Treatment of Status Epilepticus: What Are the Guidelines and Are We Following Them?

OBJECTIVES: Status epilepticus (SE) is associated with high morbidity and mortality. The American Epilepsy Society (AES) has established guidelines regarding proper dosing of antiepileptic drugs (AEDs). There are also recommendations for appropriate weaning off anesthetic agents in SE. Our aim was to determine the frequency with which guidelines were being followed during routine clinical care. METHODS: A retrospective chart review was completed for patients with a diagnosis of SE within the last 10 years. All patients with SE on anesthetic agents were included when analyzing AED dosing. Patients with anoxic brain injury were excluded when reviewing anesthetic wean times. RESULTS: Seventy-six patients were identified on anesthetic agents. Five patients had anoxic brain injury and were excluded from the anesthetic weaning analysis. Medications were under dosed as follows: lorazepam 0.05 mg/kg (N=51), midazolam 0.07 mg/kg (N=14), fosphenytoin 17.9 mg/kg (N=47), levetiracetam 21.7 mg/kg (N=42), valproate sodium 16.7 mg/kg (N=12), phenobarbital 4.1 mg/kg (N=4), lacosamide 215 mg (N=13), and topiramate 333 mg (N=3). Anesthetic agents were weaned as follows: <24 hours 32/71 (45%), 24 to 48 hours 11/71 (15%), 48 to 72 hours 12/71 (17%), and >72 hours 11/71 (15%). Seizure recurrence rates were: 8/32 (25%) <24 hours, 2/11 (18%) 24 to 48 hours, 1/12 (8.3%) 48 to 72 hours, and 1/11 (9%) at >72 hours. CONCLUSIONS: This retrospective review demonstrates how guidelines and recommendations for SE are not consistently followed. Under dosing of AEDs and aggressive weaning of anesthetic agents may result in higher morbidity and mortality.

Alternatives to sodium amobarbital in the Wada test.

OBJECTIVE: To review the literature and identify alternatives to sodium amobarbital for use in the Wada test. DATA SOURCES: A search of PubMed (1960-October 2010) was performed using the following key words alone or in combination: Wada test, intracarotid amobarbital procedure, intracarotid, intraarterial, sodium amobarbital, methohexital, Brevital, pentobarbital, etomidate, propofol, and alternative anesthetics. References of the identified articles were reviewed for relevant information. STUDY SELECTION AND DATA EXTRACTION: All articles in English identified from the data sources were evaluated. Review included comparative, prospective, and retrospective studies along with case series and case reports. DATA SYNTHESIS: Methohexital, pentobarbital, etomidate, and propofol have all been studied as alternatives to sodium amobarbital in the Wada test. Four controlled experimental trials, 1 uncontrolled experimental trial, 6 retrospective chart reviews, and 2 case reports were reviewed. Methohexital, pentobarbital, and propofol required a second injection due to their short duration of action. Etomidate was studied as a bolus injection followed by a continuous infusion until the critical speech and memory tests were administered, which differed from the standard Wada test procedure. Patients had an increased risk of seizures with methohexital, whereas 1 patient developed transient respiratory depression immediately after receiving pentobarbital. Furthermore, propofol caused increased tone with twitching and rhythmic movements, which interfered with the completion of the Wada test for 1 patient. All authors concluded that these agents were equivalent to amobarbital for the Wada test. CONCLUSIONS: Methohexital, pentobarbital, etomidate, and propofol are viable alternatives to sodium amobarbital for use in the Wada test, but each has shortcomings.