Abstracts

Rationale: Status epilepticus (SE) is a life-threatening condition that if untreated, can lead to significant morbidity and mortality. Goals of SE care begin with patient stabilization followed by first line benzodiazepines. Intravenous antiepileptic agents can subsequently be used for treatment and in refractory situations, anesthetic agents are necessary. Experts recommend a 24-48 hour timeframe of electrographic seizure control prior to slow removal of sedation agents to prevent recurrent seizures. Slow removal of anesthetic agents allows for early recognition of brain irritability through electroencephalography and prompts the provider to reevaluate treatment. Our aim is to determine the likelihood of recurrent seizures at varying wean times in SE patients on anesthetic agents. Methods: A retrospective chart review was conducted searching for patients aged 18-99 years admitted to Mayo Clinic Arizona over the last 10 years (2008-2018). Patients with SE on anesthetic agents were included regardless of etiology. Records were reviewed for seizure recurrence rates at sedation wean time frames of less than 24 hours, 24-48 hours, 48-72 hours and greater than 72 hours. Results: Seventy-seven patients were identified with a mean age of 63.4 (27-89). The majority, 62.3% (48/77), presented in non-convulsive status epilepticus (NCSE). The remaining seizure types included:  convulsive SE 26% (20/77), generalized tonic-clonic seizure followed by NCSE 7.8% (6/77), and myoclonic seizures 3.9% (3/77). Twenty-five patients had a history of seizure. Benzodiazepines were first-line treatment in 62.3% (48/77). Sedation agents included:  propofol 87% (67/77), midazolam 42.9% (33/77), and pentobarbital 2.6% (2/77). Multiple patients were on both propofol and midazolam. Anesthetic wean times were as follows: 24 hours or less 45.5% (35/77), 24-48 hours 14.3% (11/77), 48-72 hours 16.9% (13/77), and greater than 72 hours 15.6% (12/77). The remaining patients pursued comfort care early or were transferred to an outside facility in SE. Seizure recurrence rates were as follows:  28.6% (10/35) with wean less than 24 hours, 18.2% (2/11) at 24-48 hours, 15.4% (2/13) at 48-72 hours, and 16.7% (2/12) at greater than 72 hours. Conclusions: SE is life-threatening and requires patience in weaning anesthetic agents to avoid recurrence of seizures. Risk of recurrent seizures decreased nearly 50% in patients with sedation weans prior to 24 hours versus 24-48 hours and beyond. Overall, our findings suggest that weaning sedation prior to 48 hours has a significantly increased risk of seizure recurrence compared to after 48 hours. This supports existing literature suggesting a minimum time of 24-48 hours prior to anesthetic wean. In those with SE, we recommend holding anesthetic medications a minimum of 48 hours prior to a slow wean of sedation to avoid seizure recurrence. Weaning between 24 to 48 hours may be reasonable but recommend proceeding with caution. Funding: Not applicable