Refractory Status Epilepticus Management

Algorithm Steps

1. ▶

   Start

   Refractory Status Epilepticus

   SE persisting after benzodiazepine + first-line AED

   1. ●

      Action

      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
      1. ●

         Action

         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
         1. ◆

            Decision

            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
            1. ●

               Action

               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
               1. ◆

                  Decision

                  EEG Suppression Target

                  What level of suppression?

                  • Seizure suppression (minimum)
                  • Burst suppression (moderate)
                  • Isoelectric (maximum)
                  • No clear evidence one is superior
                  1. ●

                     Action

                     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
                     1. ●

                        Action

                        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
                        1. ◆

                           Decision

                           Seizure Recurrence?

                           Breakthrough during wean

                           1. ✓

                              Outcome

                              Successful Wean

                              Seizure freedom off anesthetics

                              • Continue maintenance AEDs
                              • Prolonged EEG monitoring (24-48h)
                              • ICU observation
                              • Investigate etiology
                           2. ⚠

                              Warning

                              ⚠️ 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%)
                              1. ●

                                 Action

                                 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
                                 1. ⚠

                                    Warning

                                    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
                  2. ●

                     Action

                     Seizure Suppression Only

                     Less aggressive approach

                     • Titrate to abolish electrographic seizures
                     • Background may show slowing
                     • Less hemodynamic compromise
                     • Consider if stable
            2. ●

               Action

               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
            3. ●

               Action

               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)