title: A Practical Approach to Ketogenic Diet in the Pediatric Intensive Care Unit for Super-Refractory Status Epilepticus.
abstract: Super-refractory status epilepticus (SRSE) ensues when there is no improvement of seizure control in response to anesthetic therapy or seizure recurrence after reduction of anesthetic agents. There is no consensus on standard of care for SRSE. Ketogenic diet (KD) has reported success, but technical challenges exist including inability to feed patients, concomitant steroid use, acidotic states, and lack of dieticians with experience. The optimal protocol for KD is yet to be determined. We describe our approach to initiation of KD in the pediatric intensive care unit (PICU).
  
  
  
  Patients with SRSE who had KD initiation in the PICU were identified. Data from the hospital course were supplemented by review of the electronic medical record.
  
  
  
  Nine children with SRSE who had KD initiated in the PICU were identified. Descriptive analysis was performed. Mean age was 5.4 years (SD 2.24). Median number of days to start KD from detection of seizures was 13 [interquartile range (IQR) 10-16]. Mean time to achieve ketosis was 4.2 days (SD 3.4). The median number of antiepileptic drugs (AEDs) trialed before KD was started was 4 [IQR 3-4], and the median number of continuous infusions was 2 [IQR 2-3]. After initiation of KD, most patients were weaned off anesthetic infusions by 1 week. Outcomes were variable.
  
  
  
  We demonstrated the feasibility of a practical approach to initiation of KD for children with SRSE. These children were successfully weaned off continuous anesthetic infusions. Larger studies are needed to determine effectiveness, safety, and tolerability of KD in the management of SRSE as well as ease of implementation.
authors.affiliation: Department of Child Neurology, Pediatric Neurocritical Care, Children's National Health System, 111 Michigan Avenue NW, Washington DC, 20010, USA. rfariasm@cnmc.org.
authors.forename: Raquel
authors.identifier: 0000-0001-8717-7703
authors.initials: R
authors.lastname: Farias-Moeller
authors.affiliation: Department of Child Neurology, Pediatric Neurocritical Care, Children's National Health System, 111 Michigan Avenue NW, Washington DC, 20010, USA.
authors.forename: Luca
authors.initials: L
authors.lastname: Bartolini
authors.affiliation: Department of Child Neurology, Pediatric Neurocritical Care, Children's National Health System, 111 Michigan Avenue NW, Washington DC, 20010, USA.
authors.forename: Archana
authors.initials: A
authors.lastname: Pasupuleti
authors.affiliation: Department of Nutrition, Children's National Health System, Washington DC, USA.
authors.forename: R D
authors.initials: RD
authors.lastname: Brittany Cines
authors.affiliation: Department of Child Neurology, Pediatric Neurocritical Care, Children's National Health System, 111 Michigan Avenue NW, Washington DC, 20010, USA.
authors.forename: Amy
authors.initials: A
authors.lastname: Kao
authors.affiliation: Department of Child Neurology, Pediatric Neurocritical Care, Children's National Health System, 111 Michigan Avenue NW, Washington DC, 20010, USA.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Carpenter
mesh_terms: D002648:Child; D002675:Child, Preschool; D055423:Diet, Ketogenic / Q000379:methods*; D000069279:Drug Resistant Epilepsy / Q000178:diet therapy*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D015278:Intensive Care Units, Pediatric; D008297:Male; D017063:Outcome Assessment, Health Care; D013226:Status Epilepticus / Q000178:diet therapy*
keywords: FIRES; Ketogenic diet; Super-refractory status epilepticus