title: Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study.
abstract: BACKGROUND
  Seizures refractory to third-line therapy are also labeled super-refractory status epilepticus (SRSE). These seizures are extremely difficult to control and associated with poor outcome. We aimed to characterize efficacy and side-effects of continuous infusions of pentobarbital (cIV-PTB) treating SRSE.
  
  
  METHODS
  We retrospectively reviewed continuous electroencephalography (cEEG) reports for all adults with RSE treated with cIV-PTB between May 1997 and April 2010 at our institution. Patients with post-anoxic SE and those receiving cIV-PTB for reasons other than RSE were excluded. We collected baseline information, cEEG findings, side-effects and functional outcome at discharge and one year.
  
  
  RESULTS
  Thirty one SRSE patients treated with cIV-PTB for RSE were identified. Mean age was 48 years old (interquartile range (IQR) 28,63), 26% (N = 8) had a history of epilepsy. Median SE duration was 6.5 days (IQR 4,11) and the mean duration of cIV-PTB was 6 days (IQR 3,14). 74% (N = 23) presented with convulsive SE. Underlying etiology was acute symptomatic seizures in 52% (N = 16; 12/16 with encephalitis), remote 30% (N = 10), and unknown 16% (N = 5). cIV-PTB controlled seizures in 90% (N = 28) of patients but seizures recurred in 48% (N = 15) while weaning cIV-PTB, despite the fact that suppression-burst was attained in 90% (N = 28) of patients and persisted >72 hours in 56% (N = 17). Weaning was successful after adding phenobarbital in 80% (12/15 of the patients with withdrawal seizures). Complications during or after cIV-PTB included pneumonia (32%, N = 10), hypotension requiring pressors (29%, N = 9), urinary tract infection (13%, N = 4), and one patient each with propylene glycol toxicity and cardiac arrest. One-third (35%, N = 11) had no identified new complication after starting cIV-PTB. At one year after discharge, 74% (N = 23) were dead or in a state of unresponsive wakefulness, 16% (N = 5) severely disabled, and 10% (N = 3) had no or minimal disability. Death or unresponsive wakefulness was associated with catastrophic etiology (p = 0.03), but none of the other collected variables.
  
  
  CONCLUSIONS
  cIV-PTB effectively aborts SRSE and complications are infrequent; outcome in this highly refractory cohort of patients with devastating underlying etiologies remains poor. Phenobarbital may be particularly helpful when weaning cIV-PTB.
authors.forename: Deborah
authors.initials: D
authors.lastname: Pugin
authors.forename: Brandon
authors.initials: B
authors.lastname: Foreman
authors.forename: Gian Marco
authors.initials: GM
authors.lastname: De Marchis
authors.forename: Andres
authors.initials: A
authors.lastname: Fernandez
authors.forename: J Michael
authors.initials: JM
authors.lastname: Schmidt
authors.forename: Barry M
authors.initials: BM
authors.lastname: Czeisler
authors.forename: Stephan A
authors.initials: SA
authors.lastname: Mayer
authors.forename: Sachin
authors.initials: S
authors.lastname: Agarwal
authors.forename: Christine
authors.initials: C
authors.lastname: Lesch
authors.forename: Hector
authors.initials: H
authors.lastname: Lantigua
authors.forename: Jan
authors.initials: J
authors.lastname: Claassen
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D004569:Electroencephalography / Q000187:drug effects / Q000379:methods; D005260:Female; D006801:Humans; D007022:Hypotension / Q000139:chemically induced / Q000175:diagnosis; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D010424:Pentobarbital / Q000008:administration & dosage* / Q000009:adverse effects*; D011014:Pneumonia / Q000139:chemically induced / Q000175:diagnosis; D012189:Retrospective Studies; D013226:Status Epilepticus / Q000188:drug therapy*; D016896:Treatment Outcome
chemical_list: D010424:Pentobarbital