Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study.

Abstract

INTRODUCTION:

Seizures refractory to third-line therapy are also labeled super-refractory status epilepticus (SRSE). These seizures are extremely difficult to control and associated with poor outcome. We aimed to characterize efficacy and side-effects of continuous infusions of pentobarbital (cIV-PTB) treating SRSE.

METHODS:

We retrospectively reviewed continuous electroencephalography (cEEG) reports for all adults with RSE treated with cIV-PTB between May 1997 and April 2010 at our institution. Patients with post-anoxic SE and those receiving cIV-PTB for reasons other than RSE were excluded. We collected baseline information, cEEG findings, side-effects and functional outcome at discharge and one year.

RESULTS:

Thirty one SRSE patients treated with cIV-PTB for RSE were identified. Mean age was 48 years old (interquartile range (IQR) 28,63), 26% (N = 8) had a history of epilepsy. Median SE duration was 6.5 days (IQR 4,11) and the mean duration of cIV-PTB was 6 days (IQR 3,14). 74% (N = 23) presented with convulsive SE. Underlying etiology was acute symptomatic seizures in 52% (N = 16; 12/16 with encephalitis), remote 30% (N = 10), and unknown 16% (N = 5). cIV-PTB controlled seizures in 90% (N = 28) of patients but seizures recurred in 48% (N = 15) while weaning cIV-PTB, despite the fact that suppression-burst was attained in 90% (N = 28) of patients and persisted >72 hours in 56% (N = 17). Weaning was successful after adding phenobarbital in 80% (12/15 of the patients with withdrawal seizures). Complications during or after cIV-PTB included pneumonia (32%, N = 10), hypotension requiring pressors (29%, N = 9), urinary tract infection (13%, N = 4), and one patient each with propylene glycol toxicity and cardiac arrest. One-third (35%, N = 11) had no identified new complication after starting cIV-PTB. At one year after discharge, 74% (N = 23) were dead or in a state of unresponsive wakefulness, 16% (N = 5) severely disabled, and 10% (N = 3) had no or minimal disability. Death or unresponsive wakefulness was associated with catastrophic etiology (p = 0.03), but none of the other collected variables.

CONCLUSIONS:

cIV-PTB effectively aborts SRSE and complications are infrequent; outcome in this highly refractory cohort of patients with devastating underlying etiologies remains poor. Phenobarbital may be particularly helpful when weaning cIV-PTB.

• Authors: Deborah Pugin, Brandon Foreman, Gian Marco De Marchis, Andres Fernandez, J Michael Schmidt, Barry M Czeisler, Stephan A Mayer, Sachin Agarwal, Christine Lesch, Hector Lantigua, Jan Claassen
• Journal: Critical care (London, England) (Crit Care) Vol. 18 Issue 3 Pg. R103 (May 21 2014) ISSN: 1466-609X [Electronic] England
• PMID: 24886712 (Publication Type: Journal Article, Research Support, Non-U.S. Gov't)

Chemical References

• Pentobarbital

Topics

• Adult
• Aged
• Cohort Studies
• Electroencephalography (drug effects, methods)
• Female
• Humans
• Hypotension (chemically induced, diagnosis)
• Infusions, Intravenous
• Male
• Middle Aged
• Pentobarbital (administration & dosage, adverse effects)
• Pneumonia (chemically induced, diagnosis)
• Retrospective Studies
• Status Epilepticus (drug therapy)
• Treatment Outcome