Refractory Status Epilepticus
SE persisting after benzodiazepine + first-line AED
All Pathways
NeurologyEmergency
Refractory Status Epilepticus Management
Refractory Status Epilepticus Management: Refractory Status Epilepticus → Confirm Refractory SE (RSE) → Immediate Actions → Select Continuous IV Anesthe...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Confirm Refractory SE (RSE)
Definition and criteria
- Seizures persist after adequate benzo dose
- AND after one first-line AED (fosphenytoin, VPA, LEV)
- Typically 20-30 min from onset
- Start continuous EEG monitoring
03Action Immediate Actions
Secure airway and prepare for anesthesia
- Intubate for airway protection
- Arterial line for BP monitoring
- Central venous access
- Continuous EEG (cEEG) initiation
- Vasopressor support ready
04Decision Select Continuous IV Anesthetic (CIVA)
Choose based on patient factors
- Midazolam - less hypotension
- Propofol - fast on/off, PRIS risk
- Pentobarbital - most potent, most side effects
- Ketamine - emerging evidence
05Action Midazolam Infusion
Often first-line for RSE
- Load: 0.2 mg/kg bolus
- Infusion: 0.1-2 mg/kg/hr
- Titrate to EEG target
- Repeat boluses 0.2 mg/kg PRN
- Less hypotension than others
06Decision EEG Suppression Target
What level of suppression?
- Seizure suppression (minimum)
- Burst suppression (moderate)
- Isoelectric (maximum)
- No clear evidence one is superior
07Action Burst Suppression Target
Most common target
- 1-10 bursts per minute
- Maintain for 24-48 hours initially
- Slow wean attempt after stable
- Continue maintenance AEDs
08Action Wean Attempt
After 24-48h of seizure control
- Reduce CIVA by 25-50% q6-12h
- Continuous EEG during wean
- Ensure AED levels therapeutic
- Watch for breakthrough seizures
09Decision Seizure Recurrence?
Breakthrough during wean
10Outcome Successful Wean
Seizure freedom off anesthetics
- Continue maintenance AEDs
- Prolonged EEG monitoring (24-48h)
- ICU observation
- Investigate etiology
11Warning ⚠️ Super-Refractory SE (SRSE)
SE continues/recurs ≥24h after anesthesia
- Occurs in ~10-15% of RSE
- Consider ketamine addition
- Immunotherapy if suspected autoimmune
- Hypothermia, ketogenic diet
- Neurosurgery if focal lesion
- Very high mortality (30-50%)
12Action Consider Ketamine
NMDA antagonist for RSE/SRSE
- Load: 1-3 mg/kg
- Infusion: 1-10 mg/kg/hr
- May add to midazolam/propofol
- Fewer hemodynamic effects
- Growing evidence base
13Warning Goals of Care Discussion
If SRSE persists despite all measures
- Mortality 30-50% in SRSE
- Survivors often have morbidity
- Involve family, palliative care
- Consider comfort measures
14Action Seizure Suppression Only
Less aggressive approach
- Titrate to abolish electrographic seizures
- Background may show slowing
- Less hemodynamic compromise
- Consider if stable
- Path rejoins step 08Shared downstream outcome
15Action Propofol Infusion
Rapid onset, lipid soluble
- Load: 1-2 mg/kg bolus
- Infusion: 1-15 mg/kg/hr
- Monitor for PRIS (propofol infusion syndrome)
- Check triglycerides, CK, lactate
- Limit to <5 mg/kg/hr if >48h
- Path rejoins step 06Shared downstream outcome
16Action Pentobarbital Infusion
Most potent, last resort
- Load: 5-15 mg/kg
- Infusion: 0.5-5 mg/kg/hr
- Target: burst suppression on EEG
- Significant hypotension expected
- Prolonged recovery (days)
- Path rejoins step 06Shared downstream outcome
Guideline Source
Guidelines for the Evaluation and Management of Status Epilepticus - Neurocritical Care Society
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Pediatric dosing differs significantly
- Requires ICU-level monitoring with continuous EEG
- Drug choice may vary by institutional protocol
- Super-refractory SE management less standardized
Applicable Regions
USEUglobal
EU: ILAE recommendations may differ slightly
US: NCS/AES guidelines primarily followed
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Refractory Status Epilepticus Management?
The Refractory Status Epilepticus Management is a emergency clinical algorithm for Neurology. It provides a structured decision tree to guide clinical decision-making, based on Guidelines for the Evaluation and Management of Status Epilepticus - Neurocritical Care Society.
What guideline is the Refractory Status Epilepticus Management based on?
This algorithm is based on Guidelines for the Evaluation and Management of Status Epilepticus - Neurocritical Care Society (DOI: 10.1007/s12028-012-9695-z).
What are the limitations of the Refractory Status Epilepticus Management?
Known limitations include: Pediatric dosing differs significantly; Requires ICU-level monitoring with continuous EEG; Drug choice may vary by institutional protocol; Super-refractory SE management less standardized. Individual patient factors may require deviation from these recommendations.
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