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Au YK, Kananeh MF, Rahangdale R, Moore TE, Panza GA, Gaspard N, Hirsch LJ, Fernandez A, Shah SO. Treatment of Refractory Status Epilepticus With Continuous Intravenous Anesthetic Drugs: A Systematic Review. JAMA Neurol 2024; 81:534-548. [PMID: 38466294 DOI: 10.1001/jamaneurol.2024.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Importance Multiple continuous intravenous anesthetic drugs (CIVADs) are available for the treatment of refractory status epilepticus (RSE). There is a paucity of data comparing the different types of CIVADs used for RSE. Objective To systematically review and compare outcome measures associated with the initial CIVAD choice in RSE in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Evidence Review Data sources included English and non-English articles using Embase, MEDLINE, PubMed, and Web of Science (January 1994-June 2023) as well as manual search. Study selection included peer-reviewed studies of 5 or more patients and at least 1 patient older than 12 years with status epilepticus refractory to a benzodiazepine and at least 1 standard antiseizure medication, treated with continuously infused midazolam, ketamine, propofol, pentobarbital, or thiopental. Independent extraction of articles was performed using prespecified data items. The association between outcome variables and CIVAD was examined with an analysis of variance or χ2 test where appropriate. Binary logistic regressions were used to examine the association between outcome variables and CIVAD with etiology, change in mortality over time, electroencephalography (EEG) monitoring (continuous vs intermittent), and treatment goal (seizure vs burst suppression) included as covariates. Risk of bias was addressed by listing the population and type of each study. Findings A total of 66 studies with 1637 patients were included. Significant differences among CIVAD groups in short-term failure, hypotension, and CIVAD substitution during treatment were observed. Non-epilepsy-related RSE (vs epilepsy-related RSE) was associated with a higher rate of CIVAD substitution (60 of 120 [50.0%] vs 11 of 43 [25.6%]; odds ratio [OR], 3.11; 95% CI, 1.44-7.11; P = .006) and mortality (98 of 227 [43.2%] vs 7 of 63 [11.1%]; OR, 17.0; 95% CI, 4.71-109.35; P < .001). Seizure suppression was associated with mortality (OR, 7.72; 95% CI, 1.77-39.23; P = .005), but only a small subgroup was available for analysis (seizure suppression: 17 of 22 [77.3%] from 3 publications vs burst suppression: 25 of 98 [25.5%] from 12 publications). CIVAD choice and EEG type were not predictors of mortality. Earlier publication year was associated with mortality, although the observation was no longer statistically significant after adjusting SEs for clustering. Conclusions and Relevance Epilepsy-related RSE was associated with lower mortality compared with other RSE etiologies. A trend of decreasing mortality over time was observed, which may suggest an effect of advances in neurocritical care. The overall data are heterogeneous, which limits definitive conclusions on the choice of optimal initial CIVAD in RSE treatment.
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Affiliation(s)
- Yu Kan Au
- Department of Neurosciences, Hartford Hospital, University of Connecticut, Hartford, Connecticut
- Department of Neurology, University of Connecticut, Farmington
| | - Mohammed F Kananeh
- Department of Neurology, Hackensack University Medical Center, Hackensack, New Jersey
- Department of Neurology, Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Rahul Rahangdale
- Neuroscience Institute, Ascension St John Medical Center, Tulsa, Oklahoma
| | - Timothy Eoin Moore
- Statistical Consulting Services, Center for Open Research Resources & Equipment, University of Connecticut, Storrs
| | - Gregory A Panza
- Department of Research, Hartford HealthCare, Hartford, Connecticut
| | - Nicolas Gaspard
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
- Université Libre de Bruxelles and Service de Neurologie, Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Andres Fernandez
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Syed Omar Shah
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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2
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Van S, Lam V, Patel K, Humphries A, Siddiqi J. Propofol-Related Infusion Syndrome: A Bibliometric Analysis of the 100 Most-Cited Articles. Cureus 2023; 15:e46497. [PMID: 37927719 PMCID: PMC10624560 DOI: 10.7759/cureus.46497] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
Propofol-related infusion syndrome (PRIS) is a rare, yet life-threatening sequelae to prolonged administration of the anesthetic propofol in mechanically intubated patients. The condition is characterized by progressive multi-system organ failure and eventual mortality; of note, the predominant characteristics of PRIS involve but are not limited to cardiovascular impairment and collapse, metabolic and lactic acidosis, rhabdomyolysis, hyperkalemia, and acute renal failure. While potent or extended doses of propofol have been found to be the primary precipitating factor of this condition, others such as age, critical illness, steroid therapy, and hyperlipidemia have been discovered to play a role as well. This bibliometric analysis was done to reflect the current relevance and understanding of PRIS in recent literature. The SCOPUS database was utilized to conduct a search for articles with keywords "propofol infusion syndrome" and "propofol syndrome" from February 24, 2001, until April 16, 2023, with parameters for article title, citation number, citation per year, author, institution, publishing journal, and country of origin. PRIS was first defined in 1990, just a year after its approval by the Food and Drug Administration for use as a sedative-hypnotic. Since then, interest in PRIS slowly rose up to 13 publications per year in 2013. Seven papers on the topic were published in Critical Care Medicine, six in Neurocritical Care, and four in Anesthesia. The most common institutions were Mayo Clinic, Northeastern University, and Tufts Medical Center. To our knowledge, this is the first bibliometric analysis to evaluate the most influential publications about PRIS. A majority of the research is case-based, possibly owing to the rarity of the condition. Our research suggests that confounding factors outside the precipitating dosage of propofol may be implicated in the onset and progression of PRIS. This study could therefore bring renewed interest to the topic and lead to additional research focused on fully understanding the pathophysiology of PRIS in order to promote the development of novel diagnostics and treatment.
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Affiliation(s)
- Sophie Van
- Anesthesiology, California University of Science and Medicine, Colton, USA
| | - Vicky Lam
- Anesthesiology, California University of Science and Medicine, Colton, USA
| | - Kisan Patel
- Physical Medicine and Rehabilitation, California University of Science and Medicine, Colton, USA
| | - Andrew Humphries
- Anesthesiology, California University of Science and Medicine, Colton, USA
| | - Javed Siddiqi
- Neurological Surgery, Riverside University Health System Medical Center, Moreno Valley, USA
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3
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Dessai S, Ninave S, Bele A, P S. Anesthesia for a Patient With Cerebrovascular Accident with Seizure Disorder Undergoing Medical Termination of Pregnancy: A Case Report. Cureus 2023; 15:e42487. [PMID: 37637543 PMCID: PMC10452931 DOI: 10.7759/cureus.42487] [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: 05/01/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
The term "total intravenous anesthesia" refers to the preservation of an anesthetic plane with the use of an injectable anesthetic, a sedative that is often given in intermittent boluses. The tendency to have recurrent unprovoked seizures is known as epilepsy. Its prevalence ranges from 0.5% to 1%. The highest incidence rates are in those with anatomical or developmental brain abnormalities, as well as at the extremes of age. The most common triggering factors for epilepsy are stress and fear. The main advantage of total intravenous anesthesia is the patient's rapid recovery and early ambulatory. Conscious sedation is a strategy for giving patients excellent anesthesia and analgesia. In this case report, we will describe a high-risk epileptic patient who required conscious sedation to perform a medical termination.
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Affiliation(s)
- Saiesh Dessai
- Department of Anaesthesiology, Jawaharlal Nehru Medical College,Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sanjot Ninave
- Department of Anaesthesiology, Jawaharlal Nehru Medical College,Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Amol Bele
- Department of Anaesthesiology, Jawaharlal Nehru Medical College,Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shiras P
- Department of Anaesthesiology, Jawaharlal Nehru Medical College,Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Park SJ, Baek J, Chun S, Choi EK. Anesthetic Management and Bispectral Index in a Child with Miller–Dieker Syndrome: A Case Report. CHILDREN 2023; 10:children10040631. [PMID: 37189880 DOI: 10.3390/children10040631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 03/15/2023] [Accepted: 03/27/2023] [Indexed: 03/30/2023]
Abstract
Miller–Dieker syndrome (MDS) is a genetic disorder characterized by classic lissencephaly, distinctive facial features, intellectual disability, seizures, and early death. The anesthetic management of patients with MDS should focus on airway manipulation with the risk of potentially difficult intubation, seizure control due to lissencephaly, and any other clinical complications. Herein, we report a case of anesthetic management in a child with MDS and describe relevant clinical features in a perioperative anesthetic setting. This case highlights the importance of difficult airway manipulation using a videolaryngoscope, seizure management with regard to anesthetics use, and the low validity of BIS monitoring in patients with MDS.
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5
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Treatment of refractory status epilepticus with intravenous anesthetic agents: A systematic review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.1016/j.tacc.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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6
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Dericioglu N, Ayvacioglu Cagan C, Sokmen O, Arsava EM, Topcuoglu MA. Frequency and Types of Complications Encountered in Patients With Nonconvulsive Status Epilepticus in the Neurological ICU: Impact on Outcome. Clin EEG Neurosci 2021; 54:265-272. [PMID: 34714180 DOI: 10.1177/15500594211046722] [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] [Indexed: 11/17/2022]
Abstract
Objectives. The frequency and types of complications in patients with nonconvulsive status epilepticus (NCSE) who are followed up in the intensive care unit (ICU), and the impact of these complications on outcome are not well-known. We investigated the complications and their effects on prognosis in NCSE patients. Methods. After reviewing the video-EEG monitoring (VEEGM) reports of all the consecutive patients who were followed up in our ICU between 2009 and 2019, we identified two groups of patients: 1-patients with NCSE (study group) and 2-patients who underwent VEEGM for possible NCSE but did not have ictal recordings (no-NCSE group). Electronic health records were reviewed to identify demographic and clinical data, duration of ICU care, medical and surgical complications, pharmacologic treatment, and outcome. These parameters were compared statistically between the groups. We also investigated the parameters affecting prognosis at discharge. Results. Thirty-two patients with NCSE comprised the study group. Infection developed in 84%. More than half were intubated, had tracheostomy or percutaneous endoscopic gastrostomy application. Refractory NCSE was associated with significantly more frequent complications and worse outcome. There was a higher tendency of infections in the study group (P = .059). Higher organ failure scores and prolonged stay in ICU predicted worse outcome (P < .05). Conclusion. The frequency of complications in patients with NCSE who are cared for in the ICU is considerable. Most of the complications are similar to the other patients in ICU, except for the higher frequency of infections. Increased physician awareness about modifiable parameters and timely interventions might help improve prognosis.
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Sadeghi M, Eshraghi M, Akers KG, Hadidchi S, Kakara M, Nasseri M, Mahulikar A, Marawar R. Outcomes of status epilepticus and their predictors in the elderly-A systematic review. Seizure 2020; 81:210-221. [PMID: 32862117 DOI: 10.1016/j.seizure.2020.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 11/16/2022] Open
Abstract
Status epilepticus (SE) is associated with high mortality and morbidity. Although SE is frequently seen in elderly patients, there is a lack of a cohesive report of outcome measures and associated factors within this population. Our aim was to systematically review studies reporting outcomes of SE among elderly patients and factors influencing these outcomes. A literature search was conducted in PubMed/MEDLINE, EMBASE, CINAHL Complete, and Cochrane Library from database conception to April 22, 2018. A total of 85 studies were included in this systematic review. The included studies show that mortality is higher in elderly patients than in adult patients. Lesional etiologies, higher number of comorbidities, NCSE, RSE, longer hospital and intensive care unit stays, and infection during hospitalization are associated with poor outcome. Future studies should consider measuring functional outcomes, comparative studies between elderly and adults and AED clinical trials specific for elderly with SE.
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Affiliation(s)
- Mahsa Sadeghi
- Department of Neurology, Wayne State University/Detroit Medical Center, University Health Center, 4201 St Antoine Ave, Detroit, MI, 4820, USA
| | - Mehdi Eshraghi
- Department of Internal Medicine, Wayne State University, University Health Center-4201 St. Antoine- Suite 2E, Detroit, MI, 48201, USA
| | - Kathrine G Akers
- Shiffman Medical Library, Wayne State University, 232C Shiffman Medical Library, Detroit, MI, 48201, USA
| | - Shahram Hadidchi
- Department of Radiology, Wayne State University/Detroit Medical Center, Detroit Receiving Hospital 3L-8, 4201 St. Antoine Ave, Detroit, MI, 48201, USA
| | - Mihir Kakara
- Department of Neurology, Wayne State University/Detroit Medical Center, University Health Center, 4201 St Antoine Ave, Detroit, MI, 4820, USA
| | - Morad Nasseri
- Department of Neurology, Wayne State University/Detroit Medical Center, University Health Center, 4201 St Antoine Ave, Detroit, MI, 4820, USA
| | - Advait Mahulikar
- Department of Neurology, Wayne State University/Detroit Medical Center, University Health Center, 4201 St Antoine Ave, Detroit, MI, 4820, USA
| | - Rohit Marawar
- Department of Neurology, Wayne State University/Detroit Medical Center, University Health Center, 4201 St Antoine Ave, Detroit, MI, 4820, USA.
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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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Semmlack S, Kaplan PW, Spiegel R, De Marchis GM, Hunziker S, Tisljar K, Rüegg S, Marsch S, Sutter R. Illness severity scoring in status epilepticus—When
STESS
meets
APACHE II
,
SAPS II
, and
SOFA. Epilepsia 2018; 60:189-200. [DOI: 10.1111/epi.14623] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 11/24/2018] [Accepted: 11/25/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Saskia Semmlack
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
| | - Peter W. Kaplan
- Department of Neurology Johns Hopkins Bayview Medical Center Baltimore Maryland
| | - Rainer Spiegel
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
| | | | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine University Hospital Basel Basel Switzerland
- Medical Faculty of the University of Basel Basel Switzerland
| | - Kai Tisljar
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
| | - Stephan Rüegg
- Department of Neurology University Hospital Basel Basel Switzerland
| | - Stephan Marsch
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
- Medical Faculty of the University of Basel Basel Switzerland
| | - Raoul Sutter
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
- Department of Neurology University Hospital Basel Basel Switzerland
- Medical Faculty of the University of Basel Basel Switzerland
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10
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Das AS, Lee JW, Izzy S, Vaitkevicius H. Ultra-short burst suppression as a "reset switch" for refractory status epilepticus. Seizure 2018; 64:41-44. [PMID: 30553087 DOI: 10.1016/j.seizure.2018.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 11/18/2022] Open
Affiliation(s)
- Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, United States.
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States.
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States.
| | - Henrikas Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States.
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11
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Factors associated with refractoriness and outcome in an adult status epilepticus cohort. Seizure 2018; 61:111-118. [DOI: 10.1016/j.seizure.2018.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/25/2018] [Accepted: 07/27/2018] [Indexed: 11/20/2022] Open
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12
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Lu WY, Weng WC, Wong LC, Lee WT. The etiology and prognosis of super-refractory convulsive status epilepticus in children. Epilepsy Behav 2018; 86:66-71. [PMID: 30006260 DOI: 10.1016/j.yebeh.2018.06.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 06/13/2018] [Accepted: 06/15/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Both refractory convulsive status epilepticus (SE) and super-refractory SE are medical emergencies. However, there are limited data on super-refractory SE in children. Thus, this study focuses on characterizing the demographics, outcomes, and prognostic factors for super-refractory SE in children. METHODS This study was a retrospective analysis of super-refractory SE treated in a tertiary referral center in Taiwan. The functional outcome was evaluated by modified Rankin scale (mRS). Significant functional decline was defined as an mRS difference (before hospital admission and at discharge) of more than 2. The variates and the follow-up mRS values were then analyzed statistically. RESULTS We enrolled 134 patients with 191 episodes of convulsive SE and identified 30 patients with 38 episodes of convulsive super-refractory SE. The incidence of convulsive super-refractory SE in the group with SE was 19.9%, and the age ranged from 2.5 months to 17 years. In-hospital mortality was 13.3%, which was much lower than that of adult cohorts. Newly acquired epilepsy and cognitive deficit occurred in 100% and 88.5%, respectively. Newly acquired epilepsy, as a sequel of super-refractory SE, was observed in all 18 patients (100%) who survived and had no history of epilepsy. Significant functional decline (mRS difference of more than 2) at discharge occurred in 76.7%. Poor functional outcome was associated with acute symptomatic etiology (P < 0.001) and the number of anesthetic agents (P = 0.002). The functional outcome improved after 1 year of follow-up in our population. CONCLUSIONS Super-refractory SE is associated with significant morbidity and mortality in children. However, the in-hospital mortality rate is much lower compared with adults. The functional outcome in children is associated with acute symptomatic etiology and the number of anesthetic agents and may improve after long-term follow-up.
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Affiliation(s)
- Wen-Yu Lu
- Department of Pediatrics, Min-Sheng General Hospital, No. 168, ChingKuo Rd., Taoyuan Dist., Taoyuan City 330, Taiwan; Department of Pediatrics, National Taiwan University Hospital, No. 8, Zhongshan S. Rd., Zhongzheng Dist., Taipei City 100, Taiwan
| | - Wen-Chin Weng
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Zhongshan S. Rd., Zhongzheng Dist., Taipei City 100, Taiwan; Clinical Center for Neuroscience and Behavior, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City 100, Taiwan
| | - Lee-Chin Wong
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan
| | - Wang-Tso Lee
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Zhongshan S. Rd., Zhongzheng Dist., Taipei City 100, Taiwan; Clinical Center for Neuroscience and Behavior, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City 100, Taiwan; Graduate Institute of Brain and Mind Sciences, National Taiwan University, No. 1, Sec. 4, Roosevelt Rd., Da'an Dist., Taipei City 106, Taiwan.
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13
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Abstract
Refractory and super-refractory status epilepticus (SE) are serious illnesses with a high risk of morbidity and even fatality. In the setting of refractory generalized convulsive SE (GCSE), there is ample justification to use continuous infusions of highly sedating medications-usually midazolam, pentobarbital, or propofol. Each of these medications has advantages and disadvantages, and the particulars of their use remain controversial. Continuous EEG monitoring is crucial in guiding the management of these critically ill patients: in diagnosis, in detecting relapse, and in adjusting medications. Forms of SE other than GCSE (and its continuation in a "subtle" or nonconvulsive form) should usually be treated far less aggressively, often with nonsedating anti-seizure drugs (ASDs). Management of "non-classic" NCSE in ICUs is very complicated and controversial, and some cases may require aggressive treatment. One of the largest problems in refractory SE (RSE) treatment is withdrawing coma-inducing drugs, as the prolonged ICU courses they prompt often lead to additional complications. In drug withdrawal after control of convulsive SE, nonsedating ASDs can assist; medical management is crucial; and some brief seizures may have to be tolerated. For the most refractory of cases, immunotherapy, ketamine, ketogenic diet, and focal surgery are among several newer or less standard treatments that can be considered. The morbidity and mortality of RSE is substantial, but many patients survive and even return to normal function, so RSE should be treated promptly and as aggressively as the individual patient and type of SE indicate.
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Affiliation(s)
- Samhitha Rai
- KS 457, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Frank W Drislane
- KS 457, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA.
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14
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Refractory status epilepticus: Impact of baseline comorbidity and usefulness of STESS and EMSE scoring systems in predicting mortality and functional outcome. Seizure 2018; 56:98-103. [DOI: 10.1016/j.seizure.2018.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/19/2018] [Accepted: 02/10/2018] [Indexed: 11/22/2022] Open
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15
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Kämppi L, Mustonen H, Kotisaari K, Soinila S. The essence of the first 2.5 h in the treatment of generalized convulsive status epilepticus. Seizure 2018; 55:9-16. [DOI: 10.1016/j.seizure.2017.12.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/20/2017] [Accepted: 12/27/2017] [Indexed: 12/29/2022] Open
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16
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Aroor S, Shravan K, Mundkur SC, Jayakrishnan C, Rao SS. Super-Refractory Status Epilepticus: A Therapeutic Challenge in Paediatrics. J Clin Diagn Res 2017; 11:SR01-SR04. [PMID: 28969235 PMCID: PMC5620876 DOI: 10.7860/jcdr/2017/25811.10485] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 06/20/2017] [Indexed: 11/24/2022]
Abstract
A status epilepticus which persists for 24 hours or more after starting treatment with anaesthesia or has recurred inspite of general anaesthesia is known as Super-Refractory Status Epilepticus (SRSE). It includes cases where status epilepticus recurs on reduction or withdrawal of anaesthesia. SRSE, though infrequently seen, constitutes a medical emergency due to the associated high morbidity and mortality. No clear cut guidelines are available till date for the management of SRSE. Most of the published literature was case reports and expert opinion. We hereby reported three cases of super refractory seizures as they posed a therapeutic challenge. All three children were aged 6-7 years with prior normal developmental history and no medical illness. Viral meningoencephalitis, fever induced refractory status epilepticus, and auto-immune encephalitis was the probable aetiology in the cases studied. Midazolam, pentobarbital, and ketamine are the most commonly used anaesthetic agents. Phenytoin, phenobarbitone, valproate and levetiracetam are the most commonly used antiepileptic agents. All three cases had residual neurological deficits and morbidities like pneumonia and sepsis. SRSE is associated with high rates of mortality and morbidity necessitating immediate treatment.
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Affiliation(s)
- Shrikiran Aroor
- Professor and Head, Department of Paediatrics, Kasturba Medical College, Manipal, Karnataka, India
| | - Kanaparthi Shravan
- Senior Resident, Department of Paediatrics, Kasturba Medical College, Manipal, Karnataka, India
| | - Suneel C Mundkur
- Additional Professor, Department of Paediatrics, Kasturba Medical College, Manipal, Karnataka, India
| | - C Jayakrishnan
- Associate Professor, Department of Neurology, Kasturba Medical College, Manipal, Karnataka, India
| | - Sai Sripad Rao
- Registrar, Department of Neurology, Kasturba Medical College, Manipal, Karnataka, India
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Challenges in the treatment of convulsive status epilepticus. Seizure 2017; 47:17-24. [DOI: 10.1016/j.seizure.2017.02.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 01/09/2023] Open
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Continuous Infusion Antiepileptic Medications for Refractory Status Epilepticus: A Review for Nurses. Crit Care Nurs Q 2016; 40:67-85. [PMID: 27893511 DOI: 10.1097/cnq.0000000000000143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Status epilepticus requires treatment with emergent initial therapy with a benzodiazepine and urgent control therapy with an additional antiepileptic drug (AED) to terminate clinical and/or electrographic seizure activity. However, nearly one-third of patients will prove refractory to the aforementioned therapies and are prone to a higher degree of neuronal injury, resistance to pharmacotherapy, and death. Current guidelines for refractory status epilepticus (RSE) recommend initiating a continuous intravenous (CIV) anesthetic over bolus dosing with a different AED. Continuous intravenous agents most commonly used for this indication include midazolam, propofol, and pentobarbital, but ketamine is an alternative option. Comparative studies illustrating the optimal agent are lacking, and selection is often based on adverse effect profiles and patient-specific factors. In addition, dosing and titration are largely based on small studies and expert opinion with continuous electroencephalogram monitoring used to guide intensity and duration of treatment. Nonetheless, the doses required to halt seizure activity are likely to produce profound adverse effects that clinicians should anticipate and combat. The purpose of this review was to summarize the available RSE literature focusing on CIV midazolam, pentobarbital, propofol, and ketamine, and to serve as a primer for nurses providing care to these patients.
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Ren L, Zhang F, Min S, Hao X, Qin P, Zhu X. Propofol ameliorates electroconvulsive shock-induced learning and memory impairment by regulation of synaptic metaplasticity via autophosphorylation of CaMKIIa at Thr 305 in stressed rats. Psychiatry Res 2016; 240:123-130. [PMID: 27104927 DOI: 10.1016/j.psychres.2016.03.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 02/15/2016] [Accepted: 03/16/2016] [Indexed: 01/19/2023]
Abstract
Electroconvulsive therapy (ECT) is an effective treatment for depression, but it can induce learning and memory impairment. Our previous study found propofol (γ-aminobutyric acid (GABA) receptor agonist) could ameliorate electroconvulsive shock (ECS, an analog of ECT to animals)-induced cognitive impairment, however, the underlying molecular mechanisms remain unclear. This study aimed to investigate the effects of propofol on metaplasticity and autophosphorylation of CaMKIIa in stressed rats receiving ECS. Depressive-like behavior and learning and memory function were assessed by sucrose preference test and Morris water test respectively. LTP were tested by electrophysiological experiment, the expression of CaMKIIa, p-T305-CaMKII in hippocampus and CaMKIIα in hippocampal PSD fraction were evaluated by western blot. Results suggested ECS raised the baseline fEPSP and impaired the subsequent LTP, increased the expression of p-T305-CaMKII and decreased the expression of CaMKIIα in hippocampal PSD fraction, leading to cognitive dysfunction in stressed rats. Propofol could down-regulate the baseline fEPSP and reversed the impairment of LTP partly, decreased the expression of p-T305-CaMKII and increased the expression of CaMKIIα in hippocampal PSD fraction and alleviated ECS-induced learning and memory impairment. In conclusion, propofol ameliorates ECS-induced learning and memory impairment, possibly by regulation of synaptic metaplasticity via p-T305-CaMKII.
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Affiliation(s)
- Li Ren
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fan Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Xuechao Hao
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Peipei Qin
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xianlin Zhu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Reznik ME, Berger K, Claassen J. Comparison of Intravenous Anesthetic Agents for the Treatment of Refractory Status Epilepticus. J Clin Med 2016; 5:jcm5050054. [PMID: 27213459 PMCID: PMC4882483 DOI: 10.3390/jcm5050054] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/08/2016] [Accepted: 05/16/2016] [Indexed: 11/16/2022] Open
Abstract
Status epilepticus that cannot be controlled with first- and second-line agents is called refractory status epilepticus (RSE), a condition that is associated with significant morbidity and mortality. Most experts agree that treatment of RSE necessitates the use of continuous infusion intravenous anesthetic drugs such as midazolam, propofol, pentobarbital, thiopental, and ketamine, each of which has its own unique characteristics. This review compares the various anesthetic agents while providing an approach to their use in adult patients, along with possible associated complications.
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Affiliation(s)
- Michael E Reznik
- Department of Critical Care Neurology, Columbia University Medical Center, New York, NY 10032, USA.
| | - Karen Berger
- Department of Pharmacy, Weill Cornell Medical Center, New York, NY 10065, USA.
| | - Jan Claassen
- Department of Critical Care Neurology, Columbia University Medical Center, New York, NY 10032, USA.
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Sabharwal V, Ramsay E, Martinez R, Shumate R, Khan F, Dave H, Iwuchukwu I, McGrade H. Propofol-ketamine combination therapy for effective control of super-refractory status epilepticus. Epilepsy Behav 2015; 52:264-6. [PMID: 26523340 DOI: 10.1016/j.yebeh.2015.07.040] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 07/30/2015] [Indexed: 11/25/2022]
Abstract
Retrospective analysis was conducted of patients with SRSE who were treated simultaneously with propofol and ketamine. Sixty-seven patients were identified from 2012 to 2015, and outcomes documented were resolution and mortality. The duration of combined ketamine and propofol use ranged from 1 to 28 days (mean - 3.6 days). Infusion rates ranged up to 145 and 175 mcg/kg/min. Vasopressors were used in 53 patients (79%), and were given within the first 5 days of the ICU admission in 48 (91%) patients. The overall SRSE resolution rate was 91%, and the overall mortality including patients with anoxic brain injury was 39%. Of the 13 patients with SRSE as a result of anoxic brain injury, SRSE was controlled in 5 (56%). The primary determinant of mortality was family withdrawing care related to the presence of severe medical/neurological diseases.
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Affiliation(s)
| | | | | | | | - Fawad Khan
- Ochsner Medical Center, New Orleans, LA, USA
| | - Hina Dave
- Ochsner Medical Center, New Orleans, LA, USA
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Shu S. Anesthesia-related status epilepticus after fiber optic colonoscopy in a child. SCIENCEOPEN RESEARCH 2015. [DOI: 10.14293/s2199-1006.1.sor-med.axk5rb.v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
A healthy, 8-year-old girl with a history of hematochezia underwent an uneventful fiber optic colonoscopy with propofol anesthesia. During the postoperative recovery period, she experienced acute-onset muscle rigidity, loss of consciousness, apnea, hypoxia, and hyperthermia. She was administered cardiopulmonary resuscitation and was treated with naloxone, mannitol, and midazolam. She regained consciousness after 14 hours. She underwent cerebral function rehabilitation and was discharged in 1 month without obvious neurologic sequelae. This case illustrates that propofol may affect the developing brain differently from the adult brain. Propofol-induced seizures can lead to life-threatening status epilepticus in children. Immediate diagnosis and effective treatment are essential.
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Anson JA, Vaida S, Giampetro DM, McQuillan PM. Anesthetic management of labor and delivery in patients with elevated intracranial pressure. Int J Obstet Anesth 2015; 24:147-60. [PMID: 25794413 DOI: 10.1016/j.ijoa.2015.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 12/31/2014] [Accepted: 01/12/2015] [Indexed: 10/24/2022]
Abstract
The anesthetic management of labor and delivery in patients with elevated intracranial pressure is complex. This review discusses the etiologies of diffuse and focal pathologies which lead to elevated intracranial pressure in pregnancy. The role of neuraxial and general anesthesia in the management of labor and delivery is also examined. Finally, a comprehensive review of strategies to minimize increases in intracranial pressure during general anesthesia for cesarean delivery is presented.
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Affiliation(s)
- J A Anson
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.
| | - S Vaida
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - D M Giampetro
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - P M McQuillan
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Power KN, Gramstad A, Gilhus NE, Engelsen BA. Adult nonconvulsive status epilepticus in a clinical setting: Semiology, aetiology, treatment and outcome. Seizure 2015; 24:102-6. [DOI: 10.1016/j.seizure.2014.09.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 09/08/2014] [Accepted: 09/24/2014] [Indexed: 11/29/2022] Open
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Singh SP, Agarwal S, Faulkner M. Refractory status epilepticus. Ann Indian Acad Neurol 2014; 17:S32-6. [PMID: 24791086 PMCID: PMC4001215 DOI: 10.4103/0972-2327.128647] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 12/09/2013] [Accepted: 12/09/2013] [Indexed: 12/18/2022] Open
Abstract
Refractory status epilepticus is a potentially life-threatening medical emergency. It requires early diagnosis and treatment. There is a lack of consensus upon its semantic definition of whether it is status epilepticus that continues despite treatment with benzodiazepine and one antiepileptic medication (AED), i.e., Lorazepam + phenytoin. Others regard refractory status epilepticus as failure of benzodiazepine and 2 antiepileptic medications, i.e., Lorazepam + phenytoin + phenobarb. Up to 30% patients in SE fail to respond to two antiepileptic drugs (AEDs) and 15% continue to have seizure activity despite use of three drugs. Mechanisms that have made the treatment even more challenging are GABA-R that is internalized during status epilepticus and upregulation of multidrug transporter proteins. All patients of refractory status epilepticus require continuous EEG monitoring. There are three main agents used in the treatment of RSE. These include pentobarbital or thiopental, midazolam and propofol. RSE was shown to result in mortality in 35% cases, 39.13% of patients were left with severe neurological deficits, while another 13% had mild neurological deficits.
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Affiliation(s)
- Sanjay P Singh
- Department of Neurology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Shubhi Agarwal
- Department of Neurology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - M Faulkner
- Department of Neurology, Creighton University School of Medicine, Omaha, Nebraska, USA
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Griffith CA, Hoffmann DE. Status epilepticus attributed to inadvertent intrathecal injection of cefazolin during myelography. J Vet Emerg Crit Care (San Antonio) 2013; 23:631-6. [PMID: 24304840 DOI: 10.1111/vec.12117] [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: 02/29/2012] [Accepted: 10/01/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe a case of status epilepticus believed to be a consequence of inadvertent intrathecal administration of cefazolin in a dog undergoing a myelogram. CASE SUMMARY A 4-year-old, 6.5 kg, male neutered Dachshund was referred for evaluation of an acute onset hind limb paraparesis. While performing a lumbar myelogram, cefazolin was inadvertently injected into the ventral subarachnoid space. Subsequent refractory seizure activity was attributed to the epileptogenic effects of intrathecally administered cefazolin. Supportive therapy led to eventual complete recovery. NEW OR UNIQUE INFORMATION PROVIDED Although epileptogenic effects of intrathecally administered cefazolin are well documented in the human and experimental animal model literature, to the authors' knowledge this has not been characterized in the veterinary literature. This case highlights the need to be diligent and mindful when one administers medications, and describes the management of a dog adversely affected as a consequence of a medical error.
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Affiliation(s)
- Carrie A Griffith
- Akron Veterinary Referral and Emergency Center, 1321 Centerview Circle, Akron, OH 44321
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Sutter R, Marsch S, Fuhr P, Kaplan PW, Rüegg S. Anesthetic drugs in status epilepticus: risk or rescue? A 6-year cohort study. Neurology 2013; 82:656-64. [PMID: 24319039 DOI: 10.1212/wnl.0000000000000009] [Citation(s) in RCA: 206] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the risks of continuously administered IV anesthetic drugs (IVADs) on the outcome of adult patients with status epilepticus (SE). METHODS All intensive care unit patients with SE from 2005 to 2011 at a tertiary academic medical care center were included. Relative risks were calculated for the primary outcome measures of seizure control, Glasgow Outcome Scale score at discharge, and death. Poisson regression models were used to control for possible confounders and to assess effect modification. RESULTS Of 171 patients, 37% were treated with IVADs. Mortality was 18%. Patients with anesthetic drugs had more infections during SE (43% vs 11%; p < 0.0001) and a 2.9-fold relative risk for death (2.88; 95% confidence interval 1.45-5.73), independent of possible confounders (i.e., duration and severity of SE, nonanesthetic third-line antiepileptic drugs, and critical medical conditions) and without significant effect modification by different grades of SE severity and etiologies. As IVADs were used after first- and second-line drugs failed, there was a correlation between treatment-refractory SE and the use of IVADs, leading to insignificant results regarding the risk of IVADs and outcome after additional adjustment for refractory SE. CONCLUSION Our findings heighten awareness regarding adverse effects of IVADs. Randomized controlled trials are needed to further clarify the association of IVADs with outcome in patients with SE. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that patients with SE receiving IVADs have a higher proportion of infection and an increased risk of death as compared to patients not receiving IVADs.
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Affiliation(s)
- Raoul Sutter
- From the Clinic for Intensive Care Medicine (R.S., S.M.) and the Division of Clinical Neurophysiology, Department of Neurology (R.S., P.F., S.R.), University Hospital Basel, Switzerland; the Division of Neurosciences Critical Care (R.S.), Department of Anesthesiology, Critical Care Medicine and Neurology, Johns Hopkins University School of Medicine, Baltimore; and the Department of Neurology (R.S., P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
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Synowiec AS, Singh DS, Yenugadhati V, Valeriano JP, Schramke CJ, Kelly KM. Ketamine use in the treatment of refractory status epilepticus. Epilepsy Res 2013; 105:183-8. [DOI: 10.1016/j.eplepsyres.2013.01.007] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 12/12/2012] [Accepted: 01/07/2013] [Indexed: 11/17/2022]
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Robust photoregulation of GABA(A) receptors by allosteric modulation with a propofol analogue. Nat Commun 2013; 3:1095. [PMID: 23033071 PMCID: PMC4023869 DOI: 10.1038/ncomms2094] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 08/29/2012] [Indexed: 01/09/2023] Open
Abstract
Photochemical switches represent a powerful method for improving pharmacological therapies and controlling cellular physiology. Here we report the photo-regulation of GABAA receptors (GABAARs) by a derivative of propofol (2,6-diisopropylphenol), a GABAAR allosteric modulator, that we have modified to contain photo-isomerizable azobenzene. Using α1β2γ2 GABAARs expressed in Xenopus laevis oocytes and native GABAARs of isolated retinal ganglion cells, we show that the trans-azobenzene isomer of the new compound (trans-MPC088), generated by visible light (wavelengths ~440 nm), potentiates the GABA-elicited response and at higher concentrations directly activates the receptors. cis-MPC088, generated from trans-MPC088 by UV light (~365 nm), produces little if any receptor potentiation/activation. In cerebellar slices, MPC088 co-applied with GABA affords bidirectional photo-modulation of Purkinje cell membrane current and spike-firing rate. The findings demonstrate photo-control of GABAARs by an allosteric ligand and open new avenues for fundamental and clinically oriented research on GABAARs, a major class of neurotransmitter receptors in the central nervous system.
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Bajwa SJS, Jindal R. Epilepsy and nonepilepsy surgery: Recent advancements in anesthesia management. Anesth Essays Res 2013; 7:10-7. [PMID: 25885713 PMCID: PMC4173500 DOI: 10.4103/0259-1162.113978] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Epilepsy is one of the most common encountered neurological disorders. Surgical procedures in epileptic patient throw numerous challenges to the attending anesthesiologist during the perioperative period. Various anesthetic drug interactions with antiepileptics, intraoperative and postoperative seizures management and management of status epilepticus are few considerations which an anesthesiologist can confront both during emergency or elective surgery. The role of anesthesiologist acquires significant dimensions in management of epilepsy ranging from operative procedure, status epilepticus to the intensive care management of such patients. It requires a skilful and clinically precise handling of such patients during pre-op, peri-op and post-op period. Majority of times these patients present with co-morbidities which makes the prophylactic management of epilepsy extremely difficult during surgical procedures. The responsibilities of anesthesiologist involve management of epileptic patients not only during epilepsy and nonepilepsy surgery but for other diagnostic and therapeutic procedures as well where sedation or anesthesia services are required. Postoperative management of such patients include careful observation for any seizures and/or pseudo-seizures so as to manage appropriately. The knowledge regarding various antiepileptic agents and their potential side effects and interactions with anesthetic agents are of prime concern during surgical procedures for epilepsy and nonepileptic surgeries. The present article discusses the various anesthetic implications and considerations during management of such patients for epilepsy and nonepilepsy surgery.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Patiala, Punjab, India
| | - Ravi Jindal
- Department of Anaesthesiology and Intensive Care, Amar Hospital, Patiala, India
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Third-line antiepileptic therapy and outcome in status epilepticus: the impact of vasopressor use and prolonged mechanical ventilation. Crit Care Med 2012; 40:2677-84. [PMID: 22732291 DOI: 10.1097/ccm.0b013e3182591ff1] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To characterize associations between antiepileptic drugs with sedating or anesthetic effects (third-line antiepileptic drugs) vs. other antiepileptic agents, and short-term outcomes, in status epilepticus. Furthermore, to evaluate the role of adverse hemodynamic and respiratory effects of these agents in status epilepticus treatment. DESIGN Retrospective comparative analysis. SETTING Tertiary academic medical center with two emergency departments and two neurologic intensive care units. PATIENTS Adults admitted with a diagnosis of status epilepticus defined as seizures lasting continuously >5 mins, or for discrete periods in succession. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 126 patients with 144 separate status epilepticus admissions, 57 were female (45%) with mean age 54.7 ± 15.7 yrs. Status epilepticus was convulsive in 132 cases (92%). Status epilepticus etiologies included subtherapeutic antiepileptic drugs (43%), alcohol or other nonantiepileptic drug (13%), and acute central nervous system disease (12%). Third-line antiepileptic drugs were administered in 47 cases (33%). Seventy-eight status epilepticus episodes (54%) had good outcomes (Glasgow Outcome Score = 1, 2) at the time of hospital discharge. On univariate analysis, poor outcome (Glasgow Outcome Score > 2) was associated with older age (mean 59.8 ± 15.5 vs. 50.5 ± 13.8 yrs, p < .001), acute central nervous system disease (21% vs. 4%, p = .001), mechanical ventilation (76% vs. 53%, p = .004), longer duration of ventilation (median 10 days [range 1-56] vs. 2 days [range 1-10], p < .001), treatment with vasopressors (35% vs. 5%, p < .001), and treatment with third-line antiepileptic drugs (51% vs. 17%, p < .001). Death was associated with acute central nervous system disease, prolonged ventilation, treatment with vasopressors, and treatment with third-line antiepileptic drugs. Predictors of poor outcome among all status epilepticus episodes were older age (odds ratio 1.06; 95% confidence interval 1.03-1.09; p < .001), treatment with third-line antiepileptic therapy (odds ratio 5.64; 95% confidence interval 2.31-13.75; p < .001), and first episode of status epilepticus (odds ratio 3.73; 95% confidence interval 1.38-10.10; p = .010). Among status epilepticus episodes treated by third-line antiepileptic drugs, predictors of poor outcome were older age (odds ratio, 1.09; 95% confidence interval 1.01-1.18; p = .038) and longer ventilation (odds ratio, 1.47; 95% confidence interval 1.08-2.00; p = .015). Predictors of mortality among all status epilepticus episodes were treatment with third-line antiepileptic drugs (odds ratio, 12.08; 95% confidence interval 2.30-63.39; p = .003) and older age (odds ratio, 1.06; 95% confidence interval 1.00-1.12; p = .045). CONCLUSIONS Third-line antiepileptic drug therapies with sedating or anesthetic effects predicted poor outcome and death in status epilepticus. Hypotension requiring vasopressor therapy and duration of mechanical ventilation induced by these agents may be contributing factors, especially when pentobarbital is used. These findings may inform decision making on drug therapy in status epilepticus and help develop safer and more effective treatment strategies to improve outcome.
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Abstract
PURPOSE OF REVIEW Refractory status epilepticus (RSE) has a high morbidity and mortality. There are currently no definitive data to guide both the optimal choice of therapy and treatment goals. This review focuses on RSE diagnosis and outcome and discusses both commonly used and anecdotal therapies for RSE. RECENT FINDINGS The challenges in performing randomized controlled trials (RCTs) in neurocritical care and more specifically for the treatment of RSE are illustrated by the early termination of the first RCT of RSE due to low recruitment that compared propofol to barbiturates. Recent case series include the successful treatment of recurrent RSE with ketamine, intravenous lacosamide as an add-on treatment, the use of combination antiepileptics (phenytoin, levetiracetam, and pregabalin), and surgical treatments (vagal nerve and deep brain stimulation) for the control of RSE. SUMMARY A number of different therapeutic options are available for the treatment of RSE but none have been shown to be superior to others at this point.
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Shorvon S, Ferlisi M. The outcome of therapies in refractory and super-refractory convulsive status epilepticus and recommendations for therapy. Brain 2012; 135:2314-28. [DOI: 10.1093/brain/aws091] [Citation(s) in RCA: 255] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Abstract
Epilepsy is the most common serious neurological disorder, with a prevalence of 0.5-1% of the population. While the traditional antiepileptic drugs (AEDs) still play a significant role in treatment of seizures, there has been an influx of newer agents over the last 20 yr, which are now in common usage. Anaesthetists are frequently faced with patients with epilepsy undergoing emergency or elective surgery and patients suffering seizures and status epilepticus in the intensive care unit (ICU). This review examines perioperative epilepsy management, the mode of action of AEDs and their interaction with anaesthetic agents, potential adverse effects of anaesthetic agents, and the acute management of seizures and refractory status epilepticus on the ICU. Relevant literature was identified by a Pubmed search of epilepsy and status epilepticus in conjunction with individual anaesthetic agents.
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Affiliation(s)
- A Perks
- Department of Anaesthesia, Salford Royal Hospital, Stott Lane, Salford M6 8HD, UK.
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