicine (K.R., A.A.T., N.S.A.), Children's Hospital of Philadelphia; Department of Pharmacy Services (K.R.), Children's Hospital of Philadelphia, PA; Division of Critical Care (J.M.M.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Critical Care (C.F.), Quebec, Department of Pediatrics, CHU de Québec-University of Laval Research Center; Departments of Neurology and Pediatrics (I.H., N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Anesthesia & Critical Care (A.A.T.), University of Pennsylvania Perelman School of Medicine
| | - Jennifer M MacDonald
- From the Department of Pediatrics (Division of Neurology) (M.J., C.M., M.C.K., A.K.G., I.H., N.S.A.), Children's Hospital of Philadelphia; The Epilepsy NeuroGenetics Initiative (ENGIN) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia; Department of Biomedical and Health Informatics (DBHi) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia, PA; Department of Anesthesia and Critical Care Medicine (K.R., A.A.T., N.S.A.), Children's Hospital of Philadelphia; Department of Pharmacy Services (K.R.), Children's Hospital of Philadelphia, PA; Division of Critical Care (J.M.M.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Critical Care (C.F.), Quebec, Department of Pediatrics, CHU de Québec-University of Laval Research Center; Departments of Neurology and Pediatrics (I.H., N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Anesthesia & Critical Care (A.A.T.), University of Pennsylvania Perelman School of Medicine
| | - Conall Francoeur
- From the Department of Pediatrics (Division of Neurology) (M.J., C.M., M.C.K., A.K.G., I.H., N.S.A.), Children's Hospital of Philadelphia; The Epilepsy NeuroGenetics Initiative (ENGIN) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia; Department of Biomedical and Health Informatics (DBHi) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia, PA; Department of Anesthesia and Critical Care Medicine (K.R., A.A.T., N.S.A.), Children's Hospital of Philadelphia; Department of Pharmacy Services (K.R.), Children's Hospital of Philadelphia, PA; Division of Critical Care (J.M.M.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Critical Care (C.F.), Quebec, Department of Pediatrics, CHU de Québec-University of Laval Research Center; Departments of Neurology and Pediatrics (I.H., N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Anesthesia & Critical Care (A.A.T.), University of Pennsylvania Perelman School of Medicine
| | - Ingo Helbig
- From the Department of Pediatrics (Division of Neurology) (M.J., C.M., M.C.K., A.K.G., I.H., N.S.A.), Children's Hospital of Philadelphia; The Epilepsy NeuroGenetics Initiative (ENGIN) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia; Department of Biomedical and Health Informatics (DBHi) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia, PA; Department of Anesthesia and Critical Care Medicine (K.R., A.A.T., N.S.A.), Children's Hospital of Philadelphia; Department of Pharmacy Services (K.R.), Children's Hospital of Philadelphia, PA; Division of Critical Care (J.M.M.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Critical Care (C.F.), Quebec, Department of Pediatrics, CHU de Québec-University of Laval Research Center; Departments of Neurology and Pediatrics (I.H., N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Anesthesia & Critical Care (A.A.T.), University of Pennsylvania Perelman School of Medicine
| | - Alexis A Topjian
- From the Department of Pediatrics (Division of Neurology) (M.J., C.M., M.C.K., A.K.G., I.H., N.S.A.), Children's Hospital of Philadelphia; The Epilepsy NeuroGenetics Initiative (ENGIN) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia; Department of Biomedical and Health Informatics (DBHi) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia, PA; Department of Anesthesia and Critical Care Medicine (K.R., A.A.T., N.S.A.), Children's Hospital of Philadelphia; Department of Pharmacy Services (K.R.), Children's Hospital of Philadelphia, PA; Division of Critical Care (J.M.M.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Critical Care (C.F.), Quebec, Department of Pediatrics, CHU de Québec-University of Laval Research Center; Departments of Neurology and Pediatrics (I.H., N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Anesthesia & Critical Care (A.A.T.), University of Pennsylvania Perelman School of Medicine
| | - Nicholas S Abend
- From the Department of Pediatrics (Division of Neurology) (M.J., C.M., M.C.K., A.K.G., I.H., N.S.A.), Children's Hospital of Philadelphia; The Epilepsy NeuroGenetics Initiative (ENGIN) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia; Department of Biomedical and Health Informatics (DBHi) (M.C.K., A.K.G., I.H.), Children's Hospital of Philadelphia, PA; Department of Anesthesia and Critical Care Medicine (K.R., A.A.T., N.S.A.), Children's Hospital of Philadelphia; Department of Pharmacy Services (K.R.), Children's Hospital of Philadelphia, PA; Division of Critical Care (J.M.M.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Critical Care (C.F.), Quebec, Department of Pediatrics, CHU de Québec-University of Laval Research Center; Departments of Neurology and Pediatrics (I.H., N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Anesthesia & Critical Care (A.A.T.), University of Pennsylvania Perelman School of Medicine
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Rueda Carrillo L, Garcia KA, Yalcin N, Shah M. Ketamine and Its Emergence in the Field of Neurology. Cureus 2022; 14:e27389. [PMID: 36046286 PMCID: PMC9419113 DOI: 10.7759/cureus.27389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 11/15/2022] Open
Abstract
The quest for a safe and effective anesthetic medication in the mid-20th century led to the discovery of CI-581, which was later named ketamine. Ketamine was labeled a “dissociative anesthetic” due to the state of sensory deprivation that it induces in the subjects receiving it. Although it enjoyed widespread use at the beginning of the Vietnam war, its use rapidly waned due to its psychedelic effect and it became more popular as a recreational drug, and in the field of veterinary medicine. However, as we gained more knowledge about its multiple sites of action, it has reemerged as a useful anesthetic/analgesic agent. In the last decade, the field of neurology has witnessed the growing use of ketamine for the treatment of several neurological conditions including migraine, status epilepticus, stroke, and traumatic brain injury (TBI). Ketamine acts primarily as a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist. The binding of ketamine to NMDA receptors leads to decreased frequency and duration of Ca+2 channel opening and thus inhibits glutaminergic transmission. This mechanism has proven to be neuroprotective in several neurological conditions. Ketamine does not increase intracranial pressure (ICP), and it maintains cerebral perfusion pressure (CPP) by increasing cerebral blood flow. Ketamine has also been shown to inhibit massive slow waves of neurological depolarizations called cortical spreading depolarizations (CSD), usually seen during acute neurological injury and are responsible for further neurological deterioration. Unlike other anesthetic agents, ketamine does not cause cardiac or respiratory suppression. All these favorable mechanisms and cerebral/hemodynamic actions have led to increased interest among clinicians and researchers regarding the novel uses of ketamine. This review will focus on the use of ketamine for various neurological indications.
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21
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Caranzano L, Novy J, Rossetti AO. Ketamine in adult super-refractory status epilepticus: Efficacy analysis on a prospective registry. Acta Neurol Scand 2022; 145:737-742. [PMID: 35274736 PMCID: PMC9310735 DOI: 10.1111/ane.13610] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/28/2022]
Abstract
Background Status epilepticus (SE) persisting despite two anti‐seizures medications (ASM) and anesthetics is labeled super refractory (SRSE), correlating with important morbidity and mortality. Its treatment relies on expert opinions. Due to its pharmacological properties, ketamine (KET) has received increasing attention, but data are essentially retrospective. Aims To describe an unselected cohort of adults receiving KET for SRSE. Methods Analysis of a prospective registry of consecutive SE episodes, identifying SRSE patients receiving ketamine (KET). Comparison with recent adult series including more than 10 patients. Results Eleven patients received KET after a median of 4 days (range: 2–20); median dose was 5 mg/kg/h (range: 2.5–15). KET provided permanent SE control in three (27%). Previous series, using KET administration delays and doses similar to our cohort, report KET efficacy in 28–96% of cases. Conclusions We found a lower SE control rate than existing literature, whose data are, however, often retrospective, potentially selecting patients with less severe SE forms or responding to KET. This might explain outcome differences, as KET administration modalities were comparable with our cohort. Since randomized controlled studies are lacking on this subject, the analysis of this prospective, unselected cohort, if confirmed, suggests a current overestimation of KET efficacy in SRSE.
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Affiliation(s)
- Leonardo Caranzano
- Department of Clinical Neurosciences, Neurology Service Lausanne University Hospital and University of Lausanne Lausanne Switzerland
| | - Jan Novy
- Department of Clinical Neurosciences, Neurology Service Lausanne University Hospital and University of Lausanne Lausanne Switzerland
| | - Andrea O. Rossetti
- Department of Clinical Neurosciences, Neurology Service Lausanne University Hospital and University of Lausanne Lausanne Switzerland
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22
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Why won't it stop? The dynamics of benzodiazepine resistance in status epilepticus. Nat Rev Neurol 2022; 18:428-441. [PMID: 35538233 DOI: 10.1038/s41582-022-00664-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/08/2022]
Abstract
Status epilepticus is a life-threatening neurological emergency that affects both adults and children. Approximately 36% of episodes of status epilepticus do not respond to the current preferred first-line treatment, benzodiazepines. The proportion of episodes that are refractory to benzodiazepines is higher in low-income and middle-income countries (LMICs) than in high-income countries (HICs). Evidence suggests that longer episodes of status epilepticus alter brain physiology, thereby contributing to the emergence of benzodiazepine resistance. Such changes include alterations in GABAA receptor function and in the transmembrane gradient for chloride, both of which erode the ability of benzodiazepines to enhance inhibitory synaptic signalling. Often, current management guidelines for status epilepticus do not account for these duration-related changes in pathophysiology, which might differentially impact individuals in LMICs, where the average time taken to reach medical attention is longer than in HICs. In this Perspective article, we aim to combine clinical insights and the latest evidence from basic science to inspire a new, context-specific approach to efficiently managing status epilepticus.
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23
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Xu W, Zhao Z, Falconer J, Whittaker AK, Popat A, Smith MT, Kumeria T, Han FY. Sustained release ketamine-loaded porous silicon-PLGA microparticles prepared by an optimized supercritical CO 2 process. Drug Deliv Transl Res 2022; 12:676-694. [PMID: 33907987 DOI: 10.1007/s13346-021-00991-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 12/15/2022]
Abstract
Ketamine in sub-anaesthetic doses has analgesic properties and an opioid-sparing effect. Intrathecal (i.t.) delivery of analgesics bypasses systemic metabolism and delivers the analgesic agent adjacent to the target receptors in the spinal cord and so small doses are required to achieve effective pain relief. In order to relieve intractable cancer-related pain, sustained-release ketamine formulations are required in combination with a strong opioid because frequent i.t. injection is not practical. In this study, ketamine or ketamine-loaded porous silicon (pSi) were encapsulated into poly(lactic-co-glycolic acid) (PLGA) microparticles by a novel supercritical carbon dioxide (scCO2) method, thereby avoiding the use of organic solvent. Multiple parameters including theoretical drug loading (DL), presence of pSi, size of scCO2 vessel, PLGA type, and use of co-solvent were investigated with a view to obtaining high DL and a sustained-release for an extended period. The most important finding was that the use of a large scCO2 vessel (60 mL) resulted in a much higher encapsulation efficiency (EE) compared with a small vessel (12 mL). In addition, pre-loading ketamine into pSi slightly improved the level of drug incorporation (i.e. EE and DL). Although the in vitro release was mainly affected by the drug payload, the use of the large scCO2 vessel reduced the burst release and extended the release period for PLGA microparticles with 10% or 20% ketamine loading. Together, our findings provide valuable information for optimization of drug delivery systems prepared with the aid of scCO2.
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Affiliation(s)
- Weizhi Xu
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Zonglan Zhao
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - James Falconer
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Andrew K Whittaker
- Australia Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, Australia
- ARC Centre of Excellence in Convergent Bio Nano Science and Technology, The University of Queensland, Brisbane, QLD, Australia
| | - Amirali Popat
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Maree T Smith
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Tushar Kumeria
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia.
- School of Materials Science and Engineering, The University of New South Wales, Sydney, NSW, Australia.
| | - Felicity Y Han
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
- Australia Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, Australia.
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Abstract
IMPORTANCE: The response of ICU patients to continuously infused ketamine when it is used for analgesia and/or sedation remains poorly established. OBJECTIVES: To describe continuous infusion (CI) ketamine use in critically ill patients, including indications, dose and duration, adverse effects, patient outcomes, time in goal pain/sedation score range, exposure to analgesics/sedatives, and delirium. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, retrospective, observational study from twenty-five diverse institutions in the United States. Patients receiving CI ketamine between January 2014 and December 2017. MAIN OUTCOMES AND MEASURES: Chart review evaluating institutional and patient demographics, ketamine indication, dose, administration, and adverse effects. Pain/sedation scores, cumulative doses of sedatives and analgesics, and delirium screenings in the 24 hours prior to ketamine were compared with those at 0–24 hours and 25–48 hours after. RESULTS: A total of 390 patients were included (median age, 54.5 yr; interquartile range, 39–65 yr; 61% males). Primary ICU types were medical (35.3%), surgical (23.3%), and trauma (17.7%). Most common indications were analgesia/sedation (n = 357, 91.5%). Starting doses were 0.2 mg/kg/hr (0.1–0.5 mg/kg/hr) and continued for 1.6 days (0.6–2.9 d). Hemodynamics in the first 4 hours after ketamine were variable (hypertension 24.0%, hypotension 23.5%, tachycardia 19.5%, bradycardia 2.3%); other adverse effects were minimal. Compared with 24 hours prior, there was a significant increase in proportion of time spent within goal pain score after ketamine initiation (24 hr prior: 68.9% [66.7–72.6%], 0–24 hr: 78.6% [74.3–82.5%], 25–48 hr: 80.3% [74.6–84.3%]; p < 0.001) and time spent within goal sedation score (24 hr prior: 57.1% [52.5–60.0%], 0–24 hr: 64.1% [60.7–67.2%], 25–48 hr: 68.9% [65.5–79.5%]; p < 0.001). There was also a significant reduction in IV morphine (mg) equivalents (24 hr prior: 120 [25–400], 0–24 hr: 118 [10–363], 25–48 hr: 80 [5–328]; p < 0.005), midazolam (mg) equivalents (24 hr prior: 11 [4–67], 0–24 hr: 6 [0–68], 25–48 hr: 3 [0–57]; p < 0.001), propofol (mg) (24 hr prior: 942 [223–4,018], 0–24 hr: 160 [0–2,776], 25–48 hr: 0 [0–1,859]; p < 0.001), and dexmedetomidine (µg) (24 hr prior: 1,025 [276–1,925], 0–24 hr: 285 [0–1,283], 25–48 hr: 0 [0–826]; p < 0.001). There was no difference in proportion of time spent positive for delirium (24 hr prior: 43.0% [17.0–47.0%], 0–24 hr: 39.5% [27.0–43.8%], 25–48 hr: 0% [0–43.7%]; p = 0.233). Limitations to these data include lack of a comparator group, potential for confounders and selection bias, and varying pain and sedation practices that may have changed since completion of the study. CONCLUSIONS AND RELEVANCE: There is variability in the use of CI ketamine. Hemodynamic instability was the most common adverse effect. In the 48 hours after ketamine initiation compared with the 24 hours prior, proportion of time spent in goal pain/sedation score range increased and exposure to other analgesics/sedatives decreased.
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25
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Dericioglu N, Arslan D, Arsava EM, Topcuoglu MA. Efficacy and Safety of Ketamine in Refractory/Super-refractory Nonconvulsive Status Epilepticus: Single-Center Experience. Clin EEG Neurosci 2021; 52:345-350. [PMID: 32752882 DOI: 10.1177/1550059420942677] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Refractory/super-refractory nonconvulsive status epilepticus (r/srNCSE) is an acute life-threatening neurocritical entity with significant morbidity. Failure to control SE in its earlier stages leads to multiple molecular alterations in the brain such as downregulation of GABA-A and upregulation of NMDA receptors. Recently ketamine, an NMDA receptor antagonist, has gained increased attention as a therapeutic choice in controlling refractory/super-refractory SE. We aimed to analyze the efficacy and safety profile of ketamine in our center. We retrospectively identified all the patients with nonconvulsive SE who received ketamine during their follow-up in our neurological intensive care unit between 2009 and 2019. Information about demographic, clinical, and laboratory findings; concurrent antiseizure and anesthetic medications; time of initiation, dose and duration of ketamine infusion; any adverse effects and finally prognosis were collected. The effect of day of ketamine initiation and duration of infusion on ketamine efficacy were analyzed statistically. Seven patients (4 males, 3 females; age: 44-86 years) were included in the study. Encephalitis was the most common etiology. Concurrent antiseizure medications varied between 2 and 5. Six patients received midazolam before/during ketamine infusion. Ketamine was initiated 2 to 7 days after the onset of EEG monitoring and lasted 3 to 24 days with a maximum infusion dose ranging between 1 to 5 mg/kg/h. It was definitely effective in 4 patients, and possibly effective in an additional patient. Earlier initiation was correlated with higher efficacy (P = .047). There was a trend toward higher efficacy with longer duration of infusion (P = .285). Overall prognosis was poor with 29% mortality rate. Temporary hepatic failure occurred in 1 patient. Ketamine appears to be a promising drug in r/srNCSE. Earlier and prolonged infusion, as well as combination with benzodiazepines may increase its efficacy. Adverse events are rarely observed.
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Affiliation(s)
- Nese Dericioglu
- Department of Adult Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Doruk Arslan
- Department of Adult Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ethem Murat Arsava
- Department of Adult Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Akif Topcuoglu
- Department of Adult Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Review and Updates on the Treatment of Refractory and Super Refractory Status Epilepticus. J Clin Med 2021; 10:jcm10143028. [PMID: 34300194 PMCID: PMC8304618 DOI: 10.3390/jcm10143028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/30/2021] [Accepted: 07/03/2021] [Indexed: 02/07/2023] Open
Abstract
Refractory and super-refractory status epilepticus (RSE and SRSE) are life-threatening conditions requiring prompt initiation of appropriate treatment to avoid permanent neurological damage and reduce morbidity and mortality. RSE is defined as status epilepticus that persists despite administering at least two appropriately dosed parenteral medications, including a benzodiazepine. SRSE is status epilepticus that persists at least 24 h after adding at least one appropriately dosed continuous anesthetic (i.e., midazolam, propofol, pentobarbital, and ketamine). Other therapeutic interventions include immunotherapy, neuromodulation, ketogenic diet, or even surgical intervention in certain cases. Continuous electroencephalogram is an essential monitoring tool for diagnosis and treatment. In this review, we focus on the diagnosis and treatment of RSE and SRSE.
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Saitov G, Müller A, Bastian B, Michalski D. [Pharmacotherapy and intensive care aspects of status epilepticus: update 2020/2021]. Anaesthesist 2021; 70:874-887. [PMID: 34212230 PMCID: PMC8492596 DOI: 10.1007/s00101-021-01000-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/30/2022]
Abstract
Die gezielte Therapie epileptischer Ereignisse und im Speziellen des Status epilepticus (SE) setzt das sichere Erkennen der Krankheitsbilder voraus, wofür gerade bei Formen mit vorwiegend nichtmotorischen Symptomen klinische und elektroenzephalographische Expertise notwendig ist. Die im Jahr 2020 erfolgte Fortschreibung der deutschen Leitlinie zur Behandlung des SE hält an der streng stufengerechten Therapie fest, die eskalierend die Anwendung von Benzodiazepinen, spezifischen Antiepileptika und Anästhetika vorsieht. Bisher ist die Eingrenzung eines in den allermeisten Fällen wirksamen sowie zugleich sicheren und interaktionsfreien Antiepileptikums nicht gelungen. Individuelle Vorerkrankungen und aktuelle Begleitumstände gehen daher genauso wie Erfahrungen des Behandlerteams in die differenzierte Behandlung des SE ein. Insbesondere bei therapierefraktären Formen des SE erweist sich die Therapie als durchaus kompliziert und hat regelhaft intensivmedizinische Implikationen. Mithin ergeben sich im Zuge der modernen SE-Behandlung zahlreiche interdisziplinäre Schnittstellen. Zukünftige wissenschaftliche Fragstellungen werden sich u. a. mit der optimalen Therapie des nonkonvulsiven SE und hier v. a. dem Ausmaß und dem Zeitpunkt von adäquaten Therapieschritten sowie mit assoziierten ethischen Fragen einer Therapieeskalation beschäftigen.
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Affiliation(s)
- Gabrielė Saitov
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - Annekatrin Müller
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Börge Bastian
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Dominik Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
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28
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Yeh CH, Chen BH, Tseng XW, Liao CH, Tsai WK, Chiang HS, Wu YN. Intravesical Instillation of Norketamine, a Ketamine Metabolite, and Induced Bladder Functional Changes in Rats. TOXICS 2021; 9:toxics9070154. [PMID: 34209184 PMCID: PMC8309735 DOI: 10.3390/toxics9070154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/20/2021] [Accepted: 06/25/2021] [Indexed: 12/13/2022]
Abstract
This study aimed to determine the mechanism of ketamine-induced cystitis without metabolism. A total of 24 adult male Sprague-Dawley rats were separated into control, ketamine, and norketamine groups. To induce cystitis, rats in the ketamine and norketamine groups were treated with intravesical instillation of ketamine and norketamine by mini-osmotic pump, which was placed in subcutaneous space, daily for 24 h for 4 weeks. After 4 weeks, all rats were subjected to bladder functional tests. The bladders were collected for histological and pathological evaluation. Compared to control, ketamine treatment demonstrated an increase in the bladder weight, high bladder/body coefficient, contractive pressure, voiding volume, collagen deposition, reduced smooth muscle content, damaged glycosaminoglycan layer, and low bladder compliance. Compared to ketamine, norketamine treatment showed more severe collagen deposition, smooth muscle loss, damaged glycosaminoglycan layer, and increased residual urine. Intravesical administration of ketamine and norketamine induced cystitis with different urodynamic characteristics. Norketamine treatment caused more severe bladder dysfunction than ketamine treatment. Direct treatment of the bladder with norketamine induced symptoms more consistent with those of bladder outlet obstruction than ketamine cystitis. Detailed studies of cellular mechanisms are required to determine the pathogenesis of ketamine cystitis.
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Affiliation(s)
- Chung-Hsin Yeh
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan; (C.-H.Y.); (C.-H.L.)
- Division of Urology, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei City 111, Taiwan
| | - Bo-He Chen
- Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City 242, Taiwan;
| | - Xiao-Wen Tseng
- Program in Pharmaceutical Biotechnology, College of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan;
| | - Chun-Hou Liao
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan; (C.-H.Y.); (C.-H.L.)
- Division of Urology, Department of Surgery, Cardinal Tien Hospital, New Taipei City 231, Taiwan
| | - Wei-Kung Tsai
- Department of Urology, Mackay Memorial Hospital, Taipei City 104, Taiwan;
- Ph.D. Program in Nutrition and Food Science, Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City 242, Taiwan
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan
- Mackay Junior College of Medicine, Nursing, and Management, Taipei City 252, Taiwan
| | - Han-Sun Chiang
- Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City 242, Taiwan;
- Division of Urology, Department of Surgery, Cardinal Tien Hospital, New Taipei City 231, Taiwan
- Department of Urology, Fu Jen Catholic University Hospital, New Taipei City 243, Taiwan
- Correspondence: (H.-S.C.); (Y.-N.W.); Tel.: +886-2-29052202 (H.-S.C.); +886-2-29056442 (Y.-N.W.); Fax: +886-2-29017391 (H.-S.C.); +886-2-29056100 (Y.-N.W.)
| | - Yi-No Wu
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan; (C.-H.Y.); (C.-H.L.)
- Correspondence: (H.-S.C.); (Y.-N.W.); Tel.: +886-2-29052202 (H.-S.C.); +886-2-29056442 (Y.-N.W.); Fax: +886-2-29017391 (H.-S.C.); +886-2-29056100 (Y.-N.W.)
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29
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Wabl R, Terman SW, Kwok M, Elm J, Chamberlain J, Silbergleit R, Hill CE. Efficacy of Home Anticonvulsant Administration for Second-Line Status Epilepticus Treatment. Neurology 2021; 97:e720-e727. [PMID: 34187862 DOI: 10.1212/wnl.0000000000012414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 05/11/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate whether receiving a second-line anticonvulsant medication that is part of a patient's home regimen influences outcomes in benzodiazepine-refractory convulsive status epilepticus. METHODS Using the Established Status Epilepticus Treatment Trial data, allocation to a study drug included in the patient's home anticonvulsant medication regimen was compared to receipt of an alternative second-line study medication. The primary outcome was cessation of clinical seizures with improved consciousness by 60 minutes after study drug initiation. Secondary outcomes were seizure cessation adjudicated from medical records and adverse events. We performed inverse probability of treatment-weighted (IPTW) logistic regressions. RESULTS Of 462 patients, 232 (50%) were taking 1-2 of the 3 study medications at home. The primary outcome was observed in 39/89 (44%) patients allocated to their home medication vs 76/143 (53%) allocated to a nonhome medication (IPTW odds ratio [OR] 0.66, 95% confidence interval [CI] 0.39-1.14). The adjudicated outcome occurred in 37/89 (42%) patients vs 82/143 (57%), respectively (IPTW OR 0.52, 95% CI 0.30-0.89). There was no interaction between study levetiracetam and home levetiracetam and there were no differences in adverse events. CONCLUSION There was no difference in the primary outcome for patients who received a home medication vs nonhome medication. However, the retrospective evaluation suggested an association between receiving a nonhome medication and seizure cessation. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for patients with refractory convulsive status epilepticus, use of a home second-line anticonvulsant compared to a nonhome anticonvulsant did not significantly affect the probability of stopping seizures.
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Affiliation(s)
- Rafael Wabl
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC.
| | - Samuel W Terman
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - Maria Kwok
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - Jordan Elm
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - James Chamberlain
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - Robert Silbergleit
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - Chloe E Hill
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
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Benini F, Congedi S, Giacomelli L, Papa S, Shah A, Milani G. Refractory symptoms in paediatric palliative care: can ketamine help? Drugs Context 2021; 10:dic-2021-2-5. [PMID: 34104198 PMCID: PMC8152774 DOI: 10.7573/dic.2021-2-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/15/2021] [Indexed: 01/12/2023] Open
Abstract
Background One of the main challenges for paediatric palliative care (PPC) is the management of concomitant, different and severe symptoms that frequently affect the quality of life of PPC patients and are often refractory to commonly used pharmacological treatments. Consequently, many efforts are still needed to find the best therapeutic options to handle these refractory conditions. Since the first synthesis of ketamine in the 1960s, its pharmacokinetic and pharmacodynamic properties have been largely investigated and its potential wide range of clinical applications has become clear. However, this molecule still receives poor attention in some areas, including in children and PPC. This narrative review analyses the use of ketamine in children and the potential extension of its applications in PPC in order to provide new options for treatment in the PPC setting. Methods Scientific papers published before October 2020 on MEDLINE, EMBASE and the Cochrane Library were considered. The cited references of the selected papers and the authors’ personal collections of literature were reviewed. The terms “palliative care”, “ketamine”, “neuropathic pain”, “procedural pain”, “status epilepticus”, “refractory pain” and “child”, adding “age: birth–18 years” on a further filter were used for the search. Discussion The use of ketamine in PPC should be more widely considered due to its overall favourable safety profile and its efficacy, which are supported by an increasing number of studies, although in settings different from PPC and of mixed quality. Ketamine should be proposed according to a case-by-case evaluation and the specific diagnosis and the dosage and route of administration should be tailored to the specific needs of patients. Furthermore, there is evidence to suggest that ketamine is safe and efficacious in acute pain. These findings can prompt further research on the use of ketamine for the treatment of acute pain in PPC. Conclusion Ketamine could be a suitable option after the failure of conventional drugs in the treatment of different refractory conditions in PPC.
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Affiliation(s)
- Franca Benini
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | - Sabrina Congedi
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | | | | | | | - Gregorio Milani
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.,Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Kumar A, Kohli A. Comeback of ketamine: resurfacing facts and dispelling myths. Korean J Anesthesiol 2021; 74:103-114. [PMID: 33423410 PMCID: PMC8024210 DOI: 10.4097/kja.20663] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/10/2021] [Accepted: 01/10/2021] [Indexed: 11/17/2022] Open
Abstract
Initially known as CI-581, ketamine was first synthesized in 1962 as a replacement from phencyclidine. It has since been used as an anesthetic and analgesic. In addition, it has bronchodilating, sedative, and amnestic properties, preserving airway reflexes and sympathetic nervous system tone. Since the discovery of ketamine, it has been a major topic of discussion due to controversies regarding its usage in particular sets of patients. In the past 50 years, despite its potential benefits, it is not commonly used because of concerns of "emergence phenomenon," its use as a substance of abuse, and its systemic side effects. Since 2012, three World Health Organization reviews on ketamine have addressed its international control. Researchers have been studying this wonder drug for a decade worldwide. Many myths of ketamine regarding emergence phenomenon and its use in traumatic brain injury and open eye injury have been disproved in recent times. It is becoming popular in pre-hospital settings, critical care, emergency medicine, low-dose acute pain services, and adjuvant in regional anesthesia techniques. This review highlights the current consensus on the various applications of ketamine in the literature.
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Affiliation(s)
- Abhijit Kumar
- Department of Anesthesiology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Amit Kohli
- Department of Anesthesiology, Maulana Azad Medical College, New Delhi, India
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Alcoreza OB, Patel DC, Tewari BP, Sontheimer H. Dysregulation of Ambient Glutamate and Glutamate Receptors in Epilepsy: An Astrocytic Perspective. Front Neurol 2021; 12:652159. [PMID: 33828523 PMCID: PMC8019783 DOI: 10.3389/fneur.2021.652159] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 02/24/2021] [Indexed: 12/16/2022] Open
Abstract
Given the important functions that glutamate serves in excitatory neurotransmission, understanding the regulation of glutamate in physiological and pathological states is critical to devising novel therapies to treat epilepsy. Exclusive expression of pyruvate carboxylase and glutamine synthetase in astrocytes positions astrocytes as essential regulators of glutamate in the central nervous system (CNS). Additionally, astrocytes can significantly alter the volume of the extracellular space (ECS) in the CNS due to their expression of the bi-directional water channel, aquaporin-4, which are enriched at perivascular endfeet. Rapid ECS shrinkage has been observed following epileptiform activity and can inherently concentrate ions and neurotransmitters including glutamate. This review highlights our emerging knowledge on the various potential contributions of astrocytes to epilepsy, particularly supporting the notion that astrocytes may be involved in seizure initiation via failure of homeostatic responses that lead to increased ambient glutamate. We also review the mechanisms whereby ambient glutamate can influence neuronal excitability, including via generation of the glutamate receptor subunit GluN2B-mediated slow inward currents, as well as indirectly affect neuronal excitability via actions on metabotropic glutamate receptors that can potentiate GluN2B currents and influence neuronal glutamate release probabilities. Additionally, we discuss evidence for upregulation of System x c - , a cystine/glutamate antiporter expressed on astrocytes, in epileptic tissue and changes in expression patterns of glutamate receptors.
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Affiliation(s)
- Oscar B Alcoreza
- Glial Biology in Health, Disease, and Cancer Center, Fralin Biomedical Research Institute, Virginia Tech Carilion, Roanoke, VA, United States.,School of Medicine, Virginia Tech Carilion, Roanoke, VA, United States.,Translational Biology, Medicine and Health, Virginia Tech, Blacksburg, VA, United States
| | - Dipan C Patel
- Glial Biology in Health, Disease, and Cancer Center, Fralin Biomedical Research Institute, Virginia Tech Carilion, Roanoke, VA, United States
| | - Bhanu P Tewari
- Glial Biology in Health, Disease, and Cancer Center, Fralin Biomedical Research Institute, Virginia Tech Carilion, Roanoke, VA, United States
| | - Harald Sontheimer
- Glial Biology in Health, Disease, and Cancer Center, Fralin Biomedical Research Institute, Virginia Tech Carilion, Roanoke, VA, United States
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Sperotto F, Giaretta I, Mondardini MC, Pece F, Daverio M, Amigoni A. Ketamine Prolonged Infusions in the Pediatric Intensive Care Unit: a Tertiary-Care Single-Center Analysis. J Pediatr Pharmacol Ther 2021; 26:73-80. [PMID: 33424503 DOI: 10.5863/1551-6776-26.1.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Ketamine is commonly used as an anesthetic and analgesic agent for procedural sedation, but there is little evidence on its current use as a prolonged continuous infusion in the PICU. We sought to analyze the use of ketamine as a prolonged infusion in critically ill children, its indications, dosages, efficacy, and safety. METHODS We retrospectively reviewed the clinical charts of patients receiving ketamine for ≥24 hours in the period 2017-2018 in our tertiary care center. Data on concomitant treatments pre and 24 hours post ketamine introduction and adverse events were also collected. RESULTS Of the 60 patients included, 78% received ketamine as an adjuvant of analgosedation, 18% as an adjuvant of bronchospasm therapy, and 4% as an antiepileptic treatment. The median infusion duration was 103 hours (interquartile range [IQR], 58-159; range, 24-287), with median dosages between 15 (IQR, 10-20; range, 5-47) and 30 (IQR, 20-50; range, 10-100) mcg/kg/min. At 24 hours of ketamine infusion, dosages/kg/hr of opioids significantly decreased (p < 0.001), and 81% of patients had no increases in dosages of concomitant analgosedation. For 27% of patients with bronchospasm, the salbutamol infusions were lowered at 24 hours after ketamine introduction. Electroencephalograms of epileptic patients (n = 2) showed resolution of status epilepticus after ketamine administration. Adverse events most likely related to ketamine were hypertension (n = 1), hypersalivation (n = 1), and delirium (n = 1). CONCLUSIONS Ketamine can be considered a worthy strategy for the analgosedation of difficult-to-sedate patients. Its use for prolonged sedation allows the sparing of opioids. Its efficacy in patients with bronchospasm or status epilepticus still needs to be investigated.
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Kim D, Kim JM, Cho YW, Yang KI, Kim DW, Lee ST, No YJ, Seo JG, Byun JI, Kang KW, Kim KT. Antiepileptic Drug Therapy for Status Epilepticus. J Clin Neurol 2021; 17:11-19. [PMID: 33480193 PMCID: PMC7840311 DOI: 10.3988/jcn.2021.17.1.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/31/2022] Open
Abstract
Status epilepticus (SE) is one of the most serious neurologic emergencies. SE is a condition that encompasses a broad range of semiologic subtypes and heterogeneous etiologies. The treatment of SE primarily involves the management of the underlying etiology and the use of antiepileptic drug therapy to rapidly terminate seizure activities. The Drug Committee of the Korean Epilepsy Society performed a review of existing guidelines and literature with the aim of providing practical recommendations for antiepileptic drug therapy. This article is one of a series of review articles by the Drug Committee and it summarizes staged antiepileptic drug therapy for SE. While evidence of good quality supports the use of benzodiazepines as the first-line treatment of SE, such evidence informing the administration of second- or third-line treatments is lacking; hence, the recommendations presented herein concerning the treatment of established and refractory SE are based on case series and expert opinions. The choice of antiepileptic drugs in each stage should consider the characteristics and circumstances of each patient, as well as their estimated benefit and risk to them. In tandem with the antiepileptic drug therapy, careful searching for and treatment of the underlying etiology are required.
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Affiliation(s)
- Daeyoung Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae Moon Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea.
| | - Yong Won Cho
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea.
| | - Kwang Ik Yang
- Department of Neurology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Dong Wook Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea
| | - Soon Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Young Joo No
- Department of Neurology, Samsung Noble County, Yongin, Korea
| | - Jong Geun Seo
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jung Ick Byun
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Keun Tae Kim
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
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Lee SK. Diagnosis and Treatment of Status Epilepticus. J Epilepsy Res 2020; 10:45-54. [PMID: 33659195 PMCID: PMC7903042 DOI: 10.14581/jer.20008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/10/2020] [Accepted: 11/24/2020] [Indexed: 12/03/2022] Open
Abstract
The definition of status epilepticus (SE) was revised recently in accordance with the various evidences of neuronal injury and changes in clinical settings. Currently, the most acceptable duration of continuous seizure activity is 5 minutes. In 2015, the International League Against Epilepsy Task Force, which was convened to develop a definition and classification of SE, presented a new classification based on four axes: 1) semiology, 2) etiology, 3) electroencephalogram (EEG) correlates, and 4) age. The essential element of nonconvulsive SE (NCSE) is the presence of neurological abnormalities induced by a prolonged epileptic process. The definition of refractory SE involves either clinical or electrographic seizures that persist after adequate doses of an initial benzodiazepine and acceptable second-line antiseizure drugs. The use of EEG is critical in the diagnosis and treatment of NCSE. However, there are a wide range of EEG abnormalities in NCSE. Both the Neurocritical Care Society and the American Epilepsy Society have suggested a paradigm for treating convulsive SE (CSE). The first-line treatment of CSE with benzodiazepine is well-established. The second-line treatment comprises intravenous (IV) doses of fosphenytoin (phenytoin), valproate, phenobarbital, levetiracetam, or midazolam. Although fosphenytoin (phenytoin) and valproate are commonly used in NCSE, the effectiveness of antiepileptic drugs (AEDs) on NCSE has not been well studied. New AEDs such as IV levetiracetam and lacosamide can also be used to treat NCSE with fewer side effects and drug-drug interactions. For refractory SE, general anesthesia with IV midazolam, propofol, pentobarbital, or thiopental could be applied. Use of ketamine, megadose phenobarbital therapy, and multiple combinations of various AEDs including high doses of oral AEDs can also be considered. New-onset refractory status epilepticus (NORSE) and its subcategory, febrile infection-related epilepsy syndrome, involve autoimmune processes. AEDs alone are poorly effective in the treatment of SE in autoimmune encephalitis. Immunotherapy such as steroids, immunoglobulin, rituximab, or tocilizumab can be effective.
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Affiliation(s)
- Sang Kun Lee
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
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Abstract
This article examines, using an organ-systems based approach, rapid diagnosis, resuscitation, and critical care management of the crashing poisoned patient in the emergency department. The topics discussed in this article include seizures and status epilepticus, respiratory failure, cardiovascular collapse and mechanical circulatory support, antidotes and drug-specific therapies, acute liver failure, and extracorporeal toxin removal.
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Affiliation(s)
- Aaron Skolnik
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
| | - Jessica Monas
- Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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The Unease When Using Anesthetics for Treatment-Refractory Status Epilepticus: Still Far Too Many Questions. J Clin Neurophysiol 2020; 37:399-405. [DOI: 10.1097/wnp.0000000000000606] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Willems LM, Bauer S, Jahnke K, Voss M, Rosenow F, Strzelczyk A. Therapeutic Options for Patients with Refractory Status Epilepticus in Palliative Settings or with a Limitation of Life-Sustaining Therapies: A Systematic Review. CNS Drugs 2020; 34:801-826. [PMID: 32705422 PMCID: PMC8316215 DOI: 10.1007/s40263-020-00747-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Refractory status epilepticus (RSE) represents a serious medical condition requiring early and targeted therapy. Given the increasing number of elderly or multimorbid patients with a limitation of life-sustaining therapy (LOT) or within a palliative care setting (PCS), guidelines-oriented therapy escalation options for RSE have to be omitted frequently. OBJECTIVES This systematic review sought to summarize the evidence for fourth-line antiseizure drugs (ASDs) and other minimally or non-invasive therapeutic options beyond guideline recommendations in patients with RSE to elaborate on possible treatment options for patients undergoing LOT or in a PCS. METHODS A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on fourth-line ASDs or other minimally or non-invasive therapeutic options was performed in February and June 2020 using the MEDLINE, EMBASE and Cochrane databases. The search terminology was constructed using the name of the specific ASD or therapy option and the term 'status epilepticus' with the use of Boolean operators, e.g. "(brivaracetam) AND (status epilepticus)". The respective Medical Subject Headings (MeSH) and Emtree terms were used, if available. RESULTS There is currently no level 1, grade A evidence for the use of ASDs in RSE. The best evidence was found for the use of lacosamide and topiramate (level 3, grade C), followed by brivaracetam, perampanel (each level 4, grade D) and stiripentol, oxcarbazepine and zonisamide (each level 5, grade D). Regarding non-medicinal options, there is little evidence for the use of the ketogenic diet (level 4, grade D) and magnesium sulfate (level 5, grade D) in RSE. The broad use of immunomodulatory or immunosuppressive treatment options in the absence of a presumed autoimmune etiology cannot be recommended; however, if an autoimmune etiology is assumed, steroid pulse, intravenous immunoglobulins and plasma exchange/plasmapheresis should be considered (level 4, grade D). Even if several studies suggested that the use of neurosteroids (level 5, grade D) is beneficial in RSE, the current data situation indicates that there is formal evidence against it. CONCLUSIONS RSE in patients undergoing LOT or in a PCS represents a challenge for modern clinicians and epileptologists. The evidence for the use of ASDs in RSE beyond that in current guidelines is low, but several effective and well-tolerated options are available that should be considered in this patient population. More so than in any other population, advance care planning, advance directives, and medical ethical aspects have to be considered carefully before and during therapy.
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Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany.
| | - Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Kolja Jahnke
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Martin Voss
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- Dr. Senckenberg Institute of Neuro-Oncology, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
- Department of Neurology, Epilepsy Center Hessen, Philipps University Marburg, Marburg (Lahn), Germany
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A Review of Nonanesthetic Uses of Ketamine. Anesthesiol Res Pract 2020; 2020:5798285. [PMID: 32308676 PMCID: PMC7152956 DOI: 10.1155/2020/5798285] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/07/2020] [Accepted: 03/05/2020] [Indexed: 12/20/2022] Open
Abstract
Ketamine, a nonselective NMDA receptor antagonist, is used widely in medicine as an anesthetic agent. However, ketamine's mechanisms of action lead to widespread physiological effects, some of which are now coming to the forefront of research for the treatment of diverse medical disorders. This paper aims at reviewing recent data on key nonanesthetic uses of ketamine in the current literature. MEDLINE, CINAHL, and Google Scholar databases were queried to find articles related to ketamine in the treatment of depression, pain syndromes including acute pain, chronic pain, and headache, neurologic applications including neuroprotection and seizures, and alcohol and substance use disorders. It can be concluded that ketamine has a potential role in the treatment of all of these conditions. However, research in this area is still in its early stages, and larger studies are required to evaluate ketamine's efficacy for nonanesthetic purposes in the general population.
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Borsato GS, Siegel JL, Rose MQ, Ojard M, Feyissa AM, Quinones-Hinojosa A, Jackson DA, Rogers ER, Freeman WD. Ketamine in seizure management and future pharmacogenomic considerations. THE PHARMACOGENOMICS JOURNAL 2019; 20:351-354. [PMID: 31772310 DOI: 10.1038/s41397-019-0120-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 11/12/2019] [Accepted: 11/14/2019] [Indexed: 11/09/2022]
Abstract
Ketamine is a noncompetitive N-methyl-D-aspartate antagonist with emerging evidence for use in medically refractory epilepsy. We describe the novel use of low-dose intravenous (IV) ketamine transitioning to enteral formulation in a patient with drug-resistant localization-related refractory epilepsy. We performed a National Library of Medicine (NLM) literature review using search terms "ketamine", "low dose", and "seizure" for similar cases, followed by an illustrative clinical case. Our NLM search engine methodology yielded 24 hits, none of which described use of low-dose ketamine for seizures. Anesthetic doses are used for status epilepticus, but we show that in a patient with postoperative worsening of his chronic seizure burden, low-dose IV ketamine can be used to avoid oversedation and intubation. We demonstrate that IV ketamine can be transitioned to oral regimen to shorten length of stay in the intensive care unit and hospital and has future CYP2B6 pharmacogenomic considerations for further dose individualization.
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Affiliation(s)
- Giovanna Soldatelli Borsato
- Pontifical Catholic University of Parana, R. Imaculada Conceição, 1155, Prado Velho, Curitiba - PR, 80215-901, Brazil
| | - Jason L Siegel
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA.,Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.,Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Mariah Q Rose
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Michelle Ojard
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Alfredo Quinones-Hinojosa
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.,Department of Otorhinolaryngology, Mayo Clinic, Jacksonville, FL, USA.,Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | | | - Emily R Rogers
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - William D Freeman
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA. .,Department of Neurology, Mayo Clinic, Jacksonville, FL, USA. .,Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.
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Meaden CW, Barnes S. Ketamine Implicated in New Onset Seizure. Clin Pract Cases Emerg Med 2019; 3:401-404. [PMID: 31763599 PMCID: PMC6861038 DOI: 10.5811/cpcem.2019.9.44271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/20/2019] [Accepted: 09/10/2019] [Indexed: 11/30/2022] Open
Abstract
Ketamine is used widely in emergency departments for a variety of purposes, including procedural sedation and pain management. A major benefit of using ketamine is the rapid onset and lack of respiratory depression. The known side effects include emergence reactions, hallucinations, hypertension, dizziness, nausea, and vomiting. Recent studies have shown the benefit of ketamine for refractory status epilepticus; however, this application of the drug is still being studied. We present a case where ketamine likely induced a seizure in a patient on whom it was used as a single agent in procedural sedation. Seizure is not a known side effect of ketamine in patients without a seizure history. Given the eagerness over additional uses for ketamine, this novel case of a seizure following procedural sedation with ketamine should be of interest to emergency providers.
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Affiliation(s)
- Christopher W Meaden
- St. Joseph's University Medical Center, Department of Emergency Medicine, Paterson, New Jersey
| | - Stacey Barnes
- St. Joseph's University Medical Center, Department of Emergency Medicine, Paterson, New Jersey
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Prisco L, Ganau M, Aurangzeb S, Moswela O, Hallett C, Raby S, Fitzgibbon K, Kearns C, Sen A. A pragmatic approach to intravenous anaesthetics and electroencephalographic endpoints for the treatment of refractory and super-refractory status epilepticus in critical care. Seizure 2019; 75:153-164. [PMID: 31623937 DOI: 10.1016/j.seizure.2019.09.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/23/2019] [Indexed: 12/13/2022] Open
Abstract
Status epilepticus is a common neurological emergency, with overall mortality around 20%. Over half of cases are first time presentations of seizures. The pathological process by which spontaneous seizures are generated arises from an imbalance in excitatory and inhibitory neuronal networks, which if unchecked, can result in alterations in intracellular signalling pathways and electrolyte shifts, which bring about changes in the blood brain barrier, neuronal cell death and eventually cerebral atrophy. This narrative review focusses on the treatment of status epilepticus in adults. Anaesthetic agents interrupt neuronal activity by enhancing inhibitory or decreasing excitatory transmission, primarily via GABA and NMDA receptors. Intravenous anaesthetic agents are commonly used as second or third line drugs in the treatment of refractory status epilepticus, but the optimal timing and choice of anaesthetic drug has not yet been established by high quality evidence. Titration of antiepileptic and anaesthetic drugs in critically ill patients presents a particular challenge, due to alterations in drug absorbtion and metabolism as well as changes in drug distrubution, which arise from fluid shifts and altered protein binding. Furthermore, side effects associated with prolonged infusions of anaesthetic drugs can lead to multi-organ dysfunction and a need for critical care support. Electroencelography can identify patterns of burst suppression, which may be a target to guide weaning of intravenous therapy. Continuous elctroencephalography has the potential to directly impact clinical care, but despite its utility, major barriers exist which have limited its widespread use in clinical practice. A flow chart outlining the timing and dosage of anaesthetic agents used at our institution is provided.
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Affiliation(s)
- Lara Prisco
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Anaesthesia Neuroimaging Research Group, Wellcome Centre for Integrative Neuroimaging, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Oxford Epilepsy Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK.
| | - Mario Ganau
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sidra Aurangzeb
- Oxford Epilepsy Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK; Department of Clinical Neurology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Department of Clinical Neurophysiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Olivia Moswela
- Pharmacy Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Claire Hallett
- Pharmacy Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon Raby
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karina Fitzgibbon
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christopher Kearns
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Arjune Sen
- Oxford Epilepsy Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK; Department of Clinical Neurology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Erbguth F. [Management of refractory and super-refractory status epilepticus]. Med Klin Intensivmed Notfmed 2019; 114:628-634. [PMID: 31463678 DOI: 10.1007/s00063-019-00610-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 07/30/2019] [Accepted: 07/30/2019] [Indexed: 11/30/2022]
Abstract
If status epilepticus continues despite the use of intravenous antiepileptic drugs or narcotics, it is called "refractory" or "super-refractory" status epilepticus (RSE, SRSE). Prolonged seizure activity is associated with neuronal damage, systemic complications and mortality rates of up to 50%, especially in generalized tonic clonic seizure types. In order to terminate the status, several rescue interventions with drugs and other measures are available. However, their evidence base is low because the effectiveness of the measures was almost exclusively derived from case reports and case series. In individual cases, a good outcome is possible even after several months of ongoing SRSE.
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Affiliation(s)
- Frank Erbguth
- Klinik für Neurologie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität, Breslauer Str. 201, 90471, Nürnberg, Deutschland.
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Gofton TE, Gaspard N, Hocker SE, Loddenkemper T, Hirsch LJ. New onset refractory status epilepticus research: What is on the horizon? Neurology 2019; 92:802-810. [PMID: 30894443 DOI: 10.1212/wnl.0000000000007322] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 01/17/2019] [Indexed: 12/14/2022] Open
Abstract
New-onset refractory status epilepticus (NORSE) is a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurologic disorder, with new onset of refractory status epilepticus (RSE) that does not resolve after 2 or more rescue medications, without a clear acute or active structural, toxic, or metabolic cause. Febrile infection-related epilepsy syndrome is a subset of NORSE in which fever began at least 24 hours prior to the RSE. Both terms apply to all age groups. Until recently, NORSE was a poorly recognized entity without a consistent definition or approach to care. We review the current state of knowledge in NORSE and propose a roadmap for future collaborative research. Research investigating NORSE should prioritize the following 4 domains: (1) clinical features, etiology, and pathophysiology; (2) treatment; (3) adult and pediatric evaluation and management approaches; and (4) public advocacy, professional education, and family support. We consider international collaboration and multicenter research crucial in achieving these goals.
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Affiliation(s)
- Teneille E Gofton
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT.
| | - Nicolas Gaspard
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Sara E Hocker
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Tobias Loddenkemper
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Lawrence J Hirsch
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
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Fujikawa DG. Starting ketamine for neuroprotection earlier than its current use as an anesthetic/antiepileptic drug late in refractory status epilepticus. Epilepsia 2019; 60:373-380. [PMID: 30785224 DOI: 10.1111/epi.14676] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 12/26/2022]
Abstract
Ketamine is currently being used as an anesthetic/antiepileptic drug in refractory status epilepticus. To validate its use, 2 clinical trials are recruiting patients. However, preclinical studies of its use in chemically induced status epilepticus in rodents have shown that it is remarkably neuroprotective, through N-methyl-d-aspartate-receptor blockade, even when given after the onset of status epilepticus. Human studies have shown that status epilepticus-induced brain damage can be caused by a glutamate analogue and that it occurs in the same brain regions as in the animal studies. We therefore propose that ketamine be started early in the course of human status epilepticus as a neuroprotectant and that it be continued until epileptic discharges are eliminated. Using it as an anesthetic/antiepileptic drug late in the course of refractory status epilepticus only ensures that it is given after widespread brain damage has occurred.
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Affiliation(s)
- Denson G Fujikawa
- Neurology Department, VA Greater Los Angeles Healthcare System, Sepulveda Ambulatory Care Center and Nursing Home, North Hills, California.,Department of Neurology and Brain Research Institute, David Geffen School of Medicine, Los Angeles, California
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Morano A, Iannone L, Palleria C, Fanella M, Giallonardo AT, De Sarro G, Russo E, Di Bonaventura C. Pharmacology of new and developing intravenous therapies for the management of seizures and epilepsy. Expert Opin Pharmacother 2018; 20:25-39. [PMID: 30403892 DOI: 10.1080/14656566.2018.1541349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Antiepileptic drugs (AEDs) are administered orally for chronic use. Parenteral formulations might be necessary when the oral route is not feasible (e.g. an impairment of consciousness, trauma, dysphagia, gastrointestinal illness) or for treatment of seizure emergencies. At present, few intravenous (IV) formulations are available on the market. AREAS COVERED The purpose of this review is to summarize the pharmacological characteristics and clinical applications of IV medications that have been recently introduced to the armamentarium of epilepsy therapy or are currently being developed. Apart from AEDs, other compounds belonging to different pharmacological classes (e.g. diuretics, anesthetics), which have shown potential effectiveness in seizure control, are taken into consideration, and the pathophysiological premises supporting their use for epilepsy treatment are illustrated. The authors give particular focus to immunomodulatory and immunosuppressive agents, which have become the therapeutic cornerstones for immune-mediated epilepsies, despite regulatory obstacles. EXPERT OPINION In several circumstances, especially in the case of seizure-related emergencies, clinical practice seems not match literature-based evidence, and several IV AEDs are still used off-label. Strong evidence derived from randomized clinical trials (RCTs) is needed to support the effectiveness and tolerability of any therapeutic approach, however common and "accepted' it may be, in order to guarantee patient safety and well-being.
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Affiliation(s)
- Alessandra Morano
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Luigi Iannone
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Caterina Palleria
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Martina Fanella
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Anna Teresa Giallonardo
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Giovambattista De Sarro
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Emilio Russo
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Carlo Di Bonaventura
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
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