New Care Protocol Leads to More Aggressive Therapy for Refractory Status Epilepticus
Refractory status epilepticus in children causes devastating, long-term brain changes affecting function and quality of life. Unfortunately, therapy remains difficult and research to improve pediatric care is scant. In the last year, pediatric neurologists at Cincinnati Children’s have been using a new refractory status protocol that incorporates aggressive therapy and early consideration for surgery.
The pediatric neurologists – Eileen Broomall, MD,and Katrina Peariso, MD, PhD, who specialize in pediatric neurocritical care, and J. Michael Taylor, MD, a stroke specialist – meet frequently with one another and with the epilepsy surgery group to talk about active patients and discuss treatment options. “The most common therapy for refractory status epilepticus is to put the patient in a medically induced coma to protect the brain from repeated seizures while we determine next steps,” says Broomall. “We have a very careful selection process for this therapy, and minimize the length of coma as much as we can.”
A focused, aggressive approach
The team uses the anesthetic drugs Versed (midazolam) and ketamine simultaneously to achieve faster seizure control with fewer side effects. While a patient is comatose, the team begins onboarding antiseizure medications and tries to determine the seizure etiology, which may involve doing a workup for stroke, infection or inflammatory disease. During the coma, the team also may consider the patient for ketogenic diet, or begin a surgical evaluation. After several days, patients are weaned from anesthesia. If seizure control is not achieved after two courses of anesthetic therapy, the team initiates a formal surgical evaluation. This patient population is considered to have super refractory status epilepticus.
Broomall, Peariso and Taylor each spend 16 weeks a year seeing neurology consults in the intensive care unit and on the neurology floor. “Our team is responsible for every status epilepticus patient who is admitted to Cincinnati Children’s, and this gives us greater familiarity with the antiseizure drugs, medical complications that come with coma and different treatment options,” Broomall says. “Also, we find that building relationships with families over time leads to earlier interventions and more effective care.”
Working to expand research
Cincinnati Children’s is a site for the first multicenter trial to address super refractory status epilepticus. The “Sage Study” is testing the effectiveness of allopregnanolone, a progesterone derivative. The study is currently enrolling patients age two and older, but is broadening its criteria to include children six months and older.
Peariso and Ravindra Arya, MD, DM, a pediatric epileptologist at Cincinnati Children’s, are helping to design a multicenter study to identify EEG markers that may help establish seizure etiology and indicate whether a patient’s acute seizures are subsiding during coma therapy. “Treatment for status epilepticus has come a long way in the last 30 years as researchers have established first- and second-line antiseizure agents,” Peariso says. “Finding what works for refractory cases is the next frontier.”
