Thomas P. Bleck

It's Time to Revise the Definition of Status Epilepticus

Generalized, tonic-clonic status epilepticus is well recognized as a common neurologic emergency requir- ing prompt treatment. The diagnosis is usually not diffi- cult, other than for patients with prolonged seizures, who often develop increasingly subtle clinical features (1,2). There also appears to be a consensus among physicians regarding treatment (3). Nonetheless, there is a major, persistent dilemma regarding status epilepticus: its defi- nition. Discussions concerning the precise definition of status epilepticus all too often result in agreement that current “textbook” definitions are either imprecise, at odds with clinical practice, or both. Here we propose a revised system for defining status epilepticus that ad- dresses these problems. References to status epilepticus prior to the mid- 19th century focused on cases in which seizures lasted many hours to days (4). In 1904, Clark and Prout (5) defined status epilepticus as a state in which seizures occur so frequently that ‘‘the coma and exhaustion are continuous between the seizures.” In his general textbook of neu- rology published in 1940, Kinnier Wilson (6) referred to status epilepticus as the severest form of seizures in which “the post-convulsive sleep of one attack is cut short by development of the next.” Aspects of these definitions were mirrored in the first International Clas- sification of Epileptic Seizures that was developed in 1964 by the International League Against Epilepsy (ILAE). Status epilepticus was defined as the situation in which “a seizure persists for a sufficient length of time or is repeated frequently enough to produce a fixed and enduring epileptic condition” (7). The same definition was retained in the revised classification published in 1970 (8), and it was modified slightly in 1981 to refer to the situation in which “a seizure persists for a sufficient length of time or is repeated frequently enough that re- covery between attacks does not occur” (9).

Guidelines for the Evaluation and Management of Status Epilepticus

Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Development, and Evaluation systems, as well as expert opinion when sufficient data were lacking.

Critical Care Management of Patients Following Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference

Subarachnoid hemorrhage (SAH) is an acute cerebrovascular event which can have devastating effects on the central nervous system as well as a profound impact on several other organs. SAH patients are routinely admitted to an intensive care unit and are cared for by a multidisciplinary team. A lack of high quality data has led to numerous approaches to management and limited guidance on choosing among them. Existing guidelines emphasize risk factors, prevention, natural history, and prevention of rebleeding, but provide limited discussion of the complex critical care issues involved in the care of SAH patients. The Neurocritical Care Society organized an international, multidisciplinary consensus conference on the critical care management of SAH to address this need. Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise. A jury of four experienced neurointensivists was selected for their experience in clinical investigations and development of practice guidelines. Recommendations were developed based on literature review using the GRADE system, discussion integrating the literature with the collective experience of the participants and critical review by an impartial jury. Recommendations were developed using the GRADE system. Emphasis was placed on the principle that recommendations should be based not only on the quality of the data but also tradeoffs and translation into practice. Strong consideration was given to providing guidance and recommendations for all issues faced in the daily management of SAH patients, even in the absence of high quality data.

Report of a National Conference on Donation after cardiac death.

A national conference on organ donation after cardiac death (DCD) was convened to expand the practice of DCD in the continuum of quality end‐of‐life care.

Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America

Objective:To update the practice parameters for the evaluation of adult patients who develop a new fever in the intensive care unit, for the purpose of guiding clinical practice. Participants:A task force of 11 experts in the disciplines related to critical care medicine and infectious diseases was convened from the membership of the Society of Critical Care Medicine and the Infectious Diseases Society of America. Specialties represented included critical care medicine, surgery, internal medicine, infectious diseases, neurology, and laboratory medicine/microbiology. Evidence:The task force members provided personal experience and determined the published literature (MEDLINE articles, textbooks, etc.) from which consensus was obtained. Published literature was reviewed and classified into one of four categories, according to study design and scientific value. Consensus Process:The task force met twice in person, several times by teleconference, and held multiple e-mail discussions during a 2-yr period to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the strength of the recommendation. Draft documents were composed and debated by the task force until consensus was reached by nominal group process. Conclusions:The panel concluded that, because fever can have many infectious and noninfectious etiologies, a new fever in a patient in the intensive care unit should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests. A cost-conscious approach to obtaining cultures and imaging studies should be undertaken if indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether infection is present so that additional testing can be avoided and therapeutic decisions can be made.

Propofol and Midazolam in the Treatment of Refractory Status Epilepticus

Summary:  Purpose: To explore outcome differences between propofol and midazolam (MDL) therapy for refractory status epilepticus (RSE).

Neurologic complications of critical medical illnesses

ObjectivesTo identify the neurologic complications of critical medical illnesses, and to assess their effect on mortality rates and on medical ICU and hospital lengths of stay. DesignProspective clinical evaluation of all medical ICU admissions for 2 yrs. SettingA 14-bed, general medical intensive and coronary care unit in a large university hospital. PatientsPatients (n = 1,850) admitted to the hospital, of whom 92 were admitted for primarily neurologic problems. Of the remaining 1,758 patients, 217 (12.3%) experienced a neurologic complication. InterventionsNone. Measurements and Main ResultsPatients developing a neurologic complication while in the medical ICU demonstrated an increased risk of inhospital mortality when compared with patients who did not suffer such problems (45.7% vs. 26.6%; p < .00001). Patients with neurologic complications experienced 2.5-fold longer medical ICU stay times (p < .001) and almost two-fold longer hospital stay times (p < .001). Metabolic encephalopathy, seizures, hypoxic-ischemic encephalopathy, and stroke were the most common complications. Sepsis was the most frequent cause of encephalopathy, and cerebrovascular lesions were the most common cause of seizures. Formal neurologic consulttions were requested in only 36% of the patients. ConclusionsNeurologic complications associated with increased mortality rates longer medical ICU and hospital lengths of st These conditions are probably underrecognis at present. ICUs have the potential to serve environments for neurologic teaching and search. (Crit Care Med 1993; 21:98–103)

New anticonvulsant drugs : focus on flunarizine, fosphenytoin, midazolam and stiripentol

SummaryIn the past decade, several new antiepileptic drugs have been tested. Most recently, 5 new antiepileptic drugs have been launched onto European and US markets. These include vigabatrin, oxcarbazepine and lamotrigine in Europe, and felbamate and gabapentin in the US. In addition to these, 3 additional drugs are in the clinical investigational stage: flunarizine, fosphenytoin and stiripentol. A fourth agent is midazolam, which was originally introduced in 1986, but recently has shown effectiveness in the treatment of status epilepticus.Flunarizine is a selective calcium channel blocker that has shown anticonvulsant properties in both animal and human studies. It is a long-acting anticonvulsant that clinical studies have shown to have effects similar to those of phenytoin and carbamazepine in the treatment of partial, complex partial and generalised seizures.Fosphenytoin was developed to eliminate the poor aqueous solubility and irritant properties of intravenous phenytoin. It is rapidly converted to phenytoin after intravenous or intramuscular administration. In clinical studies, this prodrug showed minimal evidence of adverse events and no serious cardiovascular or respiratory adverse reactions. It may have a clear advantage over the present parenteral formulation of phenytoin.Midazolam is a benzodiazepine that is more potent than diazepam as a sedative, muscle relaxant and in its influence on electroencephalographic measures. It has been shown to be an effective treatment for refractory seizures in status epilepticus.Stiripentol has anticonvulsant properties as well as the ability to inhibit the cytochrome P450 system. There are significant metabolic drug interactions between stiripentol and phenytoin, carbamazepine and phenobarbital (phenobarbi-tone). Stiripentol has been studied in patients with partial seizures, refractory epilepsy and refractory absence seizures with some efficacious results.

Management of Rabies in Humans

Rabies is a fatal disease in humans, and, to date, the only survivors of the disease have received rabies vaccine before the onset of illness. The approach to management of the rabies normally should be palliative. In unusual circumstances, a decision may be made to use an aggressive approach to therapy for patients who present at an early stage of clinical disease. No single therapeutic agent is likely to be effective, but a combination of specific therapies could be considered, including rabies vaccine, rabies immunoglobulin, monoclonal antibodies, ribavirin, interferon-alpha, and ketamine. Corticosteroids should not be used. As research advances, new agents may become available in the future for the treatment of human rabies.

Intravenous midazolam for the treatment of refractory status epilepticus

ObjectiveTo determine the usefulness of midazolam as a therapeutic agent for status epilepticus refractory to conventional treatment.DesignRetrospective study.SettingICUs of two university hospitals.PatientsSeven patients with refractory status epilepticus who failed treatment with diazepam, lorazep