Stage of refractory status epilepticus after 6090 minutes

If seizures continue for 60-90 minutes after the initiation of therapy, the stage of refractory status epilepticus is reached and full anaesthesia is required.28 In many emergency situations (for example, postoperative status epilepticus, severe or complicated convulsive status epilepticus, patients already in intensive care), anaesthesia can and should be introduced earlier. Prognosis in patients reaching this stage is poorer, and the longer the status continues the higher is the mortality and morbidity.

Anaesthesia can be induced by barbiturate or non-barbiturate drugs. A number of anaesthetics have been administered, although few have been subjected to formal evaluation and all have drawbacks. The most commonly used anaesthetics are the intravenous barbiturate thiopentone, the intravenous non-barbiturate propofol, or continuous midazolam infusion. A non-randomised comparison of propofol and thiopentone was unable to detect any clinically significant differences between the drugs.39 Other drugs in current use include the intravenous anaesthetic pentobarbitone (not available in the United Kingdom).

Patients require the full range of intensive care facilities, including EEG monitoring, and care should be shared between anaesthetist and neurologist. Experience with long term administration (hours or days) of the newer anaesthetic drugs is very limited. The modern anaesthetics have important pharmacokinetic advantages over the more traditional barbiturates, and are thus often chosen as first-line.

Once the patient has been free of seizures for 12-24 hours and provided that there are adequate plasma levels of concomitant antiepileptic medication, then the anaesthetic should be slowly tapered. If seizures recur, anaesthesia should be reinstituted immediately and maintained for a further 24 hours. A further attempt to taper therapy can then be made. In the occasional patient, anaesthesia is needed for days or weeks, and every time withdrawal of therapy is attempted seizures recur. Although the prognosis in these cases is generally poor, there is no alternative to prolonged anaesthesia and some patients do eventually make a good recovery.

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