Treatment of Refractory Status Epilepticus With Continuous Intravenous Anesthetic Drugs: A Systematic Review

Importance

Multiple continuous intravenous anesthetic drugs (CIVADs) are available for the treatment of refractory status epilepticus (RSE). There is a paucity of data comparing the different types of CIVADs used for RSE.

Objective

To systematically review and compare outcome measures associated with the initial CIVAD choice in RSE in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Evidence Review

Data sources included English and non-English articles using Embase, MEDLINE, PubMed, and Web of Science (January 1994-June 2023) as well as manual search. Study selection included peer-reviewed studies of 5 or more patients and at least 1 patient older than 12 years with status epilepticus refractory to a benzodiazepine and at least 1 standard antiseizure medication, treated with continuously infused midazolam, ketamine, propofol, pentobarbital, or thiopental. Independent extraction of articles was performed using prespecified data items. The association between outcome variables and CIVAD was examined with an analysis of variance or χ2 test where appropriate. Binary logistic regressions were used to examine the association between outcome variables and CIVAD with etiology, change in mortality over time, electroencephalography (EEG) monitoring (continuous vs intermittent), and treatment goal (seizure vs burst suppression) included as covariates. Risk of bias was addressed by listing the population and type of each study.

Findings

A total of 66 studies with 1637 patients were included. Significant differences among CIVAD groups in short-term failure, hypotension, and CIVAD substitution during treatment were observed. Non-epilepsy-related RSE (vs epilepsy-related RSE) was associated with a higher rate of CIVAD substitution (60 of 120 [50.0%] vs 11 of 43 [25.6%]; odds ratio [OR], 3.11; 95% CI, 1.44-7.11; P = .006) and mortality (98 of 227 [43.2%] vs 7 of 63 [11.1%]; OR, 17.0; 95% CI, 4.71-109.35; P < .001). Seizure suppression was associated with mortality (OR, 7.72; 95% CI, 1.77-39.23; P = .005), but only a small subgroup was available for analysis (seizure suppression: 17 of 22 [77.3%] from 3 publications vs burst suppression: 25 of 98 [25.5%] from 12 publications). CIVAD choice and EEG type were not predictors of mortality. Earlier publication year was associated with mortality, although the observation was no longer statistically significant after adjusting SEs for clustering.

Conclusions and Relevance

Epilepsy-related RSE was associated with lower mortality compared with other RSE etiologies. A trend of decreasing mortality over time was observed, which may suggest an effect of advances in neurocritical care. The overall data are heterogeneous, which limits definitive conclusions on the choice of optimal initial CIVAD in RSE treatment.

Neurological Critical Care Services' Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization

INTRODUCTION

Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI.

METHODS

Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05.

RESULTS

Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02).Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively.The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients.

CONCLUSION

The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS.

A young male patient with persistent fever due to tuberculous peritonitis

Tuberculous peritonitis is an uncommon disease in Hong Kong. We report a case of tuberculous peritonitis in a young male. The patient presented with persistent fever and intermittent cough for 1 month, but had no gastrointestinal symptoms. It was only through detection of slight abdominal ascites that subsequent abdominal paracentesis and laparoscopic biopsy confirmed the diagnosis. Appropriate antituberculous treatment was prescribed. Progress was complicated by persistent fever and liver function derangement, successfully managed by careful titration of antituberculous medications.

Changes of cytochemical markers in the conjunctival and corneal epithelium after corneal debridement

1. The aim of this study was to determine the epithelial changes of the conjunctiva and cornea up to 7 days after corneal debridement and the changes highlighted included (1) proliferation, (2) production of growth factor, (3) changes in calcium binding protein marker, (4) production of cytokine, and (5) maturity of the regeneration corneal epithelium. 2. The cytochemical changes of the corneal and conjunctival epithelia of rabbit were analyzed up to 7 days after debridement. 3. An increase in proliferating cell nuclear antigen (PCNA) was observed in the limbal epithelia 12 hr after lesion and reached a peak by 48 hr. 4. Some proliferating limbal cells also contained epidermal growth factor (EGF) beginning 24 hr after injury. The early limbal cell proliferation and the EGF production and their persistence until 7 days after lesion were likely involved with the process of regeneration. 5. Other positive markers appeared after lesion included tumor necrosis factor (TNFalpha) and calcium binding proteins S100A and S100B, which appeared mainly within the first 48 hr after lesion and then started to decline. The short appearance and the relatively small quantity of TNFalpha indicated that this cytokine was probably not very important in the repair process and its appearance might be related to the injury induced. The presence of S100A and S100B could be associated with both cell death after injury and the proliferation of new epithelium. 6. The cornea epithelium was still immature 7 days after lesion in that it still contained cytokeratin. 7. In conclusion, the critical hours of peak conjunctival and corneal changes after corneal debridement were in the first 2 days.

Spontaneous corneal rupture in Noonan syndrome. A case report

PURPOSE/METHODS

A variety of ocular and periocular manifestations have been described in Noonan syndrome. Collagen abnormalities have been described; however, to our knowledge spontaneous corneal rupture has not been reported. A forty-three-year-old female who presented with spontaneous corneal rupture was later diagnosed as having Noonan syndrome.

RESULTS/CONCLUSIONS

Collagen abnormalities have been described with Noonan syndrome and this is likely the cause of corneal rupture in this patient.

Increasing OR efficiency with a specialty services manual

The successful operation of a modern ophthalmology OR is dependent on a knowledgeable, well-educated nursing staff. To improve communication and teamwork between ophthalmology surgeons and nursing staff members at the Louisiana State University Medical Center University Hospital, Shreveport, we developed an OR manual. We reduced our level of frustration by producing a manual that facilitates the day-to-day operation of the surgical services department. The manual provides consistent information for our ophthalmic surgical procedures; functions as a reference source; and promotes an efficient, productive OR. Although we designed this manual for the ophthalmology surgical service at our medical center, its structure can be applied to other surgical specialties.

Removal of a corneal foreign body through a lamellar corneal pocket

A piece of glass was found in the posterior central cornea of a 43-year-old victim of a motor vehicle accident. The original entry of the foreign body had healed and epithelialized. This foreign body was removed through a peripheral corneal incision and corneal stromal pocket extended to the glass particle. This technique avoids creation of a corneal incision near the optical axis and prevents unwanted distortion of the corneal topography. The authors report this case to emphasize the importance of preserving corneal topography in corneal surgery.

Epikeratophakia to correct traumatic aphakia after penetrating keratoplasty

A 19-year-old man with keratoconus sustained ocular trauma and became aphakic in his operated left eye 2 months after penetrating keratoplasty. Original corneal wound repair was performed without intraocular lens implantation. Attempts to correct his aphakia with a contact lens failed when the patient became intolerant to its use. As an alternative, the patient had elective epikeratophakia. A standard 8.5 mm lenticule was placed over existing corneal graft. This operation resulted in +12.25 diopters of correction and a best corrected visual acuity of 20/25 at 30 months postoperatively. There was no sign of abnormalities at the host cornea or the transplanted lenticule. This case indicates that epikeratophakia may be successfully performed over existing corneal grafts.

Coagulase-negative staphylococci in conjunctivitis and blepharitis

Coagulase-negative staphylococcus (C-NS) are regarded as normal flora of the lids and conjunctiva. The ability of these organisms to cause conjunctivitis and blepharitis can be overlooked or disregarded. To elucidate the role of individual C-NS species in these eye diseases we compared Staphylococcus sp. isolated from the conjunctiva and lids of 50 healthy volunteers with 248 strains of Staphylococcus isolated from patients with staphylococcal conjunctivitis or blepharitis. S. epidermidis was the most frequent species isolated from the conjunctiva and lids of both groups. S. aureus was isolated only from infected patients. No individual C-NS species was found to be significantly associated with eye disease, but the colony count of C-NS after isolation was a useful indicator of conjunctivitis and blepharitis. The ability of Staphylococcus to ferment mannitol or mannose was associated with isolates only from infected patients.

Lateral tarsorrhaphy and disposable soft contact lenses in aniridia patients after penetrating keratoplasty

We report our experience with two patients with familial aniridia who underwent combined cataract extraction and penetrating keratoplasty. Persistent epithelial defects developed in all four eyes within 4 months. Combined lateral tarsorrhaphy and application of disposable soft contact lenses restored the integrity of the corneal epithelium, and 21 months after surgery, the grafts were clear and avascular.

Radial keratotomy in an elderly patient

A 74-year-old male complained of poor vision and diplopia as a result of cataract extraction and intraocular lens implantation. On refraction, we found -6.25 diopters (D) of myopia in his right eye. The patient, dissatisfied with wearing contact lenses and spectacles to correct vision, opted to have refractive corneal surgery. We performed a four-incision radial keratotomy with a 4 mm clear zone. This resulted in a 3.75 D (-2.5 D residual myopia) reduction in myopia at two months of follow-up. Our results indicate that radial keratotomy may be useful for correcting unacceptable myopia in older patients.

Bipolar cautery and internal thermal sclerostomy in a rabbit model

Internal thermal sclerostomy (ITS) was performed unilaterally in 35 adult New Zealand rabbits using a pinpoint bipolar cautery probe and radio-frequency power supply, with the nonoperated eyes serving as controls. Standard trabeculectomy using a limbal-based flap was also performed on 10 additional rabbits, and served as a second bench mark for comparison with the ITS technique. Intraocular pressure (IOP) was measured in all eyes preoperatively and on postoperative days 2, 4, 6, and 8. A significant (P = .005) difference between the reduction in IOP in the ITS eyes and in the control eyes was found up to postoperative day 8; on that day the reduction in IOP was 5.2 mm Hg. IOP in the eyes undergoing standard trabeculectomy was significantly (P = .05) reduced up to postoperative day 2, and gradually decreased, to 2.5 mm Hg, on postoperative day 8. The greatest reduction in IOP (2.9 mm Hg) for these eyes also occurred on postoperative day 2. Complications of ITS included iris burn (23%), peripheral corneal edema (17%), and iritis (9%). No ruptured blebs, flat anterior chambers, hyphemas, or lens damage occurred. The potential advantages of the ITS procedure using the bipolar cautery probe include a decreased risk of cataract formation because of the curved probe design. The procedure is also technically simple to perform and requires only inexpensive and readily-available equipment.

Goldmann tonometry and fluorescein solution: a way to avoid contact lens staining

Topical instillation of fluorescein during standard Goldmann tonometry may cause subsequent contact lens staining. We evaluated a method of Goldmann tonometry that uses only a small amount of fluorescein. In this experimental technique, the fluorescein is applied only to the tip of the applanation cone with fluorescein-coated tissue paper. Thirty patients had their intraocular pressures (IOPs) determined by this method. The IOP measurements were then repeated on the same eyes after instillation of fluorescein directly onto their eyes. In addition, 20 soft contact lens wearers had their IOPs determined by the experimental method, with contact lenses fitted immediately after the measurements. There was no statistically significant difference between the IOPs measured by the standard technique and by the experimental method. In addition, no fluorescein staining was detected in the 20 soft contact lenses examined. Our results suggest that the proposed method is accurate and useful in determining IOP prior to soft contact lens fitting.

A study of the optical micrometer, the coin gauge, and the diamond knife micrometer in diamond knife calibration

Reproducible results in refractive keratectomy are greatly influenced by an accurate setting of the diamond knife blade length. In this study, we evaluated the accuracy and reproducibility of three existing techniques of blade calibration: the KOI coin gauge, the KOI diamond knife handle micrometer, and the Magnum optical micrometer. Serial blade length measurements of three similarly designed KOI diamond knives were made using each of the above calibration methods. The three knife handle micrometers had the largest measurement error (3.55%, 2.83%, 1.82%), and therefore the sole reliance of the handle micrometer for blade calibration was not recommended. The measurements made by the coin gauge on the three knives had measurement errors of 1.03%, 1.64%, and 1.46%. The optical micrometer achieved an accuracy of 0.005 mm and an interobserver precision of 0.009 mm. We prefer using the optical micrometer because the potential for parallax error is eliminated; it has a lower risk of blade damage; it is easier to use; and it also allows detection of defects in the footplates, the diamond knife, and of the wobbling blade, which may contribute to calibration error.

Peripartum haemoperitoneum

We report the case of a young pregnant woman who presented with abdominal discomfort and giddiness. After an induced labour, the patient collapsed. Mid-line laparotomy revealed a ruptured and bleeding secondary deposit in the liver. A tumour of the sigmoid colon was also found.

Effect of recipient lamellar keratectomy on corneal topography in penetrating keratoplasty

Recipient tissue weakness is thought to be a cause of the high residual astigmatism that may follow penetrating keratoplasty (PK). In a rabbit model, we investigated the topographic effect of a controlled lamellar keratectomy (6 x 3 x 0.25 mm) on the recipient side following PK. Results from 10 animals indicate an overall flattening of 5 D along the axis of the keratectomy--i.e., the axis of recipient tissue weakness. Our results indicate that recipient corneal integrity may be a factor in corneal transplant topography.

Suture patterns and corneal graft rotation in the cadaver eye

Torque and antitorque running sutures as described by Eisner are commonly used in penetrating keratoplasty. We tested the rotational effect of three different 16-bite running suture patterns on eight cadaver eyes, with the following results: (1) the torque pattern rotates the corneal graft counterclockwise by 0.7 +/- 0.1 mm at the wound or 11 degrees; (2) the antitorque pattern rotates the corneal graft clockwise by 0.7 +/- 0.1 mm at the wound or 11 degrees; (3) an intermediate "no torque" pattern, the bites of which form an isosceles triangle, produces no rotational effect. We recommend the use of a "no torque" pattern to minimize corneal graft rotation.

Astigmatism and tissue-shape disparity in penetrating keratoplasty

Tissue-shape disparity between the donor and recipient cornea is a major cause of astigmatism following penetrating keratoplasty. We studied the topographic effects of recipient or donor tissue deficiency (oval donor button or recipient hole) in a penetrating keratoplasty rabbit model. The results demonstrated that a crescent-shape block resection of 0.5 mm x 6.0 mm during penetrating keratoplasty induces 4 to 7 diopters of corneal astigmatism, with the steeper meridian along the axis of tissue deficiency. Corneal topography and vector analysis of astigmatism showed steepening along the axis of tissue deficiency and flattening 90 degrees away.

A partial-thickness epithelial defect increases the adherence of Pseudomonas aeruginosa to the cornea

Some patients with infectious keratitis have no clinically demonstrable corneal abrasion predisposing them to infection. Subtle, undetectable corneal injuries may facilitate bacterial adherence to the cornea, eventually leading to keratitis. To study this concept, we have developed a rabbit model in which a partial-thickness corneal epithelial defect was induced by filter paper impression on the cornea that removed one to two layers of corneal epithelium. Following this injury, the corneas were incubated with Pseudomonas aeruginosa, washed, and the number of bacteria adhering to the injured corneas as well as to control corneas was quantitated. Corneas treated with filter paper, either ex vivo or in vivo, allowed 20 times more bacteria to adhere than did the untreated control corneas (P less than 0.01). This superficial epithelial defect increased Pseudomonas adherence to the cornea for up to 72 hr after injury. When corneal injury was extended to the stroma, the adherence of Pseudomonas was further augmented as compared to adherence to the superficially injured cornea. Thus, we conclude that a clinically subtle, partial-thickness corneal epithelial injury can markedly facilitate the adherence of Pseudomonas aeruginosa, which may be an important predisposing factor for infectious keratitis.