Refractory
status epilepticus (RSE), defined as
status epilepticus that fails to respond to the acute administration of two
antiepileptic medications, occurs in approximately a third of patients with
status epilepticus, and is associated with increased hospital
length of stay, mortality, and functional disability. Common presentations include: (1)
generalized convulsive status epilepticus or
complex partial status epilepticus that continue despite initial
therapies; (2) stupor or
coma following a generalized convulsive or complex partial seizure; or (3) stupor or
coma following brain surgery or
acute brain injury. When
status epilepticus continues or recurs 24 hours or more after the initiation of
anesthetic therapy, or recurs on the reduction or withdrawal of
anesthesia, it is termed super RSE. Published evidence on optimal management of RSE consists largely of case reports or small series. The mainstay of treatment is the administration of
anesthetic agents titrated to electrographic seizure control. Adjunctive
therapies include
hypothermia and immunosuppression and less commonly, surgery, electrical stimulation
therapies, and induction of
ketosis. Patients with cardiopulmonary complications and prolonged duration of
drug-induced
coma tend to have worse post-treatment functional outcomes. However, significant improvement over time can occur in survivors, and thus treatment is justified even in patients who require prolonged
anesthetic coma. The strongest predictors of outcome are duration of
anesthetic coma, etiology, and development of cardiopulmonary complications.