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Status epilepticus in the ICU.

Andrea O Rossetti1, Jan Claassen2, Nicolas Gaspard3,4

  • 1Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland.

Intensive Care Medicine
|December 20, 2023
PubMed
Summary

Status epilepticus (SE) is a critical medical emergency. Prompt guideline-based management, including antiseizure medications and identifying causes, improves outcomes and reduces mortality, especially in refractory and super-refractory cases.

Keywords:
MortalityOutcomeSecond-lineStatus epilepticusTreatment

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Area of Science:

  • Neurology
  • Critical Care Medicine

Background:

  • Status epilepticus (SE) is a life-threatening neurological emergency with significant morbidity and mortality.
  • Effective management requires adherence to established guidelines, often necessitating intensive care unit (ICU) admission for severe cases.
  • Accurate diagnosis, including differentiating convulsive from nonconvulsive SE (requiring electroencephalography - EEG), and identifying underlying causes are critical.

Purpose of the Study:

  • To summarize the current understanding and management strategies for status epilepticus (SE).
  • To highlight the importance of timely diagnosis and treatment in improving patient outcomes.
  • To discuss the challenges and approaches in managing refractory and super-refractory SE.

Main Methods:

  • Review of current medical literature and clinical guidelines for status epilepticus management.
  • Discussion of diagnostic criteria, including the role of EEG.
  • Outline of pharmacological interventions, from initial treatment to management of refractory and super-refractory SE.

Main Results:

  • Initial SE management involves benzodiazepines followed by intravenous antiseizure medications (ASMs) like phenytoin, levetiracetam, or valproate.
  • Refractory SE typically requires continuous infusions of sedating agents (midazolam, propofol) or alternative ASMs.
  • Super-refractory SE necessitates advanced strategies, potentially including ketamine or barbiturates, with continuous video EEG monitoring being essential.

Conclusions:

  • Adherence to evidence-based guidelines for SE management is crucial for improving outcomes.
  • Identifying and treating the underlying cause of SE is paramount, particularly in cases like autoimmune encephalitis.
  • Treatment refractoriness is directly correlated with increased mortality, ranging from 10% in responsive cases to nearly 40% in super-refractory SE.