Abstracts

Rationale: Pentobarbital coma (PBC) is used for treating refractory status epilepticus. Acceptable duration of prolonged therapy is limited by serious side effects. Recognizing major and minor adverse effects of prolonged PBC will only increase good outcomes. This study highlights the medical/surgical complications in patients with medically refractory status epilepticus treated with PBC.Methods: Retrospective review of patients in PBC from 2010 to 2011.Results: Nine patients (average age 49.3 years) were maintained in PBC 20.3 days after seizure onset for mean of 18.9 days (range 1-62 days). Two patients died within four days of initiating coma and two were still in ICU at the time of this review. Four patients followed commands after 57.8 days (19-123 days) from coma onset. Phenobarbital substitution for failure to wean PBC was required in six patients. Two to six concurrent antiepileptics were needed after PBC in all patients. The complications included peripheral neuropathy (n=7), volume overload (massive pleural effusions, n=4, requiring chest tubes, n=2, sclera edema, n=3, and massive tongue swelling, n=3), renal/metabolic (hemodialysis, n=4, lactic acidosis, n=7, with one having propylene glycol of 58mg/dL, none had significant electrolyte disturbance), gastrointestinal (ileus, n=5, diverting colostomy from sacral ulcer, n=1, significant transaminitis, n=3), endocrine (adrenal insufficiency, n=2, hypothermia, n=3, thyroid abnormalities, n=1), cardiac/hemodynamic/vascular (hypotension requiring pressors, n= 7 myocardial dysfunction, n=2, deep venous thrombosis, n=2, pulmonary embolism, n=1), respiratory (ventilated, n=9, with four requiring tracheostomy and gastrostomy), and infectious (sepsis from various sources, n=9). ICU length of stay was a mean of 53.8 days. Two patients had cerebral atrophy seen on serial brain MRIs. Number of complications correlated with duration of induced coma.Conclusions: This study highlights the medical and surgical complications encountered in prolonged PBC. Anticipating and addressing complications in prolonged PBC can improve survival and functional outcomes in patients with refractory status epilepticus.