1
|
Woodward MR, Kardon A, Manners J, Schleicher S, Pergakis MB, Ciryam P, Podell J, Denney Zimmerman W, Galvagno SM, Butt B, Pritchard J, Parikh GY, Gilmore EJ, Badjatia N, Morris NA. Comparison of induction agents for rapid sequence intubation in refractory status epilepticus: A single-center retrospective analysis. Epilepsy Behav Rep 2024; 25:100645. [PMID: 38299124 PMCID: PMC10827579 DOI: 10.1016/j.ebr.2024.100645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 02/02/2024] Open
Abstract
Endotracheal intubation, frequently required during management of refractory status epilepticus (RSE), can be facilitated by anesthetic medications; however, their effectiveness for RSE control is unknown. We performed a single-center retrospective review of patients admitted to a neurocritical care unit (NCCU) who underwent in-hospital intubation during RSE management. Patients intubated with propofol, ketamine, or benzodiazepines, termed anti-seizure induction (ASI), were compared to patients who received etomidate induction (EI). The primary endpoint was clinical or electrographic seizures within 12 h post-intubation. We estimated the association of ASI on post-intubation seizure using logistic regression. A sub-group of patients undergoing electroencephalography during intubation was identified to evaluate the immediate effect of ASI on RSE. We screened 697 patients admitted to the NCCU for RSE and identified 148 intubated in-hospital (n = 90 ASI, n = 58 EI). There was no difference in post-intubation seizure (26 % (n = 23) ASI, 29 % (n = 17) EI) in the cohort, however, there was increased RSE resolution with ASI in 24 patients with electrographic RSE during intubation (ASI: 61 % (n = 11/18) vs EI: 0 % (n = 0/6), p =.016). While anti-seizure induction did not appear to affect post-intubation seizure occurrence overall, a sub-group of patients undergoing electroencephalography during intubation had a higher incidence of seizure cessation, suggesting potential benefit in an enriched population.
Collapse
Affiliation(s)
- Matthew R. Woodward
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Adam Kardon
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Jody Manners
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Samantha Schleicher
- Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa B. Pergakis
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Prajwal Ciryam
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Jamie Podell
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - William Denney Zimmerman
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Samuel M. Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bilal Butt
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Jennifer Pritchard
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gunjan Y. Parikh
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Emily J. Gilmore
- Department of Neurology, Yale University School of Medicine, 20 York Street, New Haven, CT, USA
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| | - Nicholas A. Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, 22 S Greene St., Baltimore, MD, USA
| |
Collapse
|
2
|
Long B, Koyfman A. Nonconvulsive Status Epilepticus: A Review for Emergency Clinicians. J Emerg Med 2023; 65:e259-e271. [PMID: 37661524 DOI: 10.1016/j.jemermed.2023.05.012] [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: 11/30/2022] [Revised: 04/01/2023] [Accepted: 05/26/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Status epilepticus is associated with significant morbidity and mortality and is divided into convulsive status epilepticus and nonconvulsive status epilepticus (NCSE). OBJECTIVE This review provides a focused evaluation of NCSE for emergency clinicians. DISCUSSION NCSE is a form of status epilepticus presenting with prolonged seizure activity. This disease is underdiagnosed, as it presents with nonspecific signs and symptoms, most commonly change in mental status without overt convulsive motor activity. Causes include epilepsy, cerebral pathology or injury, any systemic insult such as infection, and drugs or toxins. Mortality is primarily related to the underlying condition. Patients most commonly present with altered mental status, but other signs and symptoms include abnormal ocular movements and automatisms such as lip smacking or subtle motor twitches in the face or extremities. The diagnosis is divided into electrographic and electroclinical, and although electroencephalogram (EEG) is recommended for definitive diagnosis, emergency clinicians should consider this disease in patients with prolonged postictal state after a seizure with no improvement in mental status, altered mental status with acute cerebral pathology (e.g., stroke, hypoxic brain injury), and unexplained altered mental status. Assessment includes laboratory evaluation and neuroimaging with EEG. Management includes treating life-threatening conditions, including compromise of the airway, hypoglycemia, hyponatremia, and hypo- or hyperthermia, followed by rapid cessation of the seizure activity with benzodiazepines and other antiseizure medications. CONCLUSIONS An understanding of the presentation and management of NCSE can assist emergency clinicians in the care of these patients.
Collapse
Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
5
|
Migdady I, Rosenthal ES, Cock HR. Management of status epilepticus: a narrative review. Anaesthesia 2022; 77 Suppl 1:78-91. [PMID: 35001380 DOI: 10.1111/anae.15606] [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] [Accepted: 10/01/2021] [Indexed: 11/26/2022]
Abstract
Status epilepticus causes prolonged or repetitive seizures that, if left untreated, can lead to neuronal injury, severe disability, coma and death in paediatric and adult populations. While convulsive status epilepticus can be diagnosed using clinical features alone, non-convulsive status epilepticus requires confirmation by electroencephalogram. Early seizure control remains key in preventing the complications of status epilepticus. This is especially true for convulsive status epilepticus, which has stronger evidence supporting the benefit of treatment on outcomes. When status epilepticus becomes refractory, often due to gamma-aminobutyric acid and N-methyl-D-aspartate receptor modulation, anaesthetic drugs are needed to suppress seizure activity, of which there is limited evidence regarding the selection, dose or duration of their use. Seizure monitoring with electroencephalogram is often needed when patients do not return to baseline or during anaesthetic wean; however, it is resource-intensive, costly, only available in highly specialised centres and has not been shown to improve functional outcomes. Thus, the treatment goals and aggressiveness of therapy remain under debate, especially for non-convulsive status epilepticus, where prolonged therapeutic coma can lead to severe complications. This review presents an evidence-based, clinically-oriented and comprehensive review of status epilepticus and its definitions, aetiologies, treatments, outcomes and prognosis at different stages of the patient's journey.
Collapse
Affiliation(s)
- I Migdady
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - E S Rosenthal
- Department of Neurology, Divisions of Clinical Neurophysiology and Neurocritical Care Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - H R Cock
- Clinical Neurosciences Academic Group, Institute of Molecular and Clinical Sciences, St. George's University of London, London, UK
| |
Collapse
|
6
|
Peedicail J, Mehdiratta N, Zhu S, Nedjadrasul P, Ng MC. Quantitative burst suppression on serial intermittent EEG in refractory status epilepticus. Clin Neurophysiol Pract 2021; 6:275-280. [PMID: 34825115 PMCID: PMC8604990 DOI: 10.1016/j.cnp.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 10/03/2021] [Accepted: 10/23/2021] [Indexed: 11/24/2022] Open
Abstract
Quantitative burst suppression ratios (QBSR) represent depth of EEG suppression. Deeper QBSR on serial intermittent EEG did not affect survival in RSE. Non-suppressive continuous EEG effects on RSE mortality merits further research.
Objectives In refractory status epilepticus (RSE), the optimal degree of suppression (EEG burst suppression or merely suppressing seizures) remains unknown. Many centers lacking continuous EEG must default to serial intermittent recordings where uncertainty from lack of data may prompt more aggressive suppression. In this study, we sought to determine whether the quantitative burst suppression ratio (QBSR) from serial intermittent EEG recording is associated with RSE patient outcome. Methods We screened the EEG database to identify non-anoxic adult RSE patients for EEG and chart review. QBSR was calculated per 10-second EEG epoch as the percentage of time during which EEG amplitude was <3 µV. Patients who survived 1–3 months after discharge from ICU and hospital comprised the favorable group. Further to initial unadjusted univariate analysis of all pooled QBSR, we conducted multivariate analyses to account for individual patient confounders (“per-capita analysis”), uneven number of EEG recordings (“per-session analysis”), and uneven number of epochs (“per-epoch analysis”). We analyzed gender, anesthetic number, and adjusted status epilepticus severity score (aSTESS) as confounders. Results In 135,765 QBSR values over 160 EEG recordings (median 2.17 h every ≥24 h) from 17 patients on Propofol, Midazolam, and/or Ketamine, QBSR was deeper in the favorable group (p < 0.001) on initial unadjusted analysis. However, on adjusted multivariate analysis, there was consistently no association between QBSR and outcome. Higher aSTESS consistently associated with unfavorable outcome on per-capita (p = 0.033), per-session (p = 0.048) and per-epoch (p < 0.001) analyses. Greater maximal number of non-barbiturate anesthetic associated with favorable outcome on per-epoch analysis (p < 0.001). Conclusions There was no association between depth of EEG suppression using non-barbiturate anesthetic and RSE patient outcome based on QBSR from serial intermittent EEG. A per-epoch association between non-barbiturate anesthetic and favorable outcome suggests an effect from non-suppressive time-varying EEG content. Significance Targeting and following deeper burst suppression through non-barbiturate anesthetics on serial intermittent EEG monitoring of RSE is of limited utility.
Collapse
Affiliation(s)
- Joseph Peedicail
- Section of Neurology, University of Manitoba, Winnipeg, MB, Canada
| | - Neil Mehdiratta
- Section of Neurology, University of Manitoba, Winnipeg, MB, Canada
| | - Shenghua Zhu
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada
| | | | - Marcus C Ng
- Section of Neurology, University of Manitoba, Winnipeg, MB, Canada
| |
Collapse
|