Abstracts

Rationale: Intravenous anesthetic drugs (IVADs) are widely used in refractory status epilepticus (RSE) to control the ictal activity. Although the IVADs are extremely beneficial in achieving total seizure suppression, an electroencephalography  (EEG) burst-suppression pattern, or an isoelectric EEG, their prolonged use can have a negative impact on outcome including mental status. Our goal is to analyze the timeline of mental status improvement and review factors affecting this after the discontinuation of commonly used IVADs in patients successfully treated for RSE.  Methods: A retrospective chart review of 158 patients with status epilepticus (SE) at Ochsner Neuro ICU during 2016 was performed with IRB approval.Diagnosis of RSE was based on EEG reviewed by board certified epileptologists and response to first and second line agents. Of the 158 patients reviewed, 117 patients had resolution of the SE and survived after hospital discharge. Of these 117, 74 were treated with the anesthetic Propofol, Ketamine, Midazolam or a combination. We reviewed the Glasgow Coma Scale (GCS) scores of each patient following discontinuation of IVADs at regular intervals (best weekly score) for up to 5 weeks of the hospitalization period and best available score post discharge.  Results: Of the 74 patients that were treated with anesthetics, 38 received Propofol only, 4 received only Ketamine, 17 received a combination of Propofol and Ketamine and 14 were treated with Midazolam alone.  The average length of stay for these patient groups were; 26 days for Propofol alone, 53 days for Ketamine alone, 37 days for Propofol and Ketamine used in combination and 21 days for Midazolam alone. The maximum doses of the IVADs were 125 mKm of Propofol, 150mKm of Ketamine and 4 mg/hour of Midazolam. Anti-seizure medication used included Levetiracetam, Lacosamide, Clobazam, Pheytoin, Valproic Acid, Vigabatrin, Zonisamide and Lamotrigine. The etiologies for RSE included cerebral hypoperfusion, cardiac arrest, electrolyte disturbances, meningitis, medications, intractable epilepsy, intracerebral hemorrhage, stroke, hepatic encephalopathy, metabolic acidosis, subarachnoid hemorrhage, and sepsis. Graphical representation of the timeline of mental status improvement in relation to IVADs (dose and duration), etiology and duration of SE, anti-seizure drugs, co-morbidities, and brain imaging will be presented.  Conclusions: In lieu of the conflicting data in the literature on the direct impact of prolonged use of IVADs on the outcome of patients with SE, the overall benefit/risk of IVADs has been a topic of much debate leading to confusion and disagreements among the care team in the ICU. Our systematic review revealed that the course of the mental status improvement following the use of IVADs was independent of the choice of IVAD. It was, however, directly affected by various factors related to the hospitalization in addition to the etiology and management of the RSE.  Funding: Department of Neurology, Ochsner Neurosciences Institute