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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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Kornilov E, Baker Erdman H, Kahana E, Fireman S, Zarchi O, Israelashvili M, Reiner J, Glik A, Weiss P, Paz R, Bergman H, Tamir I. Interleaved Propofol-Ketamine Maintains DBS Physiology and Hemodynamic Stability: A Double-Blind Randomized Controlled Trial. Mov Disord 2024; 39:694-705. [PMID: 38396358 DOI: 10.1002/mds.29746] [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: 10/10/2023] [Revised: 12/18/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The gold standard anesthesia for deep brain stimulation (DBS) surgery is the "awake" approach, using local anesthesia alone. Although it offers high-quality microelectrode recordings and therapeutic-window assessment, it potentially causes patients extreme stress and might result in suboptimal surgical outcomes. General anesthesia or deep sedation is an alternative, but may reduce physiological testing reliability and lead localization accuracy. OBJECTIVES The aim is to investigate a novel anesthesia regimen of ketamine-induced conscious sedation for the physiological testing phase of DBS surgery. METHODS Parkinson's patients undergoing subthalamic DBS surgery were randomly divided into experimental and control groups. During physiological testing, the groups received 0.25 mg/kg/h ketamine infusion and normal saline, respectively. Both groups had moderate propofol sedation before and after physiological testing. The primary outcome was recording quality. Secondary outcomes included hemodynamic stability, lead accuracy, motor and cognitive outcome, patient satisfaction, and adverse events. RESULTS Thirty patients, 15 from each group, were included. Intraoperatively, the electrophysiological signature and lead localization were similar under ketamine and saline. Tremor amplitude was slightly lower under ketamine. Postoperatively, patients in the ketamine group reported significantly higher satisfaction with anesthesia. The improvement in Unified Parkinson's disease rating scale part-III was similar between the groups. No negative effects of ketamine on hemodynamic stability or cognition were reported perioperatively. CONCLUSIONS Ketamine-induced conscious sedation provided high quality microelectrode recordings comparable with awake conditions. Additionally, it seems to allow superior patient satisfaction and hemodynamic stability, while maintaining similar post-operative outcomes. Therefore, it holds promise as a novel alternative anesthetic regimen for DBS. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Evgeniya Kornilov
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Halen Baker Erdman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
| | - Eilat Kahana
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Shlomo Fireman
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Omer Zarchi
- Intraoperative Neurophysiology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | | | - Johnathan Reiner
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Amir Glik
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Cognitive Neurology Clinic, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Penina Weiss
- Occupational Therapy Department, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Rony Paz
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Hagai Bergman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
- The Edmond and Lily Safra Center for Brain Sciences, Hebrew University, Jerusalem, Israel
| | - Idit Tamir
- Department of Neurosurgery, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
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Bell CM, Rech MA, Akuamoah-Boateng KA, Kasotakis G, McMurray JD, Moses BA, Mueller SW, Patel GP, Roberts RJ, Sakhuja A, Salvator A, Setliff EL, Droege CA. Ketamine in Critically Ill Patients: Use, Perceptions, and Potential Barriers. J Pharm Pract 2024; 37:351-363. [PMID: 36282867 DOI: 10.1177/08971900221134551] [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] [Indexed: 02/16/2024]
Abstract
Objective: To evaluate practitioner use of ketamine and identify potential barriers to use in acutely and critically ill patients. To compare characteristics, beliefs, and practices of ketamine frequent users and non-users. Methods: An online survey developed by members of the Society of Critical Care Medicine (SCCM) Clinical Pharmacy and Pharmacology Section was distributed to physician, pharmacist, nurse practitioner, physician assistant and nurse members of SCCM. The online survey queried SCCM members on self-reported practices regarding ketamine use and potential barriers in acute and critically ill patients. Results: Respondents, 341 analyzed, were mostly adult physicians, practicing in the United States at academic medical centers. Clinicians were comfortable or very comfortable using ketamine to facilitate intubation (80.0%), for analgesia (77.9%), procedural sedation (79.4%), continuous ICU sedation (65.8%), dressing changes (62.4%), or for asthma exacerbation and status epilepticus (58.8% and 40.4%). Clinicians were least comfortable with ketamine use for alcohol withdrawal and opioid detoxification (24.7% and 23.2%). Most respondents reported "never" or "infrequently" using ketamine preferentially for continuous IV analgesia (55.6%) or sedation (61%). Responses were mixed across dosing ranges and duration. The most common barriers to ketamine use were adverse effects (42.6%), other practitioners not routinely using the medication (41.5%), lack of evidence (33.5%), lack of familiarity (33.1%), and hospital/institutional policy guiding the indication for use (32.3%). Conclusion: Although most critical care practitioners report feeling comfortable using ketamine, there are many inconsistencies in practice regarding dose, duration, and reasons to avoid or limit ketamine use. Further educational tools may be targeted at practitioners to improve appropriate ketamine use.
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Affiliation(s)
- Carolyn M Bell
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Megan A Rech
- Department of Pharmacy, Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Kwame A Akuamoah-Boateng
- Department of Surgery: Division of Acute Care Surgical Services, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - George Kasotakis
- Department of Surgery, Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey D McMurray
- Department of Anesthesia, Medical University of South Carolina, Charleston, SC, USA
| | - Benjamin A Moses
- Department of Anesthesia: Division of Critical Care, University of Virginia Health, Charlottesville, VA, USA
| | - Scott W Mueller
- Department of Pharmacy, University of Colorado Health, Aurora, CO, USA
| | - Gourang P Patel
- Department of Pharmacy, University of Chicago Medical Center, Chicago, IL, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Ankit Sakhuja
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ann Salvator
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Erika L Setliff
- Department of Clinical Education Services, Atrium Health Cabarrus, Concord, NC, USA
| | - Christopher A Droege
- Department of Pharmacy Services, UC Health-University of Cincinnati Medical Center, Cincinnati, OH, USA
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García-Ruiz M, Rodríguez PM, Palliotti L, Lastras C, Romeral-Jiménez M, Morales IG, Rey CP, Rodrigo-Gisbert M, Campos-Fernández D, Santamarina E, Carbonell BP. Ketamine in the treatment of refractory and super-refractory status epilepticus: Experience from two centres. Seizure 2024; 117:13-19. [PMID: 38301485 DOI: 10.1016/j.seizure.2024.01.013] [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: 10/24/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 02/03/2024] Open
Abstract
PURPOSE There is insufficient evidence on the management of refractory status epilepticus (RSE) and super-RSE (SRSE). Ketamine is a N-methyl-d-aspartate receptor antagonist in the treatment of these entities. Our objectives were to study the effectiveness and safety of ketamine in the treatment of adult patients with RSE and SRSE, to determine the factors that can influence the response to ketamine, and to explore its use in patients without mechanical ventilation. METHODS Adult patients who had received intravenous ketamine for the treatment of RSE or SRSE at Hospital Universitario Clínico San Carlos (Madrid, Spain) or Hospital Universitari Vall d'Hebron (Barcelona, Spain) from 2017 to 2023 were retrospectively analysed. RESULTS This study included 58 adult patients, mean (standard deviation) age 60.2 (15.7) years, of whom 41 (70.7 %) were male; 33 (56.9 %) patients responded to ketamine without recurrence, with a low rate of adverse effects (8.6 %). The presence of SRSE at the time of ketamine initiation (OR 0.287, p = 0.028) and the time elapsed between status epilepticus onset and ketamine administration (OR 0.991, p = 0.034) were associated with worse response to ketamine. Patients treated without mechanical ventilation had similar rates of response without recurrence (62.5% vs 56.9 %) and lower mortality (37.5% vs 53.5 %) compared to the overall group. CONCLUSION Ketamine is an effective drug with few adverse effects. Prompt administration should be considered in patients with RSE requiring anaesthesia, in patients with SRSE, and in patients with RSE who do not respond to standard antiseizure drugs and in whom mechanical ventilation is not advised.
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Affiliation(s)
- Manuel García-Ruiz
- Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
| | - Pablo Mayo Rodríguez
- Epilepsy Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
| | - Luca Palliotti
- Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
| | - Clara Lastras
- Epilepsy Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
| | - María Romeral-Jiménez
- Epilepsy Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
| | - Irene García Morales
- Epilepsy Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain; Epilepsy Unit, Neurology Department, Hospital Ruber Internacional, Calle de La Masó, 38, Madrid 28034, Spain.
| | - Cándido Pardo Rey
- Neurology and Traumatology Unit, Intensive Care Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
| | - Marc Rodrigo-Gisbert
- Neurology Department, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron, 119, Barcelona 08035, Spain
| | - Daniel Campos-Fernández
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron, 119, Barcelona 08035, Spain
| | - Estevo Santamarina
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron, 119, Barcelona 08035, Spain
| | - Beatriz Parejo Carbonell
- Epilepsy Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, Madrid 28040, Spain
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Kimmons LA, Alzayadneh M, Metter EJ, Alsherbini K. Safety and Efficacy of Ketamine Without Intubation in the Management of Refractory Seizures: A Case Series. Neurocrit Care 2024; 40:689-697. [PMID: 37610640 DOI: 10.1007/s12028-023-01811-4] [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: 05/03/2023] [Accepted: 07/11/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Continuous infusion ketamine has demonstrated efficacy in the management of refractory seizures yet does not suppress respiratory drive like other continuous infusion anesthetics (CIAs) used for this indication. The aim of this study is to describe the safety and efficacy of ketamine infusions in patients with refractory seizure without intubation. METHODS We analyzed a retrospective cohort of adult patients who were not intubated at the time of initiation of a ketamine infusion for refractory seizures. Seizure onset was determined to be the first clinical seizure or nonconvulsive seizure reported on electroencephalography (EEG) or the start time of EEG for patients with seizures at EEG initiation. Responders were defined as patients with resolution of seizures within 24 h of initiation without the need for intubation or an additional CIA. RESULTS A total of 28 patients were analyzed (median age 62 years, 64.3% female, 82.1% African American, 82.1% with structural seizure etiology, and 85.7% focal seizures). Of patients, 78.5% received an initial bolus averaging 0.9 mg/kg, and the majority (89.3%) were initiated on an infusion at 10 μg/kg/minute; median duration was 39.8 h. Maximum infusion rates were 10 μg/kg/minute in 16 patients, 20 μg/kg/minute in seven patients, and 30 μg/kg/minute in five patients. Of patients, 71.4% were assessed to be ketamine responders; six of the eight nonresponders required intubation and an additional CIA. Responders were 80% more likely to have received ketamine 5 or more hours earlier than nonresponders. Hypotension (systolic blood pressure < 90 mmHg) occurred in 31.8% of patients receiving only ketamine, which did not correlate with duration or maximum dose of ketamine; hypertension (systolic blood pressure > 180 mmHg) occurred in 39.3%. CONCLUSIONS Ketamine represents a safe and effective treatment option for refractory seizures and has potential to reduce morbidity associated with intubation in a carefully selected patient population. Early initiation may increase the likelihood of success.
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Affiliation(s)
- Lauren A Kimmons
- Methodist University Hospital, 1265 Union Avenue, Memphis, TN, 38104, USA.
- University of Tennessee Health Sciences Center, 910 Madison Avenue, Memphis, TN, 38163, USA.
| | - Mohammad Alzayadneh
- University of Tennessee Health Sciences Center, 910 Madison Avenue, Memphis, TN, 38163, USA
| | - E Jeffrey Metter
- University of Tennessee Health Sciences Center, 910 Madison Avenue, Memphis, TN, 38163, USA
| | - Khalid Alsherbini
- Methodist University Hospital, 1265 Union Avenue, Memphis, TN, 38104, USA
- University of Tennessee Health Sciences Center, 910 Madison Avenue, Memphis, TN, 38163, USA
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Natteru PA, Jayaram S, Sanchez O, Leon K, Mishra A, Nobleza CO. Abdominal Compartment Syndrome with Super-K (Ketamine) for Super-R(efractory) Status Epilepticus: A Case Report. Clin EEG Neurosci 2024; 55:230-234. [PMID: 36285375 DOI: 10.1177/15500594221134920] [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] [Indexed: 11/17/2022]
Abstract
Refractory status epilepticus is commonly defined as status epilepticus that fails to respond to two or more appropriately dosed intravenous anti-seizure medications including at least one non-benzodiazepine drug. Super-refractory status epilepticus (SRSE) is when status epilepticus continues for ≥24 h despite anesthetic treatment or recurs on an attempted wean of the anesthetic drugs. There is little evidence to guide the management of SRSE. Of late, unconventional therapies have been described in the literature regarding the management of SRSE, with ketamine leading the pack. Studies have noted ketamine's therapeutic efficacy up to 91% in SRSE cessation. Common side effects of ketamine include nausea, vomiting, headache, and hallucinations; but to our knowledge, ketamine has not been implicated in the pathogenesis of abdominal compartment syndrome. We describe a 74-year-old male who developed severe abdominal compartment syndrome in the setting of ketamine infusion for new-onset SRSE to increase awareness about this potential complication.
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Affiliation(s)
| | - Shoba Jayaram
- Neurology, Atrium Health Neuroscience Institute, Monroe, NC, USA
| | - Oriana Sanchez
- Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kyla Leon
- Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Aditi Mishra
- Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Christa O'Hana Nobleza
- Neurology, Baptist Memorial Hospital, Memphis, TN, USA
- Neurology, University of Tennessee Health Science Center, Memphis, TN, 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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Rossetti AO, Claassen J, Gaspard N. Status epilepticus in the ICU. Intensive Care Med 2024; 50:1-16. [PMID: 38117319 DOI: 10.1007/s00134-023-07263-w] [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: 07/14/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
Status epilepticus (SE) is a common medical emergency associated with significant morbidity and mortality. Management that follows published guidelines is best suited to improve outcomes, with the most severe cases frequently being managed in the intensive care unit (ICU). Diagnosis of convulsive SE can be made without electroencephalography (EEG), but EEG is required to reliably diagnose nonconvulsive SE. Rapidly narrowing down underlying causes for SE is crucial, as this may guide additional management steps. Causes may range from underlying epilepsy to acute brain injuries such as trauma, cardiac arrest, stroke, and infections. Initial management consists of rapid administration of benzodiazepines and one of the following non-sedating intravenous antiseizure medications (ASM): (fos-)phenytoin, levetiracetam, or valproate; other ASM are increasingly used, such as lacosamide or brivaracetam. SE that continues despite these medications is called refractory, and most commonly treated with continuous infusions of midazolam or propofol. Alternatives include further non-sedating ASM and non-pharmacologic approaches. SE that reemerges after weaning or continues despite management with propofol or midazolam is labeled super-refractory SE. At this step, management may include non-sedating or sedating compounds including ketamine and barbiturates. Continuous video EEG is necessary for the management of refractory and super-refractory SE, as these are almost always nonconvulsive. If possible, management of the underlying cause of seizures is crucial particularly for patients with autoimmune encephalitis. Short-term mortality ranges from 10 to 15% after SE and is primarily related to increasing age, underlying etiology, and medical comorbidities. Refractoriness of treatment is clearly related to outcome with mortality rising from 10% in responsive cases, to 25% in refractory, and nearly 40% in super-refractory SE.
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Affiliation(s)
- Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
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Savić Vujović K, Jotić A, Medić B, Srebro D, Vujović A, Žujović J, Opanković A, Vučković S. Ketamine, an Old-New Drug: Uses and Abuses. Pharmaceuticals (Basel) 2023; 17:16. [PMID: 38276001 PMCID: PMC10820504 DOI: 10.3390/ph17010016] [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: 10/24/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 01/27/2024] Open
Abstract
Ketamine as an old-new drug has a variety of clinical implications. In the last 30 years, ketamine has become popular for acute use in humans. Ketamine in standard doses is principally utilized for the induction and maintenance of surgical procedures. Besides its use in anesthesia and analgesia, recent studies have shown that ketamine has found a place in the treatment of asthma, epilepsy, depression, bipolar affective disorders, alcohol and heroin addiction. Ketamine primarily functions as a noncompetitive antagonist targeting the N-methyl-D-aspartate (NMDA) receptor, but its mechanism of action is complex. It is generally regarded as safe, with low doses and short-term use typically not leading to significant adverse effects. Also, ketamine is known as a powerful psychostimulant. During the past decade, ketamine has been one of the commonly abused drugs.
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Affiliation(s)
- Katarina Savić Vujović
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
| | - Ana Jotić
- Clinic for Otorhinolaryngology and Maxillofacial Surgery, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia;
| | - Branislava Medić
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
| | - Dragana Srebro
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
| | | | - Janko Žujović
- Clinical Centre of Montenegro, Centre for Abdominal Surgery, 81000 Podgorica, Montenegro;
| | - Ana Opanković
- Clinical Centre of Serbia, Clinic for Psychiatry, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Sonja Vučković
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
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11
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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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12
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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.
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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
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13
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Lazaridis C, Foreman B. Management Strategies Based on Multi-Modality Neuromonitoring in Severe Traumatic Brain Injury. Neurotherapeutics 2023; 20:1457-1471. [PMID: 37491682 PMCID: PMC10684466 DOI: 10.1007/s13311-023-01411-2] [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] [Accepted: 07/14/2023] [Indexed: 07/27/2023] Open
Abstract
Secondary brain injury after neurotrauma is comprised of a host of distinct, potentially concurrent and interacting mechanisms that may exacerbate primary brain insult. Multimodality neuromonitoring is a method of measuring multiple aspects of the brain in order to understand the signatures of these different pathomechanisms and to detect, treat, or prevent potentially reversible secondary brain injuries. The most studied invasive parameters include intracranial pressure (ICP), cerebral perfusion pressure (CPP), autoregulatory indices, brain tissue partial oxygen tension, and tissue energy and metabolism measures such as the lactate pyruvate ratio. Understanding the local metabolic state of brain tissue in order to infer pathology and develop appropriate management strategies is an area of active investigation. Several clinical trials are underway to define the role of brain tissue oxygenation monitoring and electrocorticography in conjunction with other multimodal neuromonitoring information, including ICP and CPP monitoring. Identifying an optimal CPP to guide individualized management of blood pressure and ICP has been shown to be feasible, but definitive clinical trial evidence is still needed. Future work is still needed to define and clinically correlate patterns that emerge from integrated measurements of metabolism, pressure, flow, oxygenation, and electrophysiology. Pathophysiologic targets and precise critical care management strategies to address their underlying causes promise to mitigate secondary injuries and hold the potential to improve patient outcome. Advancements in clinical trial design are poised to establish new standards for the use of multimodality neuromonitoring to guide individualized clinical care.
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Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA.
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
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14
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Sheikh Z, Selioutski O, Taraschenko O, Gilmore EJ, Westover MB, Cohen AB. Systematic Evaluation of Research Priorities in Critical Care Electroencephalography. J Clin Neurophysiol 2023; 40:426-433. [PMID: 35066530 PMCID: PMC9296700 DOI: 10.1097/wnp.0000000000000916] [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] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The Critical Care EEG Monitoring Research Consortium (CCEMRC) is an international research group focusing on critical care EEG and epilepsy. As CCEMRC grew to include 50+ institutions over the past decade, members met to establish research priorities. METHODS The authors used an analytical hierarchy process-based research prioritization method, adapted from an approach previously applied to a Department of Defense health-related research program. Forty-six CCEMRC members identified and scored a set of eight clinical problems (CPs) and 15 research topic areas (RTAs) at an annual CCEMRC meeting. Members scored CPs on three criteria using a five-point ordinal scale: Incidence, Impact, and Gap Size; and RTAs on four additional criteria: Niche, Feasibility, Scientific Importance, and Medical Importance, each of which was assigned a weight. The first three RTA criteria were scored using a five-point scale, and CPs were mapped to RTAs using a four-point scale. The Medical Importance score was a weighted average of its mapping scores and the CP score. Finally, a Priority score was calculated for each RTA as a product of the four RTA criteria scores. RESULTS The CPs with the highest scores were "Altered mental status" and "Long-term neurologic disability after hospital discharge." The RTAs with the highest priority scores were "Development of risk prediction tools," "Multicenter observational studies," and "Outcome prediction." CONCLUSIONS Research prioritization helped CCEMRC evaluate its current research trajectory, identify high-priority near-term research pursuits, and create a roadmap for future research plans aligned with its mission. This approach may be helpful to other academic consortia and research programs.
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Affiliation(s)
- Zubeda Sheikh
- Department of Neurology, West Virginia University School of Medicine, Morgantown, West Virginia, U.S.A
| | - Olga Selioutski
- Epilepsy Division, Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York, U.S.A
| | - Olga Taraschenko
- Comprehensive Epilepsy Center, Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A
| | - Emily J Gilmore
- Division of Neurocritical Care, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
- Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Adam B Cohen
- The Johns Hopkins University Applied Physics Lab, National Health Mission Area, Laurel, Maryland, U.S.A.; and
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
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15
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Perlmutter M, Price M, Kothari K, Rafique Z, Rogers Keene K, De La Rosa X, Weinstein E, Patrick C. Prehospital Treatment of Benzodiazepine-Resistant Pediatric Status Epilepticus with Parenteral Ketamine: A Case Series. PREHOSP EMERG CARE 2023; 27:920-926. [PMID: 37276174 DOI: 10.1080/10903127.2023.2221967] [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: 12/08/2022] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 06/07/2023]
Abstract
We report the initial six pediatric patients treated with ketamine for benzodiazepine-resistant status epilepticus in an urban, ground-based emergency medical services (EMS) system. Evidence for ketamine as a second-line agent for both adult and pediatric refractory seizure activity in the hospital setting has increased over the past decade. The availability of an inexpensive and familiar second-line prehospital anti-epileptic drug option is extremely desirable. We believe these initial data demonstrate promising seizure control effects without significant respiratory depression, indicating a potential role for ketamine in the EMS treatment of pediatric benzodiazepine-refractory seizures.
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Affiliation(s)
- Michael Perlmutter
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Mark Price
- Harris County ESD11 Mobile Healthcare, Houston, Texas
| | - Kathryn Kothari
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Zubaid Rafique
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Kelly Rogers Keene
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Elizabeth Weinstein
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Casey Patrick
- Harris County ESD11 Mobile Healthcare, Houston, Texas
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16
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Coles L, Rosenthal ES, Bleck TP, Elm J, Zehtabchi S, Chamberlain J, Cloyd J, Shinnar S, Silbergleit R, Kapur J. Why ketamine. Epilepsy Behav 2023; 141:109066. [PMID: 36609129 PMCID: PMC10073319 DOI: 10.1016/j.yebeh.2022.109066] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023]
Abstract
We present the rationale for testing ketamine as an add-on therapy for treating benzodiazepine refractory (established) status epilepticus. In animal studies, ketamine terminates benzodiazepine refractory status epilepticus by interfering with the pathophysiological mechanisms and is a neuroprotectant. Ketamine does not suppress respiration when used for sedation and anesthesia. A Series of reports suggest that ketamine can help terminate refractory and super refractory status epilepticus. We propose to use 1 or 3 mg/Kg ketamine intravenously based on animal-to-human conversion and pharmacokinetic studies. 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)
- Lisa Coles
- Center for Orphan Drug Research, Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Thomas P Bleck
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jordan Elm
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Shahriar Zehtabchi
- Department of Emergency Medicine, Downstate Health Sciences University, Brooklyn, NY, United States
| | - James Chamberlain
- Division of Emergency Medicine, Children's National Hospital Washington, DC, United States
| | - James Cloyd
- Center for Orphan Drug Research, Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Shlomo Shinnar
- Departments of Neurology, Pediatrics, Epidemiology and Public Health, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan, School of Medicine, Ann Arbor, MI, United States
| | - Jaideep Kapur
- Department of Neurology and Neuroscience, University of Virginia, School of Medicine, Charlottesville, VA, United States.
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17
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The Role of Glutamate Receptors in Epilepsy. Biomedicines 2023; 11:biomedicines11030783. [PMID: 36979762 PMCID: PMC10045847 DOI: 10.3390/biomedicines11030783] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/26/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Glutamate is an essential excitatory neurotransmitter in the central nervous system, playing an indispensable role in neuronal development and memory formation. The dysregulation of glutamate receptors and the glutamatergic system is involved in numerous neurological and psychiatric disorders, especially epilepsy. There are two main classes of glutamate receptor, namely ionotropic and metabotropic (mGluRs) receptors. The former stimulate fast excitatory neurotransmission, are N-methyl-d-aspartate (NMDA), α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA), and kainate; while the latter are G-protein-coupled receptors that mediate glutamatergic activity via intracellular messenger systems. Glutamate, glutamate receptors, and regulation of astrocytes are significantly involved in the pathogenesis of acute seizure and chronic epilepsy. Some glutamate receptor antagonists have been shown to be effective for the treatment of epilepsy, and research and clinical trials are ongoing.
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18
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Naylor DE. In the fast lane: Receptor trafficking during status epilepticus. Epilepsia Open 2023; 8 Suppl 1:S35-S65. [PMID: 36861477 PMCID: PMC10173858 DOI: 10.1002/epi4.12718] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Abstract
Status epilepticus (SE) remains a significant cause of morbidity and mortality and often is refractory to standard first-line treatments. A rapid loss of synaptic inhibition and development of pharmacoresistance to benzodiazepines (BZDs) occurs early during SE, while NMDA and AMPA receptor antagonists remain effective treatments after BZDs have failed. Multimodal and subunit-selective receptor trafficking within minutes to an hour of SE involves GABA-A, NMDA, and AMPA receptors and contributes to shifts in the number and subunit composition of surface receptors with differential impacts on the physiology, pharmacology, and strength of GABAergic and glutamatergic currents at synaptic and extrasynaptic sites. During the first hour of SE, synaptic GABA-A receptors containing γ2 subunits move to the cell interior while extrasynaptic GABA-A receptors with δ subunits are preserved. Conversely, NMDA receptors containing N2B subunits are increased at synaptic and extrasynaptic sites, and homomeric GluA1 ("GluA2-lacking") calcium permeant AMPA receptor surface expression also is increased. Molecular mechanisms, largely driven by NMDA receptor or calcium permeant AMPA receptor activation early during circuit hyperactivity, regulate subunit-specific interactions with proteins involved with synaptic scaffolding, adaptin-AP2/clathrin-dependent endocytosis, endoplasmic reticulum (ER) retention, and endosomal recycling. Reviewed here is how SE-induced shifts in receptor subunit composition and surface representation increase the excitatory to inhibitory imbalance that sustains seizures and fuels excitotoxicity contributing to chronic sequela such as "spontaneous recurrent seizures" (SRS). A role for early multimodal therapy is suggested both for treatment of SE and for prevention of long-term comorbidities.
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Affiliation(s)
- David E Naylor
- VA Greater Los Angeles Healthcare System, Department of Neurology, David Geffen School of Medicine at UCLA, and The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California, USA
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19
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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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20
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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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21
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Wieser M, Beckmann KM, Kutter APN, Mauri N, Richter H, Zölch N, Bektas RN. Ketamine administration in idiopathic epileptic and healthy control dogs: Can we detect differences in brain metabolite response with spectroscopy? Front Vet Sci 2023; 9:1093267. [PMID: 36686158 PMCID: PMC9853535 DOI: 10.3389/fvets.2022.1093267] [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: 11/08/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction In recent years ketamine has increasingly become the focus of multimodal emergency management for epileptic seizures. However, little is known about the effect of ketamine on brain metabolites in epileptic patients. Magnetic resonance spectroscopy (MRS) is a non-invasive technique to estimate brain metabolites in vivo. Our aim was to measure the effect of ketamine on thalamic metabolites in idiopathic epileptic (IE) dogs using 3 Tesla MRS. We hypothesized that ketamine would increase the glutamine-glutamate (GLX)/creatine ratio in epileptic dogs with and without antiseizure drug treatment, but not in control dogs. Furthermore, we hypothesized that no different responses after ketamine administration in other measured brain metabolite ratios between the different groups would be detected. Methods In this controlled prospective experimental trial IE dogs with or without antiseizure drug treatment and healthy client-owned relatives of the breeds Border Collie and Greater Swiss Mountain Dog, were included. After sedation with butorphanol, induction with propofol and maintenance with sevoflurane in oxygen and air, a single voxel MRS at the level of the thalamus was performed before and 2 min after intravenous administration of 1 mg/kg ketamine. An automated data processing spectral fitting linear combination model algorithm was used to estimate all commonly measured metabolite ratios. A mixed ANOVA with the independent variables ketamine administration and group allocation was performed for all measured metabolites. A p < 0.05 was considered statistically significant. Results Twelve healthy control dogs, 10 untreated IE and 12 treated IE dogs were included. No significant effects for GLX/creatine were found. However, increased glucose/creatine ratios were found (p < 0.001) with no effect of group allocation. Furthermore, increases in the GABA/creatine ratio were found in IEU dogs. Discussion MRS was able to detect changes in metabolite/creatine ratios after intravenous administration of 1 mg/kg ketamine in dogs and no evidence was found that excitatory effects are induced in the thalamus. Although it is beyond the scope of this study to investigate the antiseizure potential of ketamine in dogs, results of this research suggest that the effect of ketamine on the brain metabolites could be dependent on the concentrations of brain metabolites before administration.
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Affiliation(s)
- Manuela Wieser
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, University of Zurich, Zurich, Switzerland,*Correspondence: Manuela Wieser ✉
| | | | - Annette P. N. Kutter
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, University of Zurich, Zurich, Switzerland
| | - Nico Mauri
- Department of Clinical Diagnostics and Services, Clinic for Diagnostic Imaging, University of Zurich, Zurich, Switzerland,Vetimage Diagnostik AG, Oberentfelden, Switzerland
| | - Henning Richter
- Department of Clinical Diagnostics and Services, Clinic for Diagnostic Imaging, University of Zurich, Zurich, Switzerland
| | - Niklaus Zölch
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Rima Nadine Bektas
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, University of Zurich, Zurich, Switzerland
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22
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Ng MC, El-Alawi H, Toutant D, Choi EH, Wright N, Khanam M, Paunovic B, Ko JH. A Pilot Study of High-Definition Transcranial Direct Current Stimulation in Refractory Status Epilepticus: The SURESTEP Trial. Neurotherapeutics 2023; 20:181-194. [PMID: 36323975 PMCID: PMC9629761 DOI: 10.1007/s13311-022-01317-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 12/13/2022] Open
Abstract
Refractory status epilepticus (RSE) is a life-threatening emergency with high mortality and poor functional outcomes in survivors. Treatment is typically limited to intravenous anesthetic infusions and multiple anti-seizure medications. While ongoing seizures can cause permanent neurological damage, medical therapies also pose severe and life-threatening side effects. We tested the feasibility of using high-definition transcranial direct current stimulation (hd-tDCS) in the treatment of RSE. We conducted 20-min hd-tDCS sessions at an outward field orientation, intensity of 2-mA, 4 + 1 channels, and customized for deployment over the electrographic maximum of epileptiform activity ("spikes") determined by real-time clinical EEG monitoring. There were no adverse events from 32 hd-tDCS sessions in 10 RSE patients. Over steady dosing states of infusions and medications in 29 included sessions, median spike rates/patient fell by 50% during hd-tDCS on both automated (p = 0.0069) and human (p = 0.0277) spike counting. Median spike rates for any given stimulation session also fell by 50% during hd-tDCS on automated spike counting (p = 0.0032). Immediately after hd-tDCS, median spike rates/patient remained down by 25% on human spike counting (p = 0.018). Compared to historical controls, hd-tDCS subjects were successfully discharged from the intensive care unit (ICU) 45.8% more often (p = 0.004). When controls were selected using propensity score matching, the discharge rate advantage improved to 55% (p = 0.002). Customized EEG electrode targeting of hd-tDCS is a safe and non-invasive method of hyperacutely reducing epileptiform activity in RSE. Compared to historical controls, there was evidence of a cumulative chronic clinical response with more hd-tDCS subjects discharged from ICU.
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Affiliation(s)
- Marcus C Ng
- Section of Neurology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.
- Undergraduate Medical Education, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada.
- Graduate Program in Biomedical Engineering, University of Manitoba, Winnipeg, Canada.
| | - Hussam El-Alawi
- Undergraduate Medical Education, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Darion Toutant
- Graduate Program in Biomedical Engineering, University of Manitoba, Winnipeg, Canada
| | - Eun Hyung Choi
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Canada
| | - Natalie Wright
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Canada
| | - Manzuma Khanam
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Canada
| | - Bojan Paunovic
- Undergraduate Medical Education, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
- Section of Critical Care Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Ji Hyun Ko
- Graduate Program in Biomedical Engineering, University of Manitoba, Winnipeg, Canada.
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Canada.
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Tam YS, Chen E, Poh ZE, Chia G, Provido M, Hum A, Lee HX. Ketamine in Severe Leptomeningeal Pain. J Palliat Med 2022; 26:591-595. [PMID: 36269856 DOI: 10.1089/jpm.2022.0184] [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: 11/13/2022] Open
Abstract
Carcinomatosis meningitis is a rare but deadly complication of medulloblastoma. Surgical and systemic treatment options are often limited in advanced stages of the cancer. Meningeal irritation from raised intracranial pressure causes leptomeningeal pain that may respond poorly to opioids and common adjuvant analgesics. We present the case of a terminally ill patient with severe leptomeningeal pain that responded to a trial of ketamine as an adjunct to opioids.
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Affiliation(s)
- Yong Seng Tam
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Elizabeth Chen
- Singhealth, Singapore General Hospital, Singapore, Singapore
| | - ZhiSheng Edmund Poh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Gerksin Chia
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Mahrley Provido
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Allyn Hum
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore.,The Palliative Care Centre for Excellence in Research and Education (PalC), Singapore, Singapore
| | - Hsien Xiong Lee
- Department of Palliative Medicine and Supportive Care, Woodlands Health, Singapore, Singapore
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Sivakumar S, Ghasemi M, Schachter SC. Targeting NMDA Receptor Complex in Management of Epilepsy. Pharmaceuticals (Basel) 2022; 15:ph15101297. [PMID: 36297409 PMCID: PMC9609646 DOI: 10.3390/ph15101297] [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: 08/06/2022] [Revised: 10/17/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022] Open
Abstract
N-methyl-D-aspartate receptors (NMDARs) are widely distributed in the central nervous system (CNS) and play critical roles in neuronal excitability in the CNS. Both clinical and preclinical studies have revealed that the abnormal expression or function of these receptors can underlie the pathophysiology of seizure disorders and epilepsy. Accordingly, NMDAR modulators have been shown to exert anticonvulsive effects in various preclinical models of seizures, as well as in patients with epilepsy. In this review, we provide an update on the pathologic role of NMDARs in epilepsy and an overview of the NMDAR antagonists that have been evaluated as anticonvulsive agents in clinical studies, as well as in preclinical seizure models.
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Affiliation(s)
- Shravan Sivakumar
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Mehdi Ghasemi
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
- Correspondence: (M.G.); (S.C.S.)
| | - Steven C. Schachter
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02114, USA
- Consortia for Improving Medicine with Innovation & Technology (CIMIT), Boston, MA 02114, USA
- Correspondence: (M.G.); (S.C.S.)
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25
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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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Factors Associated with Refractory Status Epilepticus Termination Following Ketamine Initiation: A Multivariable Analysis Model. Neurocrit Care 2022; 38:235-241. [PMID: 36002634 DOI: 10.1007/s12028-022-01578-0] [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: 03/20/2022] [Accepted: 07/26/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND In this study, we identify factors associated with ketamine success in the treatment of refractory status epilepticus (SE). We also evaluate for adverse events including systemic and cerebral hemodynamic stability and fluid volume overload. METHODS In this retrospective, large, single-center, observational study over a 10-year period, 879 consecutive patients receiving intravenous (IV) ketamine were reviewed, and 81 patients were identified as receiving IV ketamine for the treatment of SE. Descriptive analysis was done to determine treatment response and adverse events in patients receiving IV ketamine for SE. Multivariable logistic regression analyses were fitted to determine prediction models for seizure cessation. RESULTS Permanent cessation of SE was achieved in 49 of 81 (60.5%) of patients for whom ketamine was part of the treatment plan. Of those, 36 (44.4%) were attributed to ketamine as the last drug used (ketamine-associated cessation [AC]). Prior history of epilepsy had an odds ratio of 3.19 (confidence interval 0.83-12.67, p = 0.09) associated with efficacious medication response. Increased latency to ketamine was associated with cessation of SE specifically in patients in the AC group (p = 0.077). Longer SE duration (p = 0.04), administration of ketamine loading dose (bolus; p = 0.03), and anoxia (p = 0.007) were negatively associated with AC. Administration of ketamine loading dose (p = 0.02) and anoxia (p = 0.009) were negatively associated with overall SE cessation. There was no significant impact of ketamine on cerebral hemodynamics, but evidence of fluid volume overload was seen (28.4% of patients). CONCLUSIONS Our cohort is a large observational study showing a high success rate of permanent cessation of SE after the addition of ketamine. Using multivariable analysis, we demonstrate a significant association with seizure cessation in patients with prior history of epilepsy and those with prolonged latency to ketamine initiation. Furthermore, we describe the impact of fluid volume overload as an anticipated complication with ketamine use.
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27
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Evaluation and Treatment of Adult Status Epilepticus in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022. [DOI: 10.1007/s40138-022-00250-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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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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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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30
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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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31
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Midega TD, Chaves RCDF, Ashihara C, Alencar RM, Queiroz VNF, Zelezoglo GR, Vilanova LCDS, Olivato GB, Cordioli RL, Bravim BDA, Corrêa TD. Ketamine use in critically ill patients: a narrative review. Rev Bras Ter Intensiva 2022; 34:287-294. [PMID: 35946660 DOI: 10.5935/0103-507x.20220027-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/08/2022] [Indexed: 11/20/2022] Open
Abstract
Ketamine is unique among anesthetics and analgesics. The drug is a rapid-acting general anesthetic that produces an anesthetic state characterized by profound analgesia, preserved pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression. Research has demonstrated the efficacy of its use on anesthesia, pain, palliative care, and intensive care. Recently, it has been used for postoperative and chronic pain, as an adjunct in psychotherapy, as a treatment for depression and posttraumatic stress disorder, as a procedural sedative, and as a treatment for respiratory and/or neurologic clinical conditions. Despite being a safe and widely used drug, many physicians, such as intensivists and those practicing in emergency care, are not aware of the current clinical applications of ketamine. The objective of this narrative literature review is to present the theoretical and practical aspects of clinical applications of ketamine in intensive care unit and emergency department settings.
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Affiliation(s)
- Thais Dias Midega
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | - Carolina Ashihara
- Departamento de Anestesiologia, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Roger Monteiro Alencar
- Departamento de Medicina Intensiva, Hospital Municipal Dr. Moysés Deutsch - São Paulo (SP), Brasil
| | | | | | | | | | - Ricardo Luiz Cordioli
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Bruno de Arruda Bravim
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Thiago Domingos Corrêa
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
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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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Machado RA, Patel J, Elsayed MS. The role of ketamine-induced beta activity in the treatment of refractory status epilepticus. Is the EEG useful to determine responder's rate? A retrospective study. Epilepsy Behav 2022; 127:108512. [PMID: 34974373 DOI: 10.1016/j.yebeh.2021.108512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Multiple investigations have been done to evaluate the possible effect of ketamine in the treatment of status epilepticus (SE). OBJECTIVES To evaluate the electrographic effect of ketamine on EEG, and its clinical utility following-up refractory and super refractory status epilepticus (SRSE). METHODS Retrospective review of 24 patients with SE. Clinical record and Video-electroencephalogram (video-EEG) of all included patients were reviewed. The patients' EEGs were then monitored for any immediate changes after administration of the first dose of ketamine as well as at the time patients would be predicted to have peak serum concentration of ketamine. Patients with cessation of electrographic seizures and no SE recurrence within the same admissions were categorized as "Responders". Statistical differences between qualitative variables were analyzed using chi square test. Differences between median were analyzed by Mann-Whitney U test. Difference between groups were considered significant when p < 0.05. RESULTS We identified 24 patients with SE. Twelve out of 24 (50%) had SRSE and 12 out of 24 (50%) had refractory status epilepticus (RSE). The appearance of superimposed beta activity after ketamine was initiated was associated with a higher responder rate (100% versus 33.3% in the responder group versus the non-responder group respectively). Notably, the presence of a burst suppression pattern had no significant association with one group compared to the other (41.6% versus 33.3%, in the responder group vs the non-responder group respectively). CONCLUSIONS Background superimposed beta activity induced by ketamine is an early and reliable EEG finding associated with status epilepticus termination.
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Affiliation(s)
| | - Janaki Patel
- Wayne State University/Detroit Medical Center, United States
| | - Mona S Elsayed
- Adult Comprehensive Epilepsy Program, Wayne State University/Detroit Medical Center, United States
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Fan JM, Singhal NS, Guterman EL. Management of Status Epilepticus and Indications for Inpatient Electroencephalography Monitoring. Neurol Clin 2022; 40:1-16. [PMID: 34798964 DOI: 10.1016/j.ncl.2021.08.001] [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] [Indexed: 11/22/2022]
Abstract
Status epilepticus (SE) is a neurologic emergency requiring immediate time-sensitive treatment to minimize neuronal injury and systemic complications. Minimizing time to administration of first- and second-line therapy is necessary to optimize the chances of successful seizure termination in generalized convulsive SE (GCSE). The approach to refractory and superrefractory GCSE is less well defined. Multiple agents with differing complementary actions that facilitate seizure termination are recommended. Nonconvulsive SE (NCSE) has a wide range of presentations and approaches to treatment. Continuous electroencephalography is critical to the management of both GCSE and NCSE, while its use for patients without seizure continues to expand.
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Affiliation(s)
- Joline M Fan
- Department of Neurology, University of California, San Francisco, 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA 94143, USA; Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94143, USA.
| | - Neel S Singhal
- Department of Neurology, University of California, San Francisco, 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA 94143, USA; Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Elan L Guterman
- Department of Neurology, University of California, San Francisco, 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA 94143, USA; Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94143, USA
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Ioku T, Inoue T, Kuki I, Imai K, Yamamoto A, Cho M. [A case of febrile infection-related epilepsy syndrome requiring prolonged intensive care management: a trial of intravenous ketamine and intrathecal dexamethasone therapy]. Rinsho Shinkeigaku 2022; 62:123-129. [PMID: 35095046 DOI: 10.5692/clinicalneurol.cn-001624] [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: 11/05/2022]
Abstract
A 16-year-old male was brought to the emergency room with fever and status epilepticus, and was diagnosed with febrile infection-related epilepsy syndrome (FIRES). Seizure control was not achieved and the patient developed multiple complications. Ketamine infusion therapy and intrathecal dexamethasone therapy were administered, in addition to other anti-seizure treatment and immunotherapy for super-refractory status epilepticus (SRSE). The patient was weaned from the ventilator on day 170 and was able to live at home, although he continued to experience monthly focal motor seizures and moderate motor impairment. This case suggests that more aggressive treatment might be an option in FIRES with prolonged SRSE.
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Affiliation(s)
- Tetsuya Ioku
- Department of Neurology and Stroke Treatment, Kyoto First Red Cross Hospital
| | - Takeshi Inoue
- Child and Adolescent Epilepsy Center, Department of Pediatric Neurology, Osaka City General Hospital
| | - Ichiro Kuki
- Child and Adolescent Epilepsy Center, Department of Pediatric Neurology, Osaka City General Hospital
| | - Keisuke Imai
- Department of Neurology and Stroke Treatment, Kyoto First Red Cross Hospital
| | - Atsushi Yamamoto
- Department of Neurology and Stroke Treatment, Kyoto First Red Cross Hospital
| | - Masanori Cho
- Department of Neurology and Stroke Treatment, Kyoto First Red Cross Hospital
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Périn B, Szurhaj W. New onset refractory status epilepticus: State of the art. Rev Neurol (Paris) 2022; 178:74-83. [PMID: 35031143 DOI: 10.1016/j.neurol.2021.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 12/11/2022]
Abstract
NORSE (new onset refractory status epilepticus) has recently been defined as a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurological disorder, with new onset of refractory status epilepticus without a clear acute or active structural, toxic or metabolic cause. It includes the concept of FIRES described in children with a similar condition but preceded by a 2-14-day febrile illness. NORSE constitutes the acute phase of an entity preceded by a prodromal phase which may be accompanied by numerous manifestations (febrile episode, behavioural changes, headache, …), and followed by a chronic phase marked by long-term neurological sequelae, cognitive impairment, epilepsy and functional disability. There are many causes of NORSE: autoimmune, infectious, genetic, toxic, … but in half of the cases, despite an exhaustive assessment, the cause remains undetermined. Paraneoplastic and non-paraneoplastic autoimmune encephalitis remains by far the leading cause of NORSE. For these reasons, immunotherapy should be considered rapidly in parallel with the treatment of the status epilepticus, including in cryptogenic NORSE. Good communication with the family is important because the management of the acute phase is long and difficult. Although mortality remains high (11-22%), and sequelae can be severe, the majority of survivors can have a good or fair outcome.
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Affiliation(s)
- B Périn
- Department of clinical neurophysiology, Amiens University Medical Center, France
| | - W Szurhaj
- Department of clinical neurophysiology, Amiens University Medical Center, France; Équipe CHIMERE EA7516, université Picardie Jules-Verne, France.
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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.
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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
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Al-Faraj AO, Abdennadher M, Pang TD. Diagnosis and Management of Status Epilepticus. Semin Neurol 2021; 41:483-492. [PMID: 34619776 DOI: 10.1055/s-0041-1733787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Seizures are among the most common neurological presentations to the emergency room. They present on a spectrum of severity from isolated new-onset seizures to acute repetitive seizures and, in severe cases, status epilepticus. The latter is the most serious, as it is associated with high morbidity and mortality. Prompt recognition and treatment of both seizure activity and associated acute systemic complications are essential to improve the overall outcome of these patients. The purpose of this review is to provide the current viewpoint on the diagnostic evaluation and pharmacological management of patients presenting with status epilepticus, and the common associated systemic complications.
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Affiliation(s)
- Abrar O Al-Faraj
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Myriam Abdennadher
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Trudy D Pang
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Rosenthal ES. Seizures, Status Epilepticus, and Continuous EEG in the Intensive Care Unit. Continuum (Minneap Minn) 2021; 27:1321-1343. [PMID: 34618762 DOI: 10.1212/con.0000000000001012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW This article discusses the evolving definitions of seizures and status epilepticus in the critical care environment and the role of critical care EEG in both diagnosing seizure activity and serving as a predictive biomarker of clinical trajectory. RECENT FINDINGS Initial screening EEG has been validated as a tool to predict which patients are at risk of future seizures. However, accepted definitions of seizures and nonconvulsive status epilepticus encourage a treatment trial when the diagnosis on EEG is indeterminate because of periodic or rhythmic patterns or uncertain clinical correlation. Similarly, recent data have demonstrated the diagnostic utility of intracranial EEG in increasing the yield of seizure detection. EEG has additionally been validated as a diagnostic biomarker of covert consciousness, a predictive biomarker of cerebral ischemia and impending neurologic deterioration, and a prognostic biomarker of coma recovery and status epilepticus resolution. A recent randomized trial concluded that patients allocated to continuous EEG had no difference in mortality than those undergoing intermittent EEG but could not demonstrate whether this lack of difference was because of studying heterogeneous conditions, examining a monitoring tool rather than a therapeutic approach, or examining an outcome measure (mortality) perhaps more strongly associated with early withdrawal of life-sustaining therapy than to a sustained response to pharmacotherapy. SUMMARY Seizures and status epilepticus are events of synchronous hypermetabolic activity that are either discrete and intermittent or, alternatively, continuous. Seizures and status epilepticus represent the far end of a continuum of ictal-interictal patterns that include lateralized rhythmic delta activity and periodic discharges, which not only predict future seizures but may be further classified as status epilepticus on the basis of intracranial EEG monitoring or a diagnostic trial of antiseizure medication therapy. In particularly challenging cases, neuroimaging or multimodality neuromonitoring may be a useful adjunct documenting metabolic crisis. Specialized uses of EEG as a prognostic biomarker have emerged in traumatic brain injury for predicting language function and covert consciousness, cardiac arrest for predicting coma recovery, and subarachnoid hemorrhage for predicting neurologic deterioration due to delayed cerebral ischemia.
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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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Kirmani BF, Au K, Ayari L, John M, Shetty P, Delorenzo RJ. Super-Refractory Status Epilepticus: Prognosis and Recent Advances in Management. Aging Dis 2021; 12:1097-1119. [PMID: 34221552 PMCID: PMC8219503 DOI: 10.14336/ad.2021.0302] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is a life-threatening neurological emergency with high morbidity and mortality. It is defined as “status epilepticus (SE) that continues or recurs 24 hours or more after the onset of anesthesia, including those cases in which SE recurs on the reduction or withdrawal of anesthesia.” This condition is resistant to normal protocols used in the treatment of status epilepticus and exposes patients to increased risks of neuronal death, neuronal injury, and disruption of neuronal networks if not treated in a timely manner. It is mainly seen in patients with severe acute onset brain injury or presentation of new-onset refractory status epilepticus (NORSE). The mortality, neurological deficits, and functional impairments are significant depending on the duration of status epilepticus and the resultant brain damage. Research is underway to find the cure for this devastating neurological condition. In this review, we will discuss the wide range of therapies used in the management of SRSE, provide suggestions regarding its treatment, and comment on future directions. The therapies evaluated include traditional and alternative anesthetic agents with antiepileptic agents. The other emerging therapies include hypothermia, steroids, immunosuppressive agents, electrical and magnetic stimulation therapies, emergent respective epilepsy surgery, the ketogenic diet, pyridoxine infusion, cerebrospinal fluid drainage, and magnesium infusion. To date, there is a lack of robust published data regarding the safety and effectiveness of various therapies, and there continues to be a need for large randomized multicenter trials comparing newer therapies to treat this refractory condition.
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Affiliation(s)
- Batool F Kirmani
- 1Texas A&M University College of Medicine, College Station, TX, USA.,3Epilepsy and Functional Neurosurgery Program, Department of Neurology, CHI St. Joseph Health, Bryan, TX, USA
| | - Katherine Au
- 2George Washington University, School of Medicine & Health Sciences, Washington DC, USA
| | - Lena Ayari
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Marita John
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Padmashri Shetty
- 4M. S. Ramaiah Medical College, M. S. Ramaiah Nagar, Bengaluru, Karnataka, India
| | - Robert J Delorenzo
- 5Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA
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Abstract
OBJECTIVES To assess the evidence and discuss the risks and clinical relevance of ketamine for the treatment of various disease states impacting the adult critically ill population. DATA SOURCES A literature review was performed using PubMed evaluating primary literature published until August 2018. STUDY SELECTION Case reports, observational studies (cohort, case-control), and randomized controlled trials involving patients 18 years and older in a nonperioperative setting using either IV or intramuscular ketamine were included for analysis. Uses of ketamine discussed focused on critically ill patients in the ICU and emergency department settings. DATA EXTRACTION Included studies were evaluated for dosing, outcomes, and adverse effects of ketamine. For each study, the design, population, intervention, investigated outcomes, and results were assessed. DATA SYNTHESIS The evidence was organized according to use of ketamine, which included pain, sedation, status asthmaticus, alcohol withdrawal syndrome, status epilepticus, and acute behavioral psychologic disturbances. Evaluation of the evidence was based on the included primary literature along with any related guideline recommendations. CONCLUSIONS Ketamine has suggested potential benefit in several disease states impacting critically ill patients including pain, alcohol withdrawal syndrome, status epilepticus, and acute agitation. Further supporting evidence is needed to validate its use in the setting of critical illness.
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[S2k guidelines: status epilepticus in adulthood : Guidelines of the German Society for Neurology]. DER NERVENARZT 2021; 92:1002-1030. [PMID: 33751150 PMCID: PMC8484257 DOI: 10.1007/s00115-020-01036-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 01/16/2023]
Abstract
This S2k guideline on diagnosis and treatment of status epilepticus (SE) in adults is based on the last published version from 2021. New definitions and evidence were included in the guideline and the clinical pathway. A seizures lasting longer than 5 minutes (or ≥ 2 seizures over more than 5 mins without intermittend recovery to the preictal neurological state. Initial diagnosis should include a cCT or, if possible, an MRI. The EEG is highly relevant for diagnosis and treatment-monitoring of non-convulsive SE and for the exclusion or diagnosis of psychogenic non-epileptic seizures. As the increasing evidence supports the relevance of inflammatory comorbidities (e.g. pneumonia) related clinical chemistry should be obtained and repeated over the course of a SE treatment, and antibiotic therapy initiated if indicated.Treatment is applied on four levels: 1. Initial SE: An adequate dose of benzodiazepine is given i.v., i.m., or i.n.; 2. Benzodiazepine-refractory SE: I.v. drugs of 1st choice are levetiracetam or valproate; 3. Refractory SE (RSE) or 4. Super-refractory SE (SRSE): I.v. propofol or midazolam alone or in combination or thiopental in anaesthetic doses are given. In focal non-convulsive RSE the induction of a therapeutic coma depends on the circumstances and is not mandatory. In SRSE the ketogenic diet should be given. I.v. ketamine or inhalative isoflorane can be considered. In selected cased electroconvulsive therapy or, if a resectable epileptogenic zone can be defined epilepsy surgery can be applied. I.v. allopregnanolone or systemic hypothermia should not be used.
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Roynard P, Bilderback A, Dewey CW. Intravenous Ketamine Bolus(es) for the Treatment of Status Epilepticus, Refractory Status Epilepticus, and Cluster Seizures: A Retrospective Study of 15 Dogs. Front Vet Sci 2021; 8:547279. [PMID: 33681317 PMCID: PMC7925624 DOI: 10.3389/fvets.2021.547279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 01/07/2021] [Indexed: 12/02/2022] Open
Abstract
Status epilepticus (SE) and cluster seizures (CS) are common occurrences in veterinary neurology and frequent reasons of admission to veterinary hospitals. With prolonged seizure activity, gamma amino-butyric acid (GABA) receptors (GABAa receptors) become inactive, leading to a state of pharmacoresistance to benzodiazepines and other GABAergic medications, which is called refractory status epilepticus (RSE). Prolonged seizure activity is also associated with overexpression of N-methyl-D-aspartic (NMDA) receptors. Rodent models have shown the efficacy of ketamine (KET) in treating RSE, and its use has been reported in one canine case of RSE. Boluses of KET 5 mg/kg IV have become the preferred treatment for RSE in our hospital. A retrospective study was performed to evaluate and report our experience with KET IV bolus to treat prolonged and/or repeated seizure activity in cases of canine CS, SE, and RSE. A total of 15 dogs were retrieved, for 20 hospitalizations and 28 KET IV injections over 3 years. KET IV boluses were used 12 times for RSE (9 generalized seizures, 3 focal seizures) and KET terminated the episode of RSE 12/12 times (100%); however, seizures recurred 4/12 times (33%) within ≤6 h of KET IV bolus. When used for CS apart from episodes of RSE, KET IV bolus was associated with termination of the CS episode only 4/14 times (29%). Only 4/28 (14%) KET IV boluses were associated with adverse effects imputable only to the use of KET. One dog experienced a short, self-limited seizure activity during administration of KET IV, which was most likely related to a pre-mature use of KET IV (i.e., before GABAergic resistance and NMDA receptor overexpression had taken place). This study indicates that KET 5 mg/kg IV bolus may be successful for the treatment of RSE in dogs.
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Affiliation(s)
- Patrick Roynard
- Long Island Veterinary Specialists, Department of Neurology/Neurosurgery, Plainview, NY, United States
| | - Ann Bilderback
- VCA Northwest Veterinary Specialists, Clackamas, OR, United States
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Abstract
PURPOSE OF REVIEW Randomized controlled trials investigating the initial pharmacological treatment of status epilepticus have been recently published. Furthermore, status epilepticus arising in comatose survivors after cardiac arrest has received increasing attention in the last years. This review offers an updated assessment of status epilepticus treatment in these different scenarios. RECENT FINDINGS Initial benzodiazepines underdosing is common and correlates with development of status epilepticus refractoriness. The recently published ESETT trial provides high-level evidence regarding the equivalence of fosphenytoin, valproate, and levetiracetam as a second-line option. Myoclonus or epileptiform transients on electroencephalography occur in up to 1/3 of patients surviving a cardiac arrest. Contrary to previous assumptions regarding an almost invariable association with death, at least 1/10 of them may awaken with reasonably good prognosis, if treated. Multimodal prognostication including clinical examination, EEG, somatosensory evoked potentials, biochemical markers, and neuroimaging help identifying patients with a chance to recover consciousness, in whom a trial with antimyoclonic compounds and at times general anesthetics is indicated. SUMMARY There is a continuous, albeit relatively slow progress in knowledge regarding different aspect of status epilepticus; recent findings refine some treatment strategies and help improving patients' outcomes. Further high-quality studies are clearly needed to further improve the management of these patients, especially those with severe, refractory status epilepticus forms.
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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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Mastroianni G, Iannone LF, Roberti R, Gasparini S, Ascoli M, Cianci V, De Sarro G, Gambardella A, Labate A, Brigo F, Russo E, Aguglia U, Ferlazzo E. Management of status epilepticus in patients with liver or kidney disease: a narrative review. Expert Rev Neurother 2020; 21:1251-1264. [PMID: 33297776 DOI: 10.1080/14737175.2021.1862649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Status epilepticus (SE) is a neurologic and medical emergency with significant related morbidity and mortality. Hepatic or renal dysfunction can considerably affect the pharmacokinetics of drugs used for SE through a variety of direct or indirect mechanisms.Areas Covered: This review aims to focus on the therapeutic management of SE in patients with hepatic or renal impairment, highlighting drugs' selection and dose changes that may be necessary due to altered drug metabolism and excretion. The references for this review were identified by searches of PubMed and Google Scholar until May 2020.Expert opinion: According to literature evidence and clinical experience, in patients with renal disease, the authors suggest considering lorazepam as the drug of choice in pre-hospital and intra-hospital early-stage SE, phenytoin in definite SE, propofol in refractory or super-refractory SE. In patients with liver disease, the authors suggest the use of lorazepam as drug of choice in pre-hospital and intra-hospital early-stage SE, lacosamide in definite SE, propofol in refractory or super-refractory SE. A list of preferred drugs for all SE stages is provided.
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Affiliation(s)
- Giovanni Mastroianni
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy
| | | | - Roberta Roberti
- Science of Health Department, School of Medicine, Magna Græcia University, Catanzaro, Italy
| | - Sara Gasparini
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Michele Ascoli
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Vittoria Cianci
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy
| | | | - Antonio Gambardella
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
| | - Angelo Labate
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
| | - Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, Magna Græcia University, Catanzaro, Italy
| | - Umberto Aguglia
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
| | - Edoardo Ferlazzo
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
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Gaspard N. Super K for Super-R(efractory) Status Epilepticus: Bringing Down Seizures While Keeping Up Blood Pressure With Ketamine. Epilepsy Curr 2020; 21:36-39. [PMID: 34025272 PMCID: PMC7863299 DOI: 10.1177/1535759720975740] [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] [Indexed: 11/17/2022] Open
Abstract
Ketamine to treat super-refractory status epilepticus Alkhachroum A, Der-Nigoghossian CA, Mathews E, Massad N, Letchinger R, Doyle K, Chiu W-T, Kromm J, Rubinos C, Velazquez A, Roh D, Agarwal S, Park S, Connolly S, Claassen J. Neurology. 2020;95(16):e2286-e2294. doi: 10.1212/WNL.0000000000010611. Objective: To test ketamine infusion efficacy in the treatment of superrefractory status epilepticus (SRSE), we studied patients with SRSE who were treated with ketamine retrospectively. We also studied the effect of high doses of ketamine on brain physiology as reflected by invasive multimodality monitoring (MMM). Methods: We studied a consecutive series of 68 patients with SRSE who were admitted between 2009 and 2018, treated with ketamine, and monitored with scalp EEG. Eleven of these patients underwent MMM at the time of ketamine administration. We compared patients who had seizure cessation after ketamine initiation to those who did not. Results: Mean age was 53 ± 18 years and 46% of patients were female. Seizure burden decreased by at least 50% within 24 hours of starting ketamine in 55 (81%) patients, with complete cessation in 43 (63%). Average dose of ketamine infusion was 2.2 ± 1.8 mg/kg/h, with median duration of 2 (1-4) days. Average dose of midazolam was 1.0 ± 0.8 mg/kg/h at the time of ketamine initiation and was started at a median of 0.4 (0.1-1.0) days before ketamine. Using a generalized linear mixed effect model, ketamine was associated with stable mean arterial pressure (odds ratio = 1.39, 95% CI: 1.38-1.40) and with decreased vasopressor requirements over time. We found no effect on intracranial pressure, cerebral blood flow, or cerebral perfusion pressure. Conclusion: Ketamine treatment was associated with a decrease in seizure burden in patients with SRSE. Our data support the notion that high-dose ketamine infusions are associated with decreased vasopressor requirements without increased intracranial pressure. Classification of Evidence: This study provides Class IV evidence that ketamine decreases seizures in patients with SRSE.
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Yuan F, Lu A, Wu S, Wang L. Refractory Status Epilepticus Responsive to Electroacupuncture at Shuigou Acupoint: A Case Report. Front Neurol 2020; 11:580777. [PMID: 33329323 PMCID: PMC7734353 DOI: 10.3389/fneur.2020.580777] [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: 07/07/2020] [Accepted: 11/04/2020] [Indexed: 11/30/2022] Open
Abstract
Refractory status epilepticus (RSE) is a critical and intractable neurological emergency. Around 55% of RSE episodes still persist despite high dose of continuous infusion of anesthetics. It's a clinical urgency and challenge to search for novel alternative treatments to control RSE as soon as possible. Here, we reported a case of RSE in a 67-year-old woman with varicella-zoster virus encephalitis. She had persistent non-convulsive SE despite the continuous infusion of midazolam. On the basis of fundamental treatments, she was given electroacupuncture at Shuigou acupoint for 10 min. An immediate EEG suppression was seen after the electroacupuncture treatment and lasted for 9 min, and lasting epileptic discharges (> 10 s) and clinical seizures were not observed any more. Midazolam was withdrawn gradually 24 h later. This case report may bring an alternative treatment for RSE.
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Affiliation(s)
- Fang Yuan
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Aili Lu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shibiao Wu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lixin Wang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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