Some authorities have also defined rse on the basis of the duration of seizure for 1 or 2 hours. These underlying brain problems may include trauma, infections, or strokes among others. Efns guideline on the management of status epilepticus. In this episode of hallway conversations, editorinchief dr. Generalized convulsive status epilepticus emcrit project. Refractory status epilepticus seizure european journal of epilepsy. These patients were optimized using faes by combining two, three or four second line drugs if necessary. These patients only entered in the intensive care unit. As there is a limited number of intravenous aeds, orally administered aeds represent a therapeutic option particularly for longer rse episodes. Epilepsyrefractory status epilepticuspentobarbitalpropofolmidazolam. Outcomes of deviation from treatment guidelines in status epilepticus. Refractory status epilepticus rse is defined as status epilepticus that continues despite treatment with benzodiazepines and one antiepileptic drug. Thus, putting a patient into a pentobarbital coma commits them to a 12 week ventilator course. However, the problem is that it has many sideeffects including hypotension, propylene glycol toxicity and an incredibly sluggish halflife.
Refractory and superrefractory status epilepticusan update. Refractory status epilepticus is one of the most common severe and acute diseases in neurology and neurocritical care. There are also some promising new therapies on the horizon, both for the short and the longer terms. Tracy glauser, from the university of cincinnati, about new status epilepticus guidelines. The article summarises the causes, effects, pathophysiology and treatment protocols for refractory status epilepticus. Cryptogenic new onset refractory status epilepticus norse in adultsinfectious or not. Can an optimal approach be recommended based on available data. Surgery for refractory partial status epilepticus 383 episodes of myoclonic jerks were observed on the left side of his body and palate. Superrefractory status epilepticus srse is defined as status epilepticus that continues 24 h or more after the onset of anesthesia, and includes those cases in which epilepsy is recurrent upon treatment reduction. Super refractory status epilepticus is defined as status epilepticus that continues or recurs 24 h or more after the onset of anaesthetic therapy, including those cases where status epilepticus recurs on the reduction or withdrawal of anaesthesia. Status epilepticus superrefractory fires epilepsy anesthesia pediatric. Status epilepticus and refractory status epilepticus.
Refractory status epilepticus rse is continued seizures after the failure of two or more aeds. Management of superrefractory status epilepticus with. Autoimmune encephalitis is the most commonly identified cause of newonset refractory status epilepticus, but half remain cryptogenic. Refractory and superrefractory status epilepticus are lifethreatening conditions with many possible therapeutic approaches. Basic physiology of limbic status epilepticus walker 2009. Apr 24, 2014 status epilepticus is a medical emergency with a high mortality. Treatment of refractory partial status epilepticus with.
Proposed algorithm for convulsive status epilepticus. In status epilepticus seizures appear in close succession or dont stop. Srse carries a high risk of morbidity and a high mortality rate ranging from 23 to 57% 2, 3. It can be seen in up to 40% of cases of status epilepticus with an acute symptomatic etiology as the most likely cause. Management of refractory status epilepticus in adults. Refractory status epilepticus is a potentially lifethreatening medical emergency. Predictors of outcome in refractory status epilepticus. There are a variety of treatments used, almost entirely based on open observational studies or case reports. Pdf refractory and superrefractory status epilepticusan. J k murthy convulsive status epilepticus api india 20 3. Superrefractory status epilepticusstatus epilepticus that continues or recurs 24 hours or more after the onset of anesthetic therapyis a medical emergency. Treatment of refractory status epilepticus rse frequently requires application of more than three antiepileptic drugs aeds. Refractory status epilepticus is defined as status epilepticus that persists despite treatment with at least two antiepileptic drugs.
Therapies for refractory convulsive status epilepticus. The exact definition is still unclear, with different studies defining refractory status epilepticus with varying durations no time criteria, 30 minutes, 1 hour, or 2 hours and a lack of response to numbers two or three and types of medications. Ketamine for the treatment of refractory status epilepticus. Pediatric intensive care treatment of uncontrolled status epilepticus. Status epilepticus is a lifethreatening medical emergency, particularly if treatment is delayed. The norse newonset refractory status epilepticus syndrome.
The term super refractory status epilepticus was introduced during the londoninnsbruck colloquium on status epilepticus in 2011 and refers to status epilepticus that continues or recurs 24 h or. An important observation in both human and animal studies is an electroencephalography eeg progression toward status epilepticus. It is a serious condition that requires prompt medical attention. Patients who are diagnosed with refractory status epilepticus need rapid treatment, but the initiation of comainducing medications is associated with a high incidence of side effects and the need for intensive care admission. Newonset refractory status epilepticus norse is a recently coined term for refractory status epilepticus where. Summary refractory status epilepticus, while a challenge to the intensivist, can be treated with drugs that are commonly used by intensivists. We are committed to sharing findings related to covid19 as quickly and safely as possible. In the context of prevention and treatment processes, it is not only necessary to terminate epileptic seizures, but to also address the disruption of the patients. Frequency of refractory status epilepticus in status epilepticus patients 3144% no community based incidence studies in india but is expected to be high because of high prevalence of epilepsy, cns infections and treatment gap. Cryptogenic new onset refractory status epilepticus norse.
References status epilepticus care guideline agarwal p, et al. The term superrefractory status epilepticus was introduced. We then summarise the data on the utility of extended eeg monitoring and emphasise the importance of early termination of status epilepticus. Common intravenous agents such as diazepam, lorazepam, midazolam, and phenytoin used to treat rse have frequent problems with toxicity or efficacy 35. Lastline agent for superrefractory status epilepticus. Show full abstract patient with refractory status epilepticus, and he was managed with sevoflurane, an inhalational anesthetic. Status epilepticus international league against epilepsy. After some of these myoclonic bouts a slight ipsilateral hemiparesis was noted with complete recovery within a few minutes. Refractory and superrefractory status epilepticus indian pediatrics. Our approach to the epilepsies in childhood has been clarified by the broad separation into benign and malignant syndromes.
Status epilepticus manifests as many different syndromes, each defined by distinctive clinical features and electroencephalography eeg findings. Refractory status epilepticus falls under the status epilepticus category where the patient continues to show the epilepticus even while continuing the treatment using benzodiazepines and antiepileptic medicines. Refractory status epilepticus occurs in 1070% of adults. There is a lack of consensus upon its semantic definition of whether it is status epilepticus that continues despite treatment with benzodiazepine and one antiepileptic medication aed, i. Refractory status epilepticus rse can be defined as status epilepticus that. Transitioning treatment from status epilepticus to super refractory status epilepticus david roy, pharmd pgy1 pharmacy resident. Guidelines for the evaluation and management of status. Jan 14, 2015 frequency of refractory status epilepticus in status epilepticus patients 3144% no community based incidence studies in india but is expected to be high because of high prevalence of epilepsy, cns infections and treatment gap. Srse is defined as status epilepticus that continues 24 h or more after the onset of anesthesia, including those cases in which the status epilepticus recurs on the reduction or withdrawal of anesthesia. It is likewise necessary to attend to the refractory status epilepticus promptly to prevent mortality.
Many factors often combine to lower the patients seizure threshold. If seizures persist after adequate doses of a benzodiazepine and fosphenytoin, then refractory status epilepticus is diagnosed. Status epilepticus may occur in those with a history of epilepsy as well as those with an underlying problem of the brain. New status epilepticus guidelines epilepsy foundation. Treatment of refractory and superrefractory status epilepticus. Major independent outcome predictors are age not modifiable and cause which should. Guidelines for the evaluation and management of status epilepticus. The factors that suggest a poorer outcome in terms of seizures, cognition, and behaviour include the presence of. Apr 05, 2020 refractory and super refractory status epilepticus are lifethreatening conditions with many possible therapeutic approaches. Refractory status epilepticus is defined as recurrent seizure activity despite two appropriately selected and dosed antiepileptic drugs including a benzodiazepine. Status epilepticus and refractory status epilepticus represent some of the most. Status epilepticus and beyond acute and critical care. Convulsive status epilepticus cse is the most common neurological medical emergency and continues to be associated with significant morbidity and mortality. Rse should be treated promptly to prevent morbidity and mortality.
Initially, there are repeated seizures that merge into continuous seizure activity and eventually periodic epileptiform discharges treiman, 1995. Outcome at discharge is poor but improves during followup. Proposed algorithm for convulsive status epilepticus from treatment of convulsive status epilepticus in children and adults, epilepsy currents 16. The different electroclinical types of status epilepticus share eeg characteristics. How refractory is superrefractory status epilepticus a. Outcomes and complications vary greatly among these types of sta. How refractory is superrefractory status epilepticus a personal iew. Frequency and prognosis of convulsive status epilepticus of. The term superrefractory status epilepticus was introduced during the londoninnsbruck colloquium on status epilepticus in 2011 and refers to status epilepticus that continues or recurs 24 h or. Ketamine is rapid onset and relatively safe for refractory status epilepticus. Refractory status epilepticus rse has been defined variably in the literature as seizures that do not respond to 2 14 or 3 58 different antiepileptic medications, usually intravenous benzodiazepines as a firstline agent and intravenous phenytoin, phenobarbital, or valproic acid as a secondline agent. Nov 08, 2017 refractory status epilepticus falls under the status epilepticus category where the patient continues to show the epilepticus even while continuing the treatment using benzodiazepines and antiepileptic medicines.
Management of refractory and superrefractory status epilepticus. Randomized study of intravenous valproate and phenytoin in status epilepticus. Pdf refractory and superrefractory status epilepticus. Refractory status epilepticus diagnosis and treatment.
The concept of super refractory status and newer etiologies and therapeutic options are also discussed. Early recognition and initiation of treatment leads to a better response and may improve outcomes. The patient was given an inspired concentration of 0. The term superrefractory status epilepticus srse refers to a re fractory episode continuing under general anesthesia for more than 24 h. Status epilepticus is a medical emergency with a high mortality. Cole epilepsy service, department of neurology, acc 835, massachusetts general hospital, harvard medical school, boston, ma 02114, usa. The treatment of superrefractory status epilepticus. The american epilepsy society guidelines published in.
Status epilepticus is a medical and neurologic emergency that requires prompt evaluation and treatment. Mar, 2020 super refractory status epilepticus status epilepticus that continues or recurs 24 hours or more after the onset of anesthetic therapyis a medical emergency. Effects of clobazam for treatment of refractory status. Newonset refractory status epilepticus norse is defined as a condition, not a specific diagnosis, with new onset of refractory status epilepticus without a clear acute or active structural, toxic or metabolic cause in a patient without active epilepsy. Jan 28, 2015 super refractory status epilepticus srse is defined as status epilepticus that continues 24 h or more after the onset of anesthesia, and includes those cases in which epilepsy is recurrent upon treatment reduction. It is an uncommon but important clinical problem with high mortality and morbidity rates. Newonset refractory status epilepticus norse and febrile.
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