RELAPSE AND SURVIVAL AFTER BARBITURATE ANESTHETIC TREATMENT OF REFRACTORY STATUS EPILEPTICUS

Purpose: Pentobarbital is standard treatment for refractory status epi lepticus (SE) and is almost uniformly effective, but the morbidity of treatment and the mortality of refractory SE are high. Recurrence of S E after pentobarbital discontinuation may predict a worsened outcome. We sought to determine the optimal use of barbiturate anesthetic treat ment of refractory SE. Methods: We reviewed 44 episodes of barbiturate anesthetic treatment for refractory SE in 40 patients, seeking factor s predicting freedom from relapse to clinical or electrographic SE aft er treatment and predicting survival. Results: Eight of 9 patients wit h relapse of seizures after barbiturate treatment died, whereas only 9 of 26 with persistently controlled seizures died (p < 0.005). Both li kelihood of relapse and survival correlated strongly with etiology, wi th 19 of 20 patients with chronic epilepsy, infections, or focal lesio ns having good control as compared with 2 of 9 with multiple medical p roblems (p < 0.001). Treatment delay did not predict a worsened outcom e. Hypotension caused dose reduction but never required treatment disc ontinuation. Patients with more prolonged treatment and those receivin g phenobarbital (PB) at the time of pentobarbital taper were less like ly to relapse. Conclusions: Relapse of SE after barbiturate anesthetic treatment is a poor prognostic sign and should be prevented, if possi ble. Etiology was the primary predictor of outcome, but more prolonged treatment and the use of PB during pentobarbital withdrawal appeared to provide protection against relapse.