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Management of super-refractory status epilepticus with isoflurane and hypothermia.

Zhumadilov A, Gilman CP, Viderman D - Front Neurol (2015)

Bottom Line: Super-refractory status epilepticus (SRSE) is defined as status epilepticus that continues 24 h or more after the onset of anesthesia, and includes those cases in which epilepsy is recurrent upon treatment reduction.We describe the presentation and successful management of a male patient with SRSE using the inhaled anesthetic isoflurane, and mild hypothermia (HT).The potential utility of combined HT and volatile anesthesia is discussed.

View Article: PubMed Central - PubMed

Affiliation: Republican Research Center for Emergency Care , Astana , Kazakhstan.

ABSTRACT
Super-refractory status epilepticus (SRSE) is defined as status epilepticus that continues 24 h or more after the onset of anesthesia, and includes those cases in which epilepsy is recurrent upon treatment reduction. We describe the presentation and successful management of a male patient with SRSE using the inhaled anesthetic isoflurane, and mild hypothermia (HT). The potential utility of combined HT and volatile anesthesia is discussed.

No MeSH data available.


Related in: MedlinePlus

Clinical course and treatment timeline. Initial therapy included diazepam (diaz) 0.15 mg/kg, and propofol (prop) 0.027 mg/kg/min. Four hours later, the dose of propofol was increased to 0.09 mg/kg/min. Eighteen hours later, prop was exchanged for sodium thiopental (TP). Twenty-six hours later, general anesthesia was induced with isoflurane (isoflu) and HT initiated. After seizures were dormant for 72 h, the patient was removed from isoflurane and rewarmed, at which point, seizures returned. Isoflurane anesthesia and HT were reinitiated and continued for 2 weeks, during which the patient was stable without super-refractory status epilepticus (SRSE). Attempts to withdraw from treatment were unsuccessful over these 2 weeks. The patient was then gradually removed from isoflurane and HT, remained seizure-free for 72 h and was then released from the ICU.
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Figure 1: Clinical course and treatment timeline. Initial therapy included diazepam (diaz) 0.15 mg/kg, and propofol (prop) 0.027 mg/kg/min. Four hours later, the dose of propofol was increased to 0.09 mg/kg/min. Eighteen hours later, prop was exchanged for sodium thiopental (TP). Twenty-six hours later, general anesthesia was induced with isoflurane (isoflu) and HT initiated. After seizures were dormant for 72 h, the patient was removed from isoflurane and rewarmed, at which point, seizures returned. Isoflurane anesthesia and HT were reinitiated and continued for 2 weeks, during which the patient was stable without super-refractory status epilepticus (SRSE). Attempts to withdraw from treatment were unsuccessful over these 2 weeks. The patient was then gradually removed from isoflurane and HT, remained seizure-free for 72 h and was then released from the ICU.

Mentions: Figure 1 shows a schematic of the treatment/response timeline. Initial therapy consisted of diazepam 0.15 mg/kg (10 mg bolus; this dose was repeated after 5 min) and propofol 0.027 mg/kg/min, valproic acid 2 g/day, and carbamazepine 200 mg twice daily. This therapy was not sufficient to reduce seizures after 4 h and the dose of propofol was increased to 0.09 mg/kg/min. To reduce the continued hepatic damage (indicated by treatment and LDH levels), propofol is a good first choice (1); however, it failed to alleviate epileptic activity. As the combination of these drugs continued to fail at 22 h, propofol was exchanged for sodium thiopental (0.04 mg/kg/min) and 16 h later was increased to 0.07 mg/kg/min. Despite this therapy seizures continued (monitored by continuous EEG recording), resulting in hemodynamic instability with profound hypotension demanding vasopressors (epinephrine, 0.1 μg/kg/min and phenylephrine, 0.09 μg/kg/min) with continuous normal saline infusion.


Management of super-refractory status epilepticus with isoflurane and hypothermia.

Zhumadilov A, Gilman CP, Viderman D - Front Neurol (2015)

Clinical course and treatment timeline. Initial therapy included diazepam (diaz) 0.15 mg/kg, and propofol (prop) 0.027 mg/kg/min. Four hours later, the dose of propofol was increased to 0.09 mg/kg/min. Eighteen hours later, prop was exchanged for sodium thiopental (TP). Twenty-six hours later, general anesthesia was induced with isoflurane (isoflu) and HT initiated. After seizures were dormant for 72 h, the patient was removed from isoflurane and rewarmed, at which point, seizures returned. Isoflurane anesthesia and HT were reinitiated and continued for 2 weeks, during which the patient was stable without super-refractory status epilepticus (SRSE). Attempts to withdraw from treatment were unsuccessful over these 2 weeks. The patient was then gradually removed from isoflurane and HT, remained seizure-free for 72 h and was then released from the ICU.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4309114&req=5

Figure 1: Clinical course and treatment timeline. Initial therapy included diazepam (diaz) 0.15 mg/kg, and propofol (prop) 0.027 mg/kg/min. Four hours later, the dose of propofol was increased to 0.09 mg/kg/min. Eighteen hours later, prop was exchanged for sodium thiopental (TP). Twenty-six hours later, general anesthesia was induced with isoflurane (isoflu) and HT initiated. After seizures were dormant for 72 h, the patient was removed from isoflurane and rewarmed, at which point, seizures returned. Isoflurane anesthesia and HT were reinitiated and continued for 2 weeks, during which the patient was stable without super-refractory status epilepticus (SRSE). Attempts to withdraw from treatment were unsuccessful over these 2 weeks. The patient was then gradually removed from isoflurane and HT, remained seizure-free for 72 h and was then released from the ICU.
Mentions: Figure 1 shows a schematic of the treatment/response timeline. Initial therapy consisted of diazepam 0.15 mg/kg (10 mg bolus; this dose was repeated after 5 min) and propofol 0.027 mg/kg/min, valproic acid 2 g/day, and carbamazepine 200 mg twice daily. This therapy was not sufficient to reduce seizures after 4 h and the dose of propofol was increased to 0.09 mg/kg/min. To reduce the continued hepatic damage (indicated by treatment and LDH levels), propofol is a good first choice (1); however, it failed to alleviate epileptic activity. As the combination of these drugs continued to fail at 22 h, propofol was exchanged for sodium thiopental (0.04 mg/kg/min) and 16 h later was increased to 0.07 mg/kg/min. Despite this therapy seizures continued (monitored by continuous EEG recording), resulting in hemodynamic instability with profound hypotension demanding vasopressors (epinephrine, 0.1 μg/kg/min and phenylephrine, 0.09 μg/kg/min) with continuous normal saline infusion.

Bottom Line: Super-refractory status epilepticus (SRSE) is defined as status epilepticus that continues 24 h or more after the onset of anesthesia, and includes those cases in which epilepsy is recurrent upon treatment reduction.We describe the presentation and successful management of a male patient with SRSE using the inhaled anesthetic isoflurane, and mild hypothermia (HT).The potential utility of combined HT and volatile anesthesia is discussed.

View Article: PubMed Central - PubMed

Affiliation: Republican Research Center for Emergency Care , Astana , Kazakhstan.

ABSTRACT
Super-refractory status epilepticus (SRSE) is defined as status epilepticus that continues 24 h or more after the onset of anesthesia, and includes those cases in which epilepsy is recurrent upon treatment reduction. We describe the presentation and successful management of a male patient with SRSE using the inhaled anesthetic isoflurane, and mild hypothermia (HT). The potential utility of combined HT and volatile anesthesia is discussed.

No MeSH data available.


Related in: MedlinePlus