Abstracts

Rationale: Neurocritical care literature has recently addressed treatment and continuous EEG (CEEG) monitoring of refractory status epilepticus (RSE). A period of electrographic control between 24 and 48 hours is recommended before weaning continuous infusion of AEDs for RSE, and that CEEG should be continued through weaning. Subsequent "slow withdrawal" is recommended, but unfortunately, there is no guideline for methods or rate of dose reduction. Weaning protocols vary significantly among physicians, and the use of CEEG is warranted as long as the weaning is still in progress. Unneccessarily prolonged CEEG can limit availability machines for other patients, requires large amounts of tech and physician time for maintenance and interpretation, and results in scalp irritation. Methods: We reviewed all adult ICU patients who had required at least 24 hours of continuous IV AEDs and CEEG through weaning for RSE from January 2009 through January 2012. We reviewed both the rate of weaning and time to complete weaning. Based on these observations, patients were then subcategorized into either linear, nonlinear or varying reductions. Outcomes of interest within 24 hours of weaning were recurrent seizures and death, either spontaneous or by decision to withdraw support. Results: We identified 26 patients meeting above criteria. 12 patients had linear weaning, while 8 patients had nonlinear weaning. Six patients had varying weaning methods. While 12 patients had recurrent seizures within 24 hours of weaning, only 4 of these had recurrent SE. Seizure recurrence was noted in half of linear (6 patients) and nonlinear (4 patients) methods. Decision to withdraw support was made in 5 cases, and 2 cases spontaneously died within 24 hours of completing weaning. The time to complete weaning varied from 12 hours to 8 days. Shorter weaning times did not correlate with seizure recurrence. Scalp irritation following EEG electrode removal was mentioned in the chart for 14 patients, all of whom had EEG in place >4 days. Conclusions: While much research and literature has been dedicated to optimizing treatment of RSE, there is a striking paucity of study directed toward weaning of continuous infusions in this population. Thus, highly individual methods and multiday CEEGs are often utilized. Our data indicates that both nonlinear and linear methods were equally likely to result in resolution of seizures. Weaning over a shorter time frame, however, did not result in increased risk of seizure recurrence. A longer duration of the CEEG during longer weaning was often associated with noted scalp irritation. We conclude that weaning method is less important than avoiding prolonged duration. While efforts to wean patients over shorter time frames should be encouraged, there is need for prospective study and more specific guidelines for weaning of continuous IV medication following RSE.