Abstract
Background
Non-convulsive status epilepticus (NCSE) is defined as status epilepticus (SE) with no obvious motor phenomenon and is diagnosed based on electroencephalogram (EEG). Refractory SE (RSE) is the persistence of seizures despite treatment with an adequately dosed first-line and second-line agents. Although guidelines for convulsive RSE include third-line agents such as intravenous anesthetic drugs (midazolam, propofol, or barbiturates), the therapeutic approach to NCSE is not well outlined. Treatment with traditional anesthetics invariably includes endotracheal intubation, which is associated with significant adverse events. Comparatively, ketamine, a non-competitive N-methyl-D-aspartate receptor antagonist is not associated with significant cardiorespiratory depression and may help in avoiding intubation.
Objective
In this case series, we describe our experience with the early use of intravenous ketamine as the first anesthetic agent in patients with refractory NCSE to avoid endotracheal intubation.
Methods
We present a case series of nine patients managed in the Neurointensive Care Unit at a university-affiliated tertiary care hospital. The study was approved by the hospital and university institutional review boards and the requirement for informed consent was waived for retrospective analysis of existing data, per institutional policy. All cases of SE were identified from a prospective database, and a subsequent retrospective chart review identified all patients with a diagnosis of refractory NCSE in whom ketamine was used as the first anesthetic agent. The primary endpoint was the avoidance of endotracheal intubation while on ketamine infusion. The secondary endpoint was defined as cessation of both clinical and electrographic seizures recorded on continuous EEG within 24 h of ketamine administration.
Results
A total of nine patients experiencing refractory NCSE were included in this case series, with a median age of 61 (range 26–72) years and seven patients were male. The primary endpoint, avoiding intubation, was achieved in five out of nine (55%) cases. Six patients experienced resolution of refractory NCSE with ketamine administration as the sole anesthetic agent. Four patients required endotracheal intubation and three patients had a failure of seizure cessation with ketamine. Hypersalivation and pneumonia were the most common ketamine associated adverse events. In non-intubated patients, no deaths occurred. One patient was discharged home, four to subacute rehabilitation, one to a long term acute care hospital, and one patient to hospice.
Conclusion
The use of ketamine as the primary anesthetic agent may be a reasonable option to avoid endotracheal intubation in a subset of patients with refractory NCSE. This study is limited by its small sample size, retrospective design, and reliance on information obtained from chart review.
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References
Sutter R, Ruegg S, Kaplan PW. Epidemiology, diagnosis, and management of nonconvulsive status epilepticus: opening Pandora’s box. Neurol Clin Pract. 2012;2:275–86.
Glauser T, Shinnar S, Gloss D, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the american epilepsy society. Epilepsy Curr. 2016;16:48–61.
Alkhachroum AM, Rubinos C, Chatterjee A, et al. Rates and trends of endotracheal intubation in patients with status epilepticus. Neurohospitalist. 2019;9:190–6.
Rosati A, De Masi S, Guerrini R. Ketamine for refractory status epilepticus: a systematic review. CNS Drugs. 2018;32:997–1009.
Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17:3–23.
Zeiler FA, West M. Ketamine for status epilepticus: canadian physician views and time to push forward. Can J Neurol Sci. 2015;42:132–4.
Mogensen F, Muller D, Valentin N. Glycopyrrolate during ketamine/diazepam anaesthesia. A double-blind comparison with atropine. Acta Anaesthesiol Scand. 1986;30:332–6.
Griesdale DE, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal intubation in the critically ill. Intensive Care Med. 2008;34:1835–42.
Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018;120:323–52.
Kowalski RG, Ziai WC, Rees RN, et al. Third-line antiepileptic therapy and outcome in status epilepticus: the impact of vasopressor use and prolonged mechanical ventilation. Crit Care Med. 2012;40:2677–84.
Lai A, Outin HD, Jabot J, et al. Functional outcome of prolonged refractory status epilepticus. Crit Care. 2015;19:199.
Hocker SE, Britton JW, Mandrekar JN, Wijdicks EF, Rabinstein AA. Predictors of outcome in refractory status epilepticus. JAMA Neurol. 2013;70:72–7.
Kafle DR, Avinash AJ, Shrestha A. Predictors of outcome in refractory generalized convulsive status epilepticus. Epilepsia Open. 2020;5:248–54.
Rossetti AO, Reichhart MD, Schaller MD, Despland PA, Bogousslavsky J. Propofol treatment of refractory status epilepticus: a study of 31 episodes. Epilepsia. 2004;45:757–63.
Walli A, Poulsen TD, Dam M, Borglum J. Propofol infusion syndrome in refractory status epilepticus: a case report and topical review. Case Rep Emerg Med. 2016;2016:3265929.
Synowiec AS, Singh DS, Yenugadhati V, Valeriano JP, Schramke CJ, Kelly KM. Ketamine use in the treatment of refractory status epilepticus. Epilepsy Res. 2013;105:183–8.
Ilvento L, Rosati A, Marini C, L’Erario M, Mirabile L, Guerrini R. Ketamine in refractory convulsive status epilepticus in children avoids endotracheal intubation. Epilepsy Behav. 2015;49:343–6.
Yeh PS, Shen HN, Chen TY. Oral ketamine controlled refractory nonconvulsive status epilepticus in an elderly patient. Seizure. 2011;20:723–6.
Pizzi MA, Kamireddi P, Tatum WO, Shih JJ, Jackson DA, Freeman WD. Transition from intravenous to enteral ketamine for treatment of nonconvulsive status epilepticus. J Intensive Care. 2017;5:54.
Alkhachroum A, Der-Nigoghossian CA, Mathews E, et al. Ketamine to treat super-refractory status epilepticus. Neurology. 2020;95:e2286–94.
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MJS: concept, data acquisition, data analysis, manuscript writing, manuscript review. DZ: concept, data acquisition, data analysis, manuscript writing, manuscript review. SMM: concept, data acquisition, data analysis, manuscript writing, manuscript review. WM: concept, data acquisition, data analysis, manuscript writing, manuscript review.
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Maryam J. Syed, Deepti Zutshi, Syeda Maria Muzammil and Wazim Mohamed declare that they have no conflict of interest.
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Syed, M.J., Zutshi, D., Muzammil, S.M. et al. Ketamine to Prevent Endotracheal Intubation in Adults with Refractory Non-convulsive Status Epilepticus: A Case Series. Neurocrit Care (2023). https://doi.org/10.1007/s12028-023-01853-8
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DOI: https://doi.org/10.1007/s12028-023-01853-8