Authors :
Presenting Author: Ben MacDonald, – Massachusetts General Hospital
Benjamin Macdonald, BS – Neurology – Massachusetts General Hospital; Andrew Webb, PharmD – Pharmacy – Massachusetts General Hospital; Kaitlyn Piotrowski, BA – Neurology – Massachusetts General Hospital; Sophie Ack, BA – Neurology – Massachusetts General Hospital; Eric Rosenthal, MD – Neurology – Massachusetts General Hospital
Rationale:
Ketamine has been proposed as an intubation-sparing therapy to terminate established status epilepticus (SE). We examined a case series of non-intubated patients with status epilepticus treated with ketamine.Methods:
We report four cases of patients at two Boston area academic medical centers who received ketamine for SE without requiring intubation during treatment. We examined commensurate changes in vitals and EEG monitoring in response to treatment with ketamine. Results:
Patient One was a 22-year-old female admitted for new-onset refractory status epilepticus (NORSE) on BRV, CBZ, DZP, LCM, and OXC who had previously undergone burst suppression with a prolonged ventilator wean requiring tracheostomy placement. The patient had seizure recurrence while on trach mask and received two intravenous 3 mg/kg doses of ketamine with improvement in electrographic seizure activity. The patient became hypertensive and tachycardic after administration and her oxygen saturation declined from 96% to 93%, so the decision was made to put the patient back on the ventilator with propofol for burst suppression. Patient Two was a 73-year-old man admitted for focal status epilepticus. He was on LEV, PHB, and LCM at baseline without adequate seizure control so the patient was given three intravenous 0.5 mg/kg ketamine doses with initiation of a 10 mcg/kg/min continuous infusion for 24 hours. He required 1L of nasal cannula but otherwise did not experience any significant hemodynamic changes. After each bolus, the patient began following commands and was near baseline by 15 minutes post-bolus. He continued to have electrographic seizure activity, but seizures were less frequent and at lower amplitudes. Patient Three was a 66-year-old-man admitted for CAR-T therapy for CNS lymphoma complicated by focal status epilepticus. He was on LEV, LCS, and CBZ with continued seizure activity so ketamine was started without a bolus at 2 mcg/kg/min, up-titrated to a maximum of 3 mcg/kg/min. With ketamine initiation, the patient’s exam significantly improved with better verbal output and increasing alertness. No new seizures were noted on EEG after ketamine initiation. The patient was transitioned to perampanel 8mg daily with good effect. He experienced no hemodynamic alterations and remained on room air during the infusion. Patient 4 was a 59-year-old man with known epilepsy admitted for focal status. He was on LEV, LCS, VPA, and CBZ with continued seizure activity and so was started on ketamine without an initial bolus at 5 mcg/kg/min, up-titrated to 20 mcg/kg/min. While there was evidence of partial treatment response as the seizures became lower amplitude, less rhythmic, and less sharp, electrographic seizure response was still evident so the patient was intubated and started on propofol and ketamine at 100 mcg/kg/min. There were no significant hemodynamic alterations while on low-dose ketamine and the patient remained on room air while on a dose of 20 mcg/kg/min.
Conclusions:
Low-dose ketamine appears to be effective in terminating established SE and was well-tolerated in non-intubated patients.Funding: This study was not supported financially.