Hi Dr. Weingart & Dr. Farkas,
I recently came across the PulmCrit article on Rapid Sequence Termination of Status Epilepticus (linked below) and became quite interested in the idea of using propofol +/- ketamine as an aggressive management option; the protocol makes sense to me and seems like a reasonable option with relatively few risks.
I've had a fairly thorough look at the available literature and it seems while early propofol is considered somewhat standard amongst the neurocrit. world that early ketamine is almost unheard of.
Of the available papers and case series I have found two retrospective observational studies: Gaspard et. al. (2013) which describe ketamine use in ~60 patients with initial administration times from 6hours - 30 days; and Synowiec et al (2013) includes only 13 patients who all had SE for >24 hours.
Barring one case study where administration occured "within hours of SE onset" because of haemodynamic complications the remaining case series available that discuss ketamine use only in refractory SE and usually when SE has been ongoing for a very long time (20+ days).
What are your thoughts on this? Has your treatment protocol changed since the publication of that PulmCrit article/have you had recent success with early propofol + ketamine?
Quick discussions with my ICU consultant made it clear that their preferred route/the hospitals protocol here is managing with a barbituate coma if 3rd/4th line anti-epileptics fail.
I'd love to hear your thoughts on this.
Final year medical student from Australia
PulmCrit article: http://emcrit.org/pulmcrit/rapid-sequence-termination-rst-of-status-epilepticus/
Retrospective study references:
Gaspard N, Foreman B, Judd LM, Brenton JN, Nathan BR, McCoy BM, et al. Intravenous ketamine for the treatment of refractory status epilepticus: A retrospective multicenter study. Epilepsia. 2013;54(8):1498–503. http://www.ncbi.nlm.nih.gov/pubmed/23369676
Synowiec AS, Singh DS, Yenugadhati V, Valeriano JP, Schramke CJ, Kelly KM. Ketamine use in the treatment of refractory status epilepticus. Epilepsy Research [Internet]. Elsevier B.V.; 2013;105(1-2):183–8. Available from: http://dx.doi.org/10.1016/j.eplepsyres.2013.01.007