Abstracts

Rationale: Super-refractory status epilepticus (SRSE) is defined as status epilepticus (SE) that continues or recurs despite 24 hours of high dose suppressive therapy. SRSE carries very significant morbidity in the pediatric population. The ketogenic diet (KD) has been reported to be effective to abort SRSE. Implementation of the KD in the ICU can be challenging. Here we report our experience with the KD for SRSE in children. Methods: A retrospective chart review to identify children with SRSE who initiated the KD at the Hospital for Sick Children, Toronto, Canada, from 2007-2014. Charts were reviewed for demographic and patient factors, details of diet administration and outcomes. Results: Eleven children (7 boys, 4 girls), age 0.5-13.4 years(mean±SD=8.1±3.5) with SRSE were identified. In all cases, the diet was given via nasogastric tube. Diet ratios and calories were calculated according to patient's weight, age, bowel routine and concomitant treatments (steroid treatment and intubation). During the ICU admission, diets were modified up to 4 times per patient to achieve adequate ketosis by raising ratios or restricting calories. Ratios were adjusted up to a 5:1 for patients with steroid therapy or insufficient ketosis. Post ICU discharge, diet ratios were reduced once seizure control was achieved. Six children started at a 4:1, 1 at 4.5:1, 3 at 3:1 and 1 was at 2:1 ratio. Ten of the 11 children reached ketosis on day 1. One child had delayed onset of ketosis on day 4, after receiving a sweetened suspension medication during the first 3 days. The KD was effective in aborting SRSE in 9 of 11 (82%) children. In these 9 children the diet was started between 0-34 days(mean±SD=11.6 days±6.2) after ICU admission. They were discharged from the ICU 3-43 days(mean±SD=15.1±14.1) following admission. In 8 of these 9 children, urinary ketones ranged from 8 to above 16 mmol/L. The remaining child had ketones ranging from 4-16 mmol/L. KD failed to control seizures in 2 patients. In these children, KD treatment was initiated at 36 and 46 days after onset of SE. In both cases, urinary ketones fluctuated between 0.5 to above16 mmol/L and both were receiving excess carbohydrates(CHO) from medications, which likely contributed to unstable ketosis. Data on longer term KD management was available for 6 children. In all, diet ratios were gradually decreased as the seizures improved, to KD ratios of 2.75:1 to 4.25:1. Calories were also adjusted to maintain growth. Conclusions: We have demonstrated success in utilizing the KD to abort SRSE in children. Multiple diet adjustments of calories and ratios were required to achieve stable ketosis. Difficulty in eliminating excess CHO from IV fluids, medications and other sources are a barrier to effective KD administration in the ICU. In this series, children who did not respond to the KD, initiated the diet later in the clinical course of SRSE. Earlier initiation of the KD, and consistent moderate to high levels of ketosis were more common among those children in whom the SRSE was aborted. Longer-term diet and seizure outcomes in this series are currently under review. .