Management of refractory status epilepticus at a tertiary care centre in a developing country

Abstract

The earliest known description of status epilepticus was in the 25th and 26th tablets of the Sakikku cuneiform of the Neo-Babylonian era, written during 718–612 BC.¹ x 1 Shorvon, S. Status epilepticus: its clinical features and treatment in children and adults. University Press, Cambridge; 1994 Crossref | Google Scholar See all References The operational definition of status epilepticus is an empirical compromise dictated by therapeutic needs, because treatment should not be delayed until patients are in established status epilepticus, when neuronal injury and time-dependent development of pharmacoresistance have occurred.² x 2 Chen, W.Y.J. and Wasterlain, G.C. Status epilepticus: pathophysiology and management in adults. Lancet Neurol. 2006; 5: 246–256 Abstract | Full Text | Full Text PDF | PubMed | Scopus (308) | Google Scholar See all References In its most severe form, refractory SE (RSE), continuous or repetitive seizures do not respond to benzodiazepines such as lorazepam and phenytoin-therapy.³ x 3 Jagoda, A. and Riggio, S. Refractory status epilepticus in adults. Ann Emerg Med. 1993; 22: 1337–1348 Abstract | Full Text PDF | PubMed | Scopus (64) | Google Scholar See all References ^{, 4} x 4 Bleck, T.P. Advances in the management of refractory status epilepticus. Crit Care Med. 1993; 21: 955–957 Crossref | PubMed | Google Scholar See all References Refractory status epilepticus (RSE) has been defined as seizures lasting >60 min, despite treatment with benzodiazepines (BZDs) and adequate antiepileptic medications (AEDs), or persistence of discrete seizures without return to baseline even with appropriate therapy. Randomized controlled trials comparing treatment strategies for RSE have not been performed to date, to our knowledge. RSE occurs in approximately 30% of patients with SE and is associated with increased hospital length of stay and functional disability and morbidity.⁵ x 5 Mayer, A.S., Claassen, J., Lokin, J., Mendelsohn, F., Dennis, J.L., and Fitzsimmons, B.F. Refractory status epilepticus frequency, risk factors, and impact on outcome. Arch Neurol. 2002; 59: 205–210 Crossref | PubMed | Scopus (439) | Google Scholar See all References There should be no hesitation to intubate and severe arterial hypotension should be avoided because as it will curtail the cerebral blood flow.² x 2 Chen, W.Y.J. and Wasterlain, G.C. Status epilepticus: pathophysiology and management in adults. Lancet Neurol. 2006; 5: 246–256 Abstract | Full Text | Full Text PDF | PubMed | Scopus (308) | Google Scholar See all References However, in developing countries where facilities of intubation, adequate ventilation, Intensive Care Units and general anaesthesia are not always available,⁶ x 6 Murthy, J.M., Jayalaxmi, S.S., and Kanikannan, M.A. Convulsive status epilepticus: clinical profile in a developing country. Epilepsia. 2007; 48: 2217–2223 PubMed | Google Scholar See all References need for an alternative AEDs which can abort the need for ventilation and buy time for transportation to a centre where ICU facilities are available, are needed. There have been studies with valproate and levetiracetam earlier with favourable results.¹¹ x 11 Sinha, S. and Naritoku, K.D. Intravenous valproate is well tolerated in unstable patients with status epilepticus. 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