Journal of Clinical Medicine

Editorial

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Open AccessEditorial

Epileptic Seizures in Critically Ill Patients: Diagnosis, Management, and Outcomes

by Mathilde Holleville, Gwenaëlle Jacq, François Perier, Candice Fontaine and Stephane Legriel

J. Clin. Med. 2020, 9(7), 2218; https://doi.org/10.3390/jcm9072218 - 13 Jul 2020

Cited by 1 | Viewed by 1947

Abstract

Epileptic seizures in critically ill patients represent a major source of concern, because they are associated with significant mortality and morbidity rates. Despite recent advances that have enabled a better understanding of the global epidemiology of this entity, epileptic seizures in critically ill [...] Read more.

Epileptic seizures in critically ill patients represent a major source of concern, because they are associated with significant mortality and morbidity rates. Despite recent advances that have enabled a better understanding of the global epidemiology of this entity, epileptic seizures in critically ill patients remain associated with a high degree of uncertainty and numerous questions remain unanswered. The present Special Issue aims to invite authors to contribute original research articles as well as review articles related to all aspects of epileptic seizures in critically ill patients, diagnosis, management, and outcomes. Full article

(This article belongs to the Special Issue Epileptic Seizures in Critically Ill Patients: Diagnosis, Management, and Outcomes)

Research

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12 pages, 1074 KiB

Open AccessArticle

First-Response ABCDE Management of Status Epilepticus: A Prospective High-Fidelity Simulation Study

by Paulina S. C. Kliem, Kai Tisljar, Sira M. Baumann, Pascale Grzonka, Gian Marco De Marchis, Stefano Bassetti, Roland Bingisser, Sabina Hunziker, Stephan Marsch and Raoul Sutter

J. Clin. Med. 2022, 11(2), 435; https://doi.org/10.3390/jcm11020435 - 15 Jan 2022

Cited by 5 | Viewed by 12485

Abstract

Respiratory infections following status epilepticus (SE) are frequent, and associated with higher mortality, prolonged ICU stay, and higher rates of refractory SE. Lack of airway protection may contribute to respiratory infectious complications. This study investigates the order and frequency of physicians treating a [...] Read more.

Respiratory infections following status epilepticus (SE) are frequent, and associated with higher mortality, prolonged ICU stay, and higher rates of refractory SE. Lack of airway protection may contribute to respiratory infectious complications. This study investigates the order and frequency of physicians treating a simulated SE following a systematic Airways-Breathing-Circulation-Disability-Exposure (ABCDE) approach, identifies risk factors for non-adherence, and analyzes the compliance of an ABCDE guided approach to SE with current guidelines. We conducted a prospective single-blinded high-fidelity trial at a Swiss academic simulator training center. Physicians of different affiliations were confronted with a simulated SE. Physicians (n = 74) recognized SE and performed a median of four of the five ABCDE checks (interquartile range 3–4). Thereof, 5% performed a complete assessment. Airways were checked within the recommended timeframe in 46%, breathing in 66%, circulation in 92%, and disability in 96%. Head-to-toe (exposure) examination was performed in 15%. Airways were protected in a timely manner in 14%, oxygen supplied in 69%, and antiseizure drugs (ASDs) administered in 99%. Participants’ neurologic affiliation was associated with performance of fewer checks (regression coefficient −0.49; p = 0.015). We conclude that adherence to the ABCDE approach in a simulated SE was infrequent, but, if followed, resulted in adherence to treatment steps and more frequent protection of airways. Full article

(This article belongs to the Special Issue Epileptic Seizures in Critically Ill Patients: Diagnosis, Management, and Outcomes)

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11 pages, 667 KiB

Open AccessArticle

Epileptiform Discharge and Electrographic Seizures during the Hypothermia Phase as Predictors of Rewarming Seizures in Children after Resuscitation

by Jainn-Jim Lin, Mei-Hsin Hsu, Shao-Hsuan Hsia, Ying-Jui Lin, Huei-Shyong Wang, Hsuan-Chang Kuo, Ming-Chou Chiang, Oi-Wa Chan, En-Pei Lee, Kuang-Lin Lin and the iCNS Group

J. Clin. Med. 2020, 9(7), 2151; https://doi.org/10.3390/jcm9072151 - 8 Jul 2020

Cited by 2 | Viewed by 2586

Abstract

The aim of this study was to determine the frequency, timing, and predictors of rewarming seizures in a cohort of children undergoing therapeutic hypothermia after resuscitation. We retrospectively reviewed consecutive pediatric patients undergoing therapeutic hypothermia after resuscitation admitted to our pediatric intensive care [...] Read more.

The aim of this study was to determine the frequency, timing, and predictors of rewarming seizures in a cohort of children undergoing therapeutic hypothermia after resuscitation. We retrospectively reviewed consecutive pediatric patients undergoing therapeutic hypothermia after resuscitation admitted to our pediatric intensive care unit between January 2000 and December 2019. Continuous electroencephalographic monitoring was performed during hypothermia (24 h for cardiac aetiologies and 72 h for asphyxial aetiologies), rewarming (72 h), and then an additional 12 h of normothermia. Thirty comatose children undergoing therapeutic hypothermia after resuscitation were enrolled, of whom 10 (33.3%) had rewarming seizures. Two (20%) of these patients had their first seizure during the rewarming phase. Four (40%) patients had electroclinical seizures, and six (60%) had nonconvulsive seizures. The median time from starting rewarming to the onset of rewarming seizures was 37.3 h (range 6 to 65 h). The patients with interictal epileptiform activity and electrographic seizures during the hypothermia phase were more likely to have rewarming seizures compared to those without interictal epileptiform activity or electrographic seizures (p = 0.019 and 0.019, respectively). Therefore, in high-risk patients, continuous electroencephalographic monitoring for a longer duration may help to detect rewarming seizures and guide clinical management. Full article

(This article belongs to the Special Issue Epileptic Seizures in Critically Ill Patients: Diagnosis, Management, and Outcomes)

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Review

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11 pages, 1194 KiB

Open AccessReview

Review and Updates on the Treatment of Refractory and Super Refractory Status Epilepticus

by Yazeed S. Alolayan, Kelly McKinley, Ritwik Bhatia and Ayham Alkhachroum

J. Clin. Med. 2021, 10(14), 3028; https://doi.org/10.3390/jcm10143028 - 7 Jul 2021

Cited by 8 | Viewed by 5943

Abstract

Refractory and super-refractory status epilepticus (RSE and SRSE) are life-threatening conditions requiring prompt initiation of appropriate treatment to avoid permanent neurological damage and reduce morbidity and mortality. RSE is defined as status epilepticus that persists despite administering at least two appropriately dosed parenteral [...] Read more.

Refractory and super-refractory status epilepticus (RSE and SRSE) are life-threatening conditions requiring prompt initiation of appropriate treatment to avoid permanent neurological damage and reduce morbidity and mortality. RSE is defined as status epilepticus that persists despite administering at least two appropriately dosed parenteral medications, including a benzodiazepine. SRSE is status epilepticus that persists at least 24 h after adding at least one appropriately dosed continuous anesthetic (i.e., midazolam, propofol, pentobarbital, and ketamine). Other therapeutic interventions include immunotherapy, neuromodulation, ketogenic diet, or even surgical intervention in certain cases. Continuous electroencephalogram is an essential monitoring tool for diagnosis and treatment. In this review, we focus on the diagnosis and treatment of RSE and SRSE. Full article

(This article belongs to the Special Issue Epileptic Seizures in Critically Ill Patients: Diagnosis, Management, and Outcomes)

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14 pages, 309 KiB

Open AccessReview

Time Is Brain: Acute Control of Repetitive Seizures and Status Epilepticus Using Alternative Routes of Administration of Benzodiazepines

by Sulaiman Almohaish, Melissa Sandler and Gretchen M. Brophy

J. Clin. Med. 2021, 10(8), 1754; https://doi.org/10.3390/jcm10081754 - 17 Apr 2021

Cited by 26 | Viewed by 6313

Abstract

Time plays a major role in seizure evaluation and treatment. Acute repetitive seizures and status epilepticus are medical emergencies that require immediate assessment and treatment for optimal therapeutic response. Benzodiazepines are considered the first-line agent for rapid seizure control. Thus, various routes of [...] Read more.

Time plays a major role in seizure evaluation and treatment. Acute repetitive seizures and status epilepticus are medical emergencies that require immediate assessment and treatment for optimal therapeutic response. Benzodiazepines are considered the first-line agent for rapid seizure control. Thus, various routes of administration of benzodiazepines have been studied to facilitate a quick, effective, and easy therapy administration. Choosing the right agent may vary based on the drug and route properties, patient’s environment, caregiver’s skills, and drug accessibility. The pharmacokinetic and pharmacodynamic aspects of benzodiazepines are essential in the decision-making process. Ultimately, agents and routes that give the highest bioavailability, fastest absorption, and a modest duration are preferred. In the outpatient setting, intranasal and buccal routes appear to be equally effective and more rapidly administered than rectal diazepam. On the other hand, in the inpatient setting, if available, the IV route is ideal for benzodiazepine administration to avoid any potential absorption delay. In this article, we will provide an overview and comparison of the various routes of benzodiazepine administration for acute control of repetitive seizures and status epilepticus. Full article

(This article belongs to the Special Issue Epileptic Seizures in Critically Ill Patients: Diagnosis, Management, and Outcomes)

10 pages, 1006 KiB

Open AccessReview

Seizures and Sepsis: A Narrative Review

by Francesco Alessandri, Rafael Badenes and Federico Bilotta

J. Clin. Med. 2021, 10(5), 1041; https://doi.org/10.3390/jcm10051041 - 3 Mar 2021

Cited by 8 | Viewed by 4072

Abstract

Patients with sepsis-associated encephalopathy (SAE) can develop convulsive or nonconvulsive seizures. The cytokine storm and the overwhelming systemic inflammation trigger the electric circuits that promote seizures. Several neurologic symptoms, associated with this disease, range from mild consciousness impairment to coma. Focal or generalized [...] Read more.

Patients with sepsis-associated encephalopathy (SAE) can develop convulsive or nonconvulsive seizures. The cytokine storm and the overwhelming systemic inflammation trigger the electric circuits that promote seizures. Several neurologic symptoms, associated with this disease, range from mild consciousness impairment to coma. Focal or generalized convulsive seizures are frequent in sepsis, although nonconvulsive seizures (NCS) are often misdiagnosed and prevalent in SAE. In order to map the trigger zone in all patients that present focal or generalized seizures and also to detect NCS, EEG is indicated but continuous EEG (cEEG) is not very widespread; timing, duration, and efficacy of this tool are still unknown. The long-term risk of seizures in survivors is increased. The typical stepwise approach of seizures management begins with benzodiazepines and follows with anticonvulsants up to anesthetic drugs such as propofol or thiopental, which are able to induce burst suppression and interrupt the pathological electrical circuits. This narrative review discusses pathophysiology, clinical presentation, diagnosis and treatment of seizures in sepsis. Full article

(This article belongs to the Special Issue Epileptic Seizures in Critically Ill Patients: Diagnosis, Management, and Outcomes)

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17 pages, 693 KiB

Open AccessReview

Pearls and Pitfalls of Introducing Ketogenic Diet in Adult Status Epilepticus: A Practical Guide for the Intensivist

by Jason B. Katz, Kent Owusu, Ilisa Nussbaum, Rachel Beekman, Nicholas A. DeFilippo, Emily J. Gilmore, Lawrence J. Hirsch, Mackenzie C. Cervenka and Carolina B. Maciel

J. Clin. Med. 2021, 10(4), 881; https://doi.org/10.3390/jcm10040881 - 22 Feb 2021

Cited by 19 | Viewed by 6966

Abstract

Background: Status epilepticus (SE) carries an exceedingly high mortality and morbidity, often warranting an aggressive therapeutic approach. Recently, the implementation of a ketogenic diet (KD) in adults with refractory and super-refractory SE has been shown to be feasible and effective. Methods: We describe [...] Read more.

Background: Status epilepticus (SE) carries an exceedingly high mortality and morbidity, often warranting an aggressive therapeutic approach. Recently, the implementation of a ketogenic diet (KD) in adults with refractory and super-refractory SE has been shown to be feasible and effective. Methods: We describe our experience, including the challenges of achieving and maintaining ketosis, in an adult with new onset refractory status epilepticus (NORSE). Case Vignette: A previously healthy 29-year-old woman was admitted with cryptogenic NORSE following a febrile illness; course was complicated by prolonged super-refractory SE. A comprehensive work-up was notable only for mild cerebral spinal fluid (CSF) pleocytosis, elevated nonspecific serum inflammatory markers, and edematous hippocampi with associated diffusion restriction on magnetic resonance imaging (MRI). Repeat CSF testing was normal and serial MRIs demonstrated resolution of edema and diffusion restriction with progressive hippocampal and diffuse atrophy. She required prolonged therapeutic coma with high anesthetic infusion rates, 16 antiseizure drug (ASD) trials, empiric immunosuppression and partial bilateral oophorectomy. Enteral ketogenic formula was started on hospital day 28. However, sustained beta-hydroxybutyrate levels >2 mmol/L were only achieved 37 days later following a comprehensive adjustment of the care plan. KD was challenging to maintain in the intensive care unit (ICU) and was discontinued due to poor nutritional state and pressure ulcers. KD was restarted again in a non-ICU unit facilitating ASD tapering without re-emergence of SE. Discussion: There are inconspicuous carbohydrates in commonly administered medications for SE including antibiotics, electrolyte repletion formulations, different preparations of the same drug (i.e., parenteral, tablet, or suspension) and even solutions used for oral care―all challenging the use of KD in the hospitalized patient. Tailoring comprehensive care and awareness of possible complications of KD are important for the successful implementation and maintenance of ketosis. Full article

(This article belongs to the Special Issue Epileptic Seizures in Critically Ill Patients: Diagnosis, Management, and Outcomes)

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12 pages, 1417 KiB

Open AccessReview

The Role of Secondary Brain Insults in Status Epilepticus: A Systematic Review

by Candice Fontaine, Gwenaelle Jacq, François Perier, Mathilde Holleville and Stephane Legriel

J. Clin. Med. 2020, 9(8), 2521; https://doi.org/10.3390/jcm9082521 - 5 Aug 2020

Cited by 6 | Viewed by 3103

Abstract

(1) Background: Little is known about the impact of pathophysiological mechanisms that underlie the enhancement of excitotoxicity and the neuronal consequences of status epilepticus (SE), as well as the clinical consequences of secondary brain insults (SBI) in patients with SE on outcome; (2) [...] Read more.

(1) Background: Little is known about the impact of pathophysiological mechanisms that underlie the enhancement of excitotoxicity and the neuronal consequences of status epilepticus (SE), as well as the clinical consequences of secondary brain insults (SBI) in patients with SE on outcome; (2) Methods: Electronic searches were conducted in May 2020 using Medline via PubMed, Embase, and Google Scholar (#CRD42019139092). Experimental studies of animals or randomized, observational, controlled trials of patients with SE in indexed journals were included. There were no language or date restrictions for the published literature included in this review. Information was extracted on study design, sample size, SBI characteristics, and primary and secondary outcomes, including the timing of evaluation; (3) Results: Among the 2209 articles responding to our inclusion criteria, 56 were included in this systematic review. There are numerous experimental data reporting the deleterious effects associated with each of the SBI in animals exposed to SE. In humans, only the effect of target temperature management in hypothermia (32–34 °C) has been explored. (4) Conclusions: There is little experimental evidence that favors the control of secondary brain insult after SE. Further studies are required to assess the neuroprotective interest of secondary brain insult control after SE in humans. Full article

(This article belongs to the Special Issue Epileptic Seizures in Critically Ill Patients: Diagnosis, Management, and Outcomes)

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