Efficacy and safety of ketamine in refractory status epilepticus in children

ArticleinNeurology 79(24) · November 2012with24 Reads
DOI: 10.1212/WNL.0b013e318278b685 · Source: PubMed
Abstract
OBJECTIVE: To evaluate the efficacy and safety of ketamine (KE) in the management of refractory convulsive status epilepticus (RSE) in children. METHODS: In November 2009, we started using KE for treating all children consecutively referred for RSE. Clinical and treatment data were analyzed. RESULTS: Between November 2009 and June 2011, 9 children with RSE received IV KE. In 8 patients, SE had persisted for more than 24 hours (super-refractory RSE), with a median of 6 days (mean 8.5 ± 7.5; range 2-26 days). Prior to KE administration, conventional anesthetics were used, including midazolam, thiopental, and propofol in 9, 5, and 4 patients each. Median dose of KE in continuous IV infusion was 40 gamma(μg)/kg/min (mean 36.5 ± 18.6 gamma[μg]/kg/min; range 10-60 gamma[μg]/kg/min). Midazolam was administered add-on to prevent emergence reactions. The use of KE was associated with resolution of RSE in 6 children. None of the patients experienced serious adverse events. Among the 3 individuals who did not respond to KE, 2 were cured by surgical removal of epileptogenic focal cortical dysplasia. CONCLUSION: In this small, open-label, unblinded series with no concurrent control group, KE appears effective and safe in treating RSE in children. Larger, randomized studies are needed to confirm data emerging from this preliminary observation. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that IV KE can be effective in treating children with RSE (no statistical analysis was done).
    • "Meanwhile, patients who regain consciousness after ketamine is stopped may experience psychiatric emergence phenomena, including agitation, confusion, and psychosis. Though experience with ketamine for RSE is more limited than with the other cIV-AEDs, a number of case reports and case series detail its use [51,[53][54][55][56][57][58][59][60][61][62][63]. Both a multi-center retrospective study by Gaspard et al. [51] and a meta-analysis that included it, along with 22 other studies [63], showed that ketamine appeared to contribute to seizure control in RSE for approximately 57% of adult patients—however, outcomes and more detailed information for most of these patients in the meta-analysis was not available. "
    [Show abstract] [Hide abstract] ABSTRACT: Status epilepticus that cannot be controlled with first- and second-line agents is called refractory status epilepticus (RSE), a condition that is associated with significant morbidity and mortality. Most experts agree that treatment of RSE necessitates the use of continuous infusion intravenous anesthetic drugs such as midazolam, propofol, pentobarbital, thiopental, and ketamine, each of which has its own unique characteristics. This review compares the various anesthetic agents while providing an approach to their use in adult patients, along with possible associated complications.
    Full-text · Article · May 2016
    • "Electrographic or electro-clinical seizures frequently recur during weaning of pharmacologic coma medications [97][98][99][100], indicating that pharmacologic coma should be considered as a window during which specific therapies can be instituted for some status epilepticus etiologies and during which other anti-seizure medications can be initiated to provide additional coverage. Only case reports and series are available to guide management at this stage, and the options include topiramate [101][102][103][104][105][106][107], lacosamide [108][109][110], phenobarbital [111][112][113][114], ketamine [115][116][117][118][119], pyridoxine [120][121][122][123][124][125], neurosteroids [126], lidocaine [127][128][129], the ketogenic diet [90,102,[130][131][132][133][134][135][136], therapeutic hypothermia [137][138][139][140][141], immunomodulation [142,143], epilepsy surgery [115,[144][145][146][147][148][149][150][151][152][153][154], vagal nerve stimulation [155], and electroconvulsive therapy [156][157][158]. These options have been reviewed recently [21,91,94,159]. "
    [Show abstract] [Hide abstract] ABSTRACT: Status epilepticus is a common pediatric neurological emergency. Management includes prompt administration of appropriately selected anti-seizure medications, identification and treatment of seizure precipitant(s), as well as identification and management of associated systemic complications. This review discusses the definitions, classification, epidemiology and management of status epilepticus and refractory status epilepticus in children.
    Full-text · Article · Apr 2016
    • "Our series (Class IV of evidence), although small, provides further evidence of the efficacy of KE for treating RCSE in children and its safety profile [14]. Status epilepticus resolution was obtained in 14/19 RCSE episodes, and none of the 13 patients experienced serious adverse events. "
    [Show abstract] [Hide abstract] ABSTRACT: The purpose of this study was to report on the efficacy and safety of intravenous ketamine (KE) in refractory convulsive status epilepticus (RCSE) in children and highlight its advantages with particular reference to avoiding endotracheal intubation. Since November 2009, we have used a protocol to treat RCSE including intravenous KE in all patients referred to the Neurology Unit of the Meyer Children's Hospital. From November 2009 to February 2015, 13 children (7 females; age: 2months-11years and 5months) received KE. Eight patients were treated once, two were treated twice, and the remaining three were treated 3 times during different RCSE episodes, for a total of 19 treatments. Most of the RCSE episodes were generalized (14/19). A malformation of cortical development was the most frequent etiology (4/13 children). Ketamine was administered from a minimum of 22h to a maximum of 17days, at doses ranging from 7 to 60mcg/kg/min, obtaining a resolution of the RCSE in 14/19 episodes. Five patients received KE in lieu of conventional anesthetics, thus, avoiding endotracheal intubation. Ketamine was effective in 4 of them. Suppression-burst pattern was observed after the initial bolus of 3mg/kg in the majority of the responder RCSE episodes (10/14). Ketamine is effective in treating RCSE and represents a practical alternative to conventional anesthetics for the treatment of RCSE. Its use avoids the pitfalls and dangers of endotracheal intubation, which is known to worsen RCSE prognosis. This article is part of a Special Issue entitled "Status Epilepticus". Copyright © 2015 Elsevier Inc. All rights reserved.
    Article · Jul 2015
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