Abstracts

Rationale: Patients in status epilepticus are often treated with pharmacologic coma using a number of agents including pentobarbital. Status epilepticus patterns can be controversial. We report on six cases that emerged from pentobarbital coma with a pattern of atypical triphasic waves which could be mistaken for a more refractory status epilepticus pattern. Methods: This was a retrospective case series of patients who were placed in pentobarbital coma for refractory status epilepticus. The pattern of interest was identified in these six patients. A chart review was undertaken to determine if any other factors were common to all of the patients and if any other factor was responsible for this pattern. Results: All six cases showed an atypical triphasic wave pattern on emergence. Two cases showed the same pattern on emergence from repeated rounds of pentobarbital coma. All patients were on antiepileptic drugs (AEDs) in addition to pentobarbital. No other drug was common to every patient other than the pentobarbital be it an AED or other medication. Laboratory tests did not reveal evidence of liver enzyme elevations, elevated ammonia or elevated BUN/creatinine in all patients. All of the patients were in partial status going into pentobarbital coma. All of the patients successfully had the status epilepticus terminated and survived the status epilepticus. However, one patient was withdrawn from care by her family later in the hospital stay for poor prognosis based on her overall condition. No other cause could be found other than the pentobarbital and the pattern typically disappeared within several days of totally discontinuing pentobarbital. Conclusions: This pattern of atypical triphasic waves needs to be appreciated neurologists and epileptologists. Misinterpretation of this pattern could lead to overtreating a patient and placing the patient back in pentobarbital coma before allowing the pattern to disappear. This would lead to unending futility with each emergence from pentobarbital coma. Thus the patient may be mistakenly labeled as having refractory status epilepticus leading to the withdraw of care when this is a reversible and self limited, medication emergence pattern associated with discontinuation of pentobarbital during the treatment of status epilepticus.