Abstracts

Rationale: Refractory status epilepticus (RSE) is defined as status that fails to respond to first and second-line therapy requiring general anesthesia. RSE constitutes a medical emergency with a significant morbidity and mortality. The aim of this study was to assess the response to treatment and short-term outcomes in a cohort of patients with RSE treated with coma induction in a Neurointensive Care Unit (Neuro ICU) under continuous video EEG monitoring (CVEEGM). Methods: A retrospective study was carried out in patients admitted to Neuro ICU with RSE who underwent coma induction, between September 2007 and December 2008. The treatment was guided by CVEEGM. The goal of treatment was to achieve EEG burst suppression pattern. Epidemiological characteristics, EEG findings, clinical features, treatments and short-term outcomes were reviewed and compared to patients who failed to achieve burst suppression pattern. Results: Eighty patients with RSE were treated in the Neuro ICU during a period of 15 months; sixty-three patients fulfill inclusion criteria. 76.2% had non-convulsive status and 55.6% of them had an APACHE II score ≥ 16; 54% were male, mean age of 43 years. The etiology of RSE was 74.6% associated with a neurological injury (51% stroke, 14.9% infection, 14.9% anoxia, 10.6% trauma, 8.5% others), 20.6% associated with underlying epileptic disease and 4.8% due to systemic abnormalities. The coma was induced with midazolam, propofol and thiopental in 87.3%, 44.4% and 4.8% of the patients, respectively. In addition, stepwise antiepileptic drugs, such as valproic acid, levetiracetam, topiramate and phenobarbital, were used. EEG burst suppression was achieved within 8 days in 87.3% of the patients. The EEG patterns during coma induction before burst suppression include focal electrographic seizure activity in 81.8%, periodic discharges in 96.4%, and pseudoperiodic discharges in 44.4%. The mean follow up with CVEEGM was 147 +/- 79.3 hours. In-hospital mortality was 18.1% in those patients who achieved EEG burst suppression pattern compared to 62.5% in patients who failed to achieve EEG burst suppression pattern in 8 days (p:0.01). At one-month follow up, 45.8% of patients regained their independent activities of daily life. Survival and a modified Rankin score ≤ 2 (at one month) were higher in patients who achieved burst suppression pattern (81.8% vs. 37.5%, p: 0.01) and those with convulsive RSE type (76.9% vs. 34.3%, p: 0.008). Conclusions: In patients with RSE, the management under a team of neurointensivists, neurophysiologists and neurologists, guided by CVEEGM, permits an adequate assessment and management of these patients. The achievement of EEG burst suppression pattern appears to be associated with a better outcome, especially in those patients with convulsive RSE.