Therapeutic coma for the treatment of status epilepticus

Background

There are scarce data available on the treatment of refractory status epilepticus (SE) where general anesthetics are recommended. However, these may be related to increased morbidity (and possibly mortality).

Question

When and how should therapeutic coma be used in this clinical setting?

Methods

Critical review of available international literature in the past 50 years as well as of personal experience.

Results

Patients with generalized convulsive or nonconvulsive SE in coma not responding to benzodiazepines and an antiepileptic drug should be treated under electroencephalographic (EEG) monitoring with coma induction and general anesthetics. Initially, midazolam/propofol seem to represent the safest options. A progressive weaning attempt should be made after 24?h without EEG seizures. Patients with absence SE should never be treated with coma, and in those with focal SE with preserved consciousness coma should be deferred after the trial of other nonsedating compounds. In cases of super-refractory SE, ketamine and/or a ketogenic diet may be considered.

Conclusion

In view of the limited current evidence, it seems reasonable to avoid indiscriminate use of general anesthetics in SE.