背景:非惊厥性癫痫持续状态(NCSE)被定义为没有明显运动现象的癫痫持续状态(SE),并根据脑电图(EEG)进行诊断。难治性SE(RSE)是尽管使用适当剂量的一线和二线药物进行治疗,但仍持续发作。尽管惊厥性RSE的指南包括三线药物,例如静脉麻醉药物(咪达唑仑,异丙酚,或巴比妥酸盐),NCSE的治疗方法没有很好的概述。传统麻醉药的治疗总是包括气管内插管,这与重大不良事件有关。相对而言,氯胺酮,非竞争性N-甲基-D-天冬氨酸受体拮抗剂与显著心肺抑制无关,可能有助于避免插管.
目的:在本系列中,我们描述了在难治性NCSE患者中早期使用静脉注射氯胺酮作为首选麻醉剂以避免气管插管的经验.
方法:我们介绍了在大学附属三级护理医院的神经重症监护病房管理的9例患者。该研究获得了医院和大学机构审查委员会的批准,并放弃了对现有数据进行回顾性分析的知情同意要求。根据机构政策。所有SE病例都是从前瞻性数据库中确定的,随后的回顾性图表审查确定了所有诊断为难治性NCSE的患者,其中氯胺酮被用作第一麻醉剂.主要终点是在输注氯胺酮时避免气管内插管。次要终点定义为氯胺酮给药24小时内连续EEG记录的临床和电记录癫痫发作的停止。
结果:共有9例难治性NCSE患者纳入本病例系列,中位年龄61岁(26-72岁),7例患者为男性。主端点,避免插管,在九分之五(55%)的案例中取得了进展。以氯胺酮作为唯一的麻醉剂,六名患者经历了难治性NCSE的消退。四名患者需要气管插管,三名患者因氯胺酮而无法停止癫痫发作。唾液分泌过度和肺炎是最常见的氯胺酮相关不良事件。在未插管的患者中,没有死亡发生。一名病人出院回家,四到亚急性康复,一家长期急性护理医院,还有一个病人到临终关怀医院.
结论:在一部分难治性NCSE患者中,使用氯胺酮作为主要麻醉剂可能是避免气管插管的合理选择。这项研究受到样本量小的限制,回顾性设计,并依赖图表审查获得的信息。
BACKGROUND: Non-convulsive status epilepticus (NCSE) is defined as status epilepticus (SE) with no obvious motor phenomenon and is diagnosed based on electroencephalogram (EEG). Refractory SE (RSE) is the persistence of seizures despite treatment with an adequately dosed first-line and second-line agents. Although guidelines for convulsive RSE include third-line agents such as intravenous anesthetic drugs (midazolam, propofol, or barbiturates), the therapeutic approach to NCSE is not well outlined. Treatment with traditional anesthetics invariably includes endotracheal intubation, which is associated with significant adverse events. Comparatively, ketamine, a non-competitive N-methyl-D-aspartate receptor antagonist is not associated with significant cardiorespiratory depression and may help in avoiding intubation.
OBJECTIVE: In this case series, we describe our experience with the early use of intravenous ketamine as the first anesthetic agent in patients with refractory NCSE to avoid endotracheal intubation.
METHODS: We present a case series of nine patients managed in the Neurointensive Care Unit at a university-affiliated tertiary care hospital. The study was approved by the hospital and university institutional review boards and the requirement for informed consent was waived for retrospective analysis of existing data, per institutional policy. All cases of SE were identified from a prospective database, and a subsequent retrospective chart review identified all patients with a diagnosis of refractory NCSE in whom ketamine was used as the first anesthetic agent. The primary endpoint was the avoidance of endotracheal intubation while on ketamine infusion. The secondary endpoint was defined as cessation of both clinical and electrographic seizures recorded on continuous EEG within 24 h of ketamine administration.
RESULTS: A total of nine patients experiencing refractory NCSE were included in this case series, with a median age of 61 (range 26-72) years and seven patients were male. The primary endpoint, avoiding intubation, was achieved in five out of nine (55%) cases. Six patients experienced resolution of refractory NCSE with ketamine administration as the sole anesthetic agent. Four patients required endotracheal intubation and three patients had a failure of seizure cessation with ketamine. Hypersalivation and pneumonia were the most common ketamine associated adverse events. In non-intubated patients, no deaths occurred. One patient was discharged home, four to subacute rehabilitation, one to a long term acute care hospital, and one patient to hospice.
CONCLUSIONS: The use of ketamine as the primary anesthetic agent may be a reasonable option to avoid endotracheal intubation in a subset of patients with refractory NCSE. This study is limited by its small sample size, retrospective design, and reliance on information obtained from chart review.