Abstracts

Rationale: Status epilepticus (SE) is the second most common neurological emergency. SE can be refractory to first and second line treatment (Tx) with benzodiazepines (BZD) and anticonvulsants (AEDs) in up to 43% of the cases. Since RSE becomes more resistant to Tx with time and number of AEDs used, induction of iatrogenic (induced) coma is advocated as a next step. To date, there have only been a few observational studies looking at iatrogenic coma as a Tx for RSE. These studies have primarily focused on comparing the efficacy of different agents as well as the depth of coma. However, the duration of iatrogenic coma has never been studied as an independent factor for successful treatment of RSE. Methods: We conducted a retrospective cohort-study analyzing the correlation between duration of iatrogenic coma (defined as burst suppression or suppression of epileptic pattern for either < 24hrs, 24 to 48hrs, or >48hrs) and seizure recurrence within the first 48 hours of lightening sedation in adult patients admitted for RSE to the UCSF Medical Center in the time period from 1/2009 to 12/2015. Secondary outcomes looked at morbidity and mortality associated with prolonged duration of iatrogenic coma. Results: 108 consecutive patients with RSE were identified and included in the analysis. 81 patients (75%) had no seizure recurrence after their initial treatment with iatrogenic coma and 27 (25%) did. There was no association found between treatment duration and seizure recurrence (p = 0.44). Extended duration (>24 hrs) of iatrogenic coma and early seizure recurrence were independently associated with a prolonged intubation, ICU and hospital stay (all p < 0.005). The cohort with seizure recurrence and extended duration of coma had an increased mortality rate (19 versus 6%; p = 0.055) and was less likely to be discharged home without any permanent neurologic deficit (22 versus 44%; p = 0.04). Conclusions: Since our analysis has shown that early seizure recurrence is an independent risk factor for increased mortality and morbidity related to RSE, it seems crucial to identify pertinent characteristics of the patient cohort that might benefit from a prolonged Tx duration to prevent worse outcomes. Ideally these characteristics could then be used for the development of a clinical scoring system that would guide the decision making process about Tx duration early on. Despite such an helpful clinical tool, the optimal Tx duration would still be based on experience and expert opinion as randomized, controlled trials with higher patient numbers and an exact documentation of treatment duration would be required to identify an optimal duration of iatrogenic coma in the Tx of RSE. Funding: Pathways to Discovery Grant from the University of California San Francisco (UCSF)