Treatment of super-refractory status epilepticus: the sooner the better with less adverse effects.

Commentary One of the areas within the field of epilepsy upon which there is universal agreement is the importance of avoiding the adverse effects of continuous, uncontrolled seizures due to the demonstrated or feared consequences on the brain, including exacerbation of chronic seizures, and new or chronic neuro-logical disabilities (e.g. cognitive, motor), and systemic that can lead directly to mortality. Thus, there is no disagreement regarding the necessity of terminating convulsive and noncon-vulsive seizures as soon as possible. That is where the consensus ends. The definition of 'status epilepticus' (SE) remains based in custom without consideration of evidence-based consequences and continues to range from 5 to 30 minutes in the modern literature. Similarly, the designation 'refractory status epilepticus' (RSE) was created to describe continuous seizures (independent of type, repetitive, etiology) not responsive to arbitrarily defined first-and second-line medications. Most recently, 'super-refractory SE' (SRSE) has been used to describe status epilepticus that continues beyond 24 hours following initiation of an anesthetic agent (1). The definition is purely operational and is too new to have an acquired evidence-based or even international consensus. Why do—and should—we have or care about these descriptors? Ultimately, the answer lies in utility in the design, implementation and evaluation of treatment pathways to optimize outcomes. The state of the literature regarding the treatment (2) and outcome (3) of RSE/SRSE has been recently summarized in comprehensive reviews in which it is noted that SRSE occurs in approximately 15% of adults. The frequency in children is unknown but certainly occurs in some fraction of those that are refractory to first-and second-line therapies. In that recent review, it was documented that the vast majority of reported cases of SRSE (920/1171, 79%) were treated with pentobarbi-tal, midazolam, or propofol. Ketamine accounted for 17 cases in 7 published reports with resolution of seizures in 82%. Its potential neuroprotective effects support the use of this anesthetic agent as an NMDA receptor antagonist, in addition to its anticonvulsant properties. A significant contribution to our knowledge regarding the utility of ketamine in children has been provided by the recent report of Rosati and colleagues. This is the largest and best characterized series of children in whom ketamine has been used for refractory or SRSE. The study population is a familiar (and all too common) subset of children with epilepsy intractable to medications; that is, those with epileptic encephalopathies and motor dysfunction that are of unknown and …