Continuous infusion, general anesthesia and other intensive care treatment for uncontrolled status epilepticus

To discuss the use of continuous infusions, general anesthesia, hypothermia, and ketogenic diet as treatment for uncontrolled status epilepticus in pediatric patients.

Recent studies demonstrate that clinical practitioners have a hierarchy in approach in controlling refractory status epilepticus (RSE) and super-refractory status epilepticus in children. In the acute setting of RSE, midazolam achieves clinical seizure control at a mean of 41 min after starting an infusion. When midazolam has failed to control RSE, the evidence points to barbiturate anesthesia as the next frequently used option. When both midazolam and barbiturates have failed, use of isoflurane or ketamine anesthesia has been tried at a mean of 10 days after RSE onset, although the studies are largely anecdotal. Increasingly, the use of therapeutic hypothermia or ketogenic diet is described as a strategy for super-refractory status epilepticus, and better evidence for their use may become available from ongoing randomized studies.

Uncontrolled episodes of status epilepticus require intensive care treatment and the literature describes a common pathway of care used by many. However, cases of truly refractory and super-refractory status epilepticus are seen infrequently at any given institution. One strategy to improve the quality of evidence is to develop prospective, national and multinational case registries to determine the range of presentations and causes, efficacy of treatments, and clinical outcomes.