Treatment deviating from guidelines does not influence status epilepticus prognosis
Service de Neurologie, CHUV, BH-07, 1011, Lausanne, Switzerland, . Journal of Neurology
(Impact Factor: 3.38).
08/2012; 260(2). DOI: 10.1007/s00415-012-6644-x
Status epilepticus (SE) prognosis is related to nonmodifiable factors (age, etiology), but the exact role of drug treatment is unclear. This study was undertaken to address the prognostic role of treatment adherence to guidelines (TAG). We prospectively studied over 26 months a cohort of adults with incident SE (excluding postanoxic). TAG was assessed in terms of drug doses (±30 % of recommendations) and medication sequence; its prognostic impact on mortality and return to baseline conditions was adjusted for etiology, SE severity [Status Epilepticus Severity Score (STESS)], and comorbidities. Of 225 patients, 26 (12 %) died and 82 (36 %) were discharged with a new handicap; TAG was observed in 142 (63 %). On univariate analysis, age, etiology, SE severity, and comorbidities were significantly related to outcome, while TAG was associated with neither outcome nor likelihood of SE control. Logistic regression for mortality identified etiology [odds ratio (OR) 18.8, 95 % confidence interval (CI) 4.3-82.8] and SE severity (STESS ≥3; OR 1.7, 95 % CI 1.2-2.4) as independent predictors, and for lack of return to baseline, again etiology (OR 7.4, 95 % CI 3.9-14.0) and STESS ≥3 (OR 1.7, 95 % CI 1.4-2.2). Similar results were found for the subgroup of 116 patients with generalized-convulsive SE. Receiver operator characteristic (ROC) analyses confirmed that TAG did not improve outcome prediction. This study of a large SE cohort suggests that treatment adherence to recommendations using current medications seems to play a negligible prognostic role (class III), confirming the importance of the biological background. Awaiting further treatment trials, it appears mandatory to apply resources towards identification of new therapeutic approaches.
Available from: Eugen Trinka
- "Two randomized controlled trials have been attempted, and both had to be stopped early because of low enrolment  . A survey of neurologists performed in 2003  and a prospective study examining treatment adherence to guidelines  have contributed additional information about treatment practices in the established, refractory, and super refractory stages. Aside from these, there is little published information about the epidemiology and current treatment practices around the world, and none of the widely recommended drugs or procedures have been subjected to an adequate systematic review, despite their adoption worldwide. "
Available from: Johannes Roesche
- "gency service physician even ini - tiated anaesthesia . Additionally there was a considerable delay of treatment in the episodes of NCSE . However , in - hospital mortality with 8% of treatment episodes and 11% of patients was well comparable to that of previous studies ( e . g . ( Kellinghaus and Stögbauer , 2012 ) : 10% of treatment episodes ; ( Rossetti et al . , 2013 ) : 12% of patients ) . There - fore we are confident that our data are representative for clinical practice applied in many countries ."
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ABSTRACT: Since randomized controlled trials are difficult to perform for ethical reasons in a potentially deadly condition like status epilepticus (SE), a retrospective database analysis may be welcome to broaden the evidence for the treatment of SE. In this retrospective study we evaluated every SE treatment at the neurological department of the University of Rostock from January 2000 to December 2009 in order to determine the efficacy of different antiepileptic drugs (AEDs) in terminating different kinds of SE. We analyzed the frequency of refractory courses in different types of SE, at which time which AED was administered and at which time which AED was effective to terminate the different epileptic conditions. A second aim of this study was to evaluate the course and the outcome of different kinds of SE. Statistical comparisons were performed with the χ(2)-test. 167 episodes of SE in 118 patients could be evaluated. The efficacy rates of AEDs differed significantly, mainly due to the superior efficacy of clonazepam (CZP). CZP seemed to be more effective than DZP, LEV, MDM and VPA in terminating generalized convulsive status epilepticus (GCSE), whereas there was no significant difference in the efficacy for terminating nonconvulsive status epilepticus (NCSE) and epilepsia partialis continua (EPC) between the used AEDs. Anaesthesia and CZP both terminated GCSE more effectively than NCSE and EPC. Concerning the course of the different kinds of SE the following results were obtained: 13 patients died during hospital treatment. Treatment in NCSE and EPC started significantly later than in GCSE. There was no significant difference in mortality between the types of SE. However the frequency of refractory courses differed between the types of SE. At the time of SE termination without the administration of anaesthesia a combination therapy using 2 or more AEDs was established in most episodes.
- "Second, it is possible that BDZ overdose " prevented " worse outcome in severe SE forms, balancing off diverging effects and resulting in similar final outcomes. Nevertheless, this hypothesis seems rather unlikely, since our previous study suggested that medication dose has a marginal role in SE prognosis, even after adjustment for major outcome predictors (Rossetti et al., 2013). Third, although we prospectively recorded indications for intubation, this may reflect SE severity and refractoriness, rather than being related to BDZ administration . "
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ABSTRACT: Benzodiazepine (BDZ), a widely recognized first-line status epilepticus (SE) treatment, may lead to respiratory depression. This cohort study investigates the effect of BDZ doses in SE patients in terms of morbidity and mortality. It considers incident SE episodes from a prospective registry (2009-2012), comparing patients receiving standard BDZ dose to those receiving exceeding doses (>30% above recommended dose), in terms of likelihood to receive intubation, morbidity, and mortality. Duration of hospitalization was assessed for subjects needing intubation for airways protection (not for refractory SE treatment) versus matched subjects not admitted to the intensive care unit (ICU). We identified 29 subjects receiving "excessive" and 173 "standard" BDZ dose; 45% of the overtreated patients were intubated for airways protection, but only 8% in the standard-dose group (p < 0.001). However, both groups presented similar clinical outcomes: 50% returned to baseline, 40% acquired a new handicap, and 10% died. Orotracheal intubation due to airways protection was associated with significantly longer hospitalization (mean 2 weeks vs. 1 week, p = 0.008). In conclusion, although administration of excessive BDZ doses in SE treatment does not seem to influence outcome, it is related to higher respiratory depression risk and longer hospitalization, potentially exposing patients to additional complications and costs.
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