Phenobarbital in super-refractory status epilepticus (PIRATE): A retrospective, multicenter analysis

Area of Science:

• Neuroscience
• Critical Care Medicine
• Pharmacology

Background:

• Super-refractory status epilepticus (SRSE) is a prolonged or recurrent form of status epilepticus (SE) persisting for over 24 hours despite general anesthesia.
• Effective treatment strategies for SRSE remain a significant challenge in neurocritical care.

Purpose of the Study:

• To evaluate the efficacy and safety of phenobarbital (PB) in treating patients with SRSE.
• To identify factors associated with successful seizure termination and clinical outcomes in SRSE patients treated with PB.

Main Methods:

• A retrospective, multicenter study involving 91 neurointensive care unit (NICU) patients with SRSE treated with PB from 2015 to 2020.
• Seizure termination was the primary outcome, with secondary evaluations including serum PB levels, treatment duration, and clinical complications.
• Multivariate generalized linear models were used to analyze the data.

Main Results:

• Seizure termination was achieved in 59.3% of patients treated with PB.
• Higher serum levels of PB were significantly associated with successful seizure control (adj.OR=1.1, p<.01).
• Despite seizure control, 89% of patients experienced clinical complications, and only 6.6% had a favorable modified Rankin scale (mRS) score at discharge. In-hospital mortality was higher when seizure control was not achieved.

Conclusions:

• Phenobarbital demonstrates a high rate of seizure control in SRSE, particularly with higher serum levels.
• While PB can terminate seizures, the overall clinical outcome for critically ill SRSE patients remains poor due to prolonged NICU stays and complications.
• Further prospective studies are warranted to explore optimal PB dosing strategies and long-term outcomes.