Abstracts

Rationale: Management of Super Refractory Status Epilepticus (SRSE), which is defined as refractory status epilepticus resistant to initial standard antiepileptic treatment and requires the use of intravenous anesthetic agents. In addition to benzodiazepines, barbiturates and propofol: ketamine infusion is increasingly being used for management of SRSE. Its unique mechanism of action (an NMDA antagonist) and a favorable hemodynamic profile of (increase in cardiac output, blood pressure) makes it a suitable agent for management of patients with hemodynamic instability. Our objectives were to study the resolution rates of SRSE with ketamine infusion as adjunct to other AED's. To study the mortality rate with ketamine as part of the treatment regime. Methods: After IRB approval we reviewed the charts of 36 patients admitted to the Neurological ICU for management of SRSE between years 2010 and 2014 at Ochsner Medical Center. Analysis included patients demographics, mortality rate, resolution of RSE, as well as the dose range and duration of both ketamine and/or propofol infusions individually and when used in combination. Results: Thirty six patients with ages ranging from 25-89 years, 23 females and 13 males were managed with a combination of propofol and ketamine infusions or with ketamine infusion alone. Ketamine infusion rates ranged from 25-175 mcg/kg/min; the duration varied from 2 - 28 days. Propofol infusion rates varied from 10 - 180 mcg/kg/minute; the duration of propofol infusion ranged from 0-41 days. The duration of combination therapy varied from 0-26 days. In 2 patients ketamine was the sole anesthetic agent used. Using this anesthetic combination in addition to other anti-epileptic drugs we were able to achieve adequate control of SRSE in 35/36: resolution rate of 97% The combination of ketamine and /or propofol infusions, even for prolonged periods, did lead to some hemodynamic changes that were easily managed with aggressive fluid resuscitation and in some cases with vasoactive agents. The mortality rate was 11/36 (31%). Mortality resulted from the following reasons: a) Withdrawal of care (per patient's wishes) as a result of the severe initial neurological insult and a poor prognosis based on the initial insult: majority b) Withdrawal of care because of multi-system organ failure resulting from complications from anesthetics or infectious causes or underlying medical conditions. Conclusions: Short term or prolonged infusion of ketamine, with or without propofol infusion, is effective in controlling SRSE. The hemodynamic profile of ketamine along with aggressive fluid resuscitation makes it a favorable agent for use in patients with RSE. Refractory status epilepticus often occurs in the setting of severe medical neurological diseases. In all but one RSE was controlled with the combination of propofol and ketamine. Infusion rates of propofol and ketamine ranged up to 10-180 mcg/kg/min and 25-175 mcg/kg/min respectively without any treatment limiting side effects. These findings suggest that this regimen can be an effective modality in the treatment of super refractory status epilepticus.