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Super Refractory Status Epilepticus / Refractory

Source: https://pca.st/d3fgfxpa (Sep 2020)

Refractory Status = SE - Continued plus two anticonvulsive (Benzo plus One AED) - So not much!

Super-refractory status = Usually is when status persists after continuous anaesthetic, or refractory more than 24hrs

Guidance:

Lorazepam = 0.1mg/kg (4mg at a time) - Not just a 2mg at a time Midazolam = 0.2mg/kg bolus at the start

Flashcard type:basic
What RCT can you use to determine what antiepileptic to use in Status Epilepticus? ESETT Trial
What does the ESETT trial say about antepileptics in status epilepticus? Keppra, Phenytoin, Valproate are all just as good as each other
What does the ESETT trial say about how effective anti epileptics are? After benzodiazepines, the actual antiepileptics only have a 50:50 chance of working
How likely is it that your first antiepileptic drug will terminate status if the benzos didn't? About 50:50 according to ESETT

Anticonvulsants:

  • Study for this ESETT trial (2011)
  • Benzorefractory SE
  • Phenytoin, Keppra, Valproic Acid
  • Primary Outcome: Response within 60 mins
  • 400 patients
  • No difference between the three treatments
  • Overall success rate was less than 50%
  • If you do respond, its normally within 10 mins, so don't need to wait too long before trying something else
  • In this trial 10% had non epileptic seizures
  • This trial, it only looked at clinical resolution, didn't look at EEG stuff
  • So use whatever you like, but know only half works
  • Keppra dose in this trial was a high dose (4.5g at max, 60mg/kg, given over 10mins)

What about Lacosamide?

  • Lacosamide not as first line, seeing as youve the ESETT trial looking at efficacy of the others
  • it prolongs PR, but not by much at all

What to do?

  • If benzo plus one has failed, what should you do?

  • Second AED or Intubate?

  • Where should you go?

  • Equivocal

  • Propofol infn or midazolam

  • If this one not worked, try the other, if both fails:

    • Ketamine - NMDA receptor antagonist
    • Phenobarbitol

What about non-pharmacological stuff

  • Therapeutic hypothermia - No doesnt work
  • Isoflurane - Works but difficult
  • Ketogenic diet - Works but difficult

The aim in status epilepticus is seizure termination and control, go fast and high doses, you can always wean back later on in patient stay.