Therapeutic coma for status epilepticus

Nicola A. Marchi, BM; Jan Novy, MD; Mohamed Faouzi, PhD; Christine Stähli, RN; Bernard Burnand, MD, MPH; Andrea O. Rossetti, MD.  Status Epilepticus: Impact of Therapeutic Coma on Outcome.  Crit Care Med. 2015;43(5):1003-1009.

This study provides class III evidence that therapeutic coma is associated with poorer outcome after status epilepticus; furthermore, it portends higher infection rates and longer hospitalizations. These data suggest caution in the straightforward use of this approach, especially in patients with complex partial status epilepticus… 

Treatment recommendations for SE are based on a three-step approach;  in this context, SE not responding to benzodiazepines (first-line therapy) followed by an antiepileptic drug (second-line therapy) is commonly labeled as refractory SE (RSE). This condition occurs in 23–43% of patients with SE, and management with therapeutic coma (TC) is advocated in current guidelines (third-line therapy), although there is no high-level evidence… 

Prevalence of infectious complications was analyzed in a nested case-control assessment comparing all patients managed with TC and a control group of the same number of subjects treated without TC, matched for outcome, potentially fatal etiology, STESS, and CCI; results are given in odds ratio (OR) and 95% CI…

 

The principal finding of this study is that TC administered for SE treatment is associated with a worse clinical outcome, including mortality, after taking into account the etiology and severity of the underlying condition; this relationship (class III evidence) appears stronger in patients with forms of SE other than "proper" GCSE and NCSEC. In addition, subjects treated with this approach displayed higher infection rates and longer acute hospital stay when discharged alive… 

This study shows that TC is associated with mortality, poorer functional outcome, higher infection rates, and longer acute hospital stay after adjustment for the most important outcome predictors, and thus suggests caution in the straightforward use of this therapeutic approach, particularly in patients with complex partial SE at the moment of diagnosis. However, we acknowledge that factors such as severe impairment of consciousness with loss of airways protection or durable generalized convulsive seizure leading to neuronal injury may direct the risk-benefit scale in favor of TC. Accordingly, the use of this approach for patients with GCSE or NCSEC appears fully justified. Multicenter, prospective studies are needed to better identify which further category of patients with SE would take the best advantage from this approach, since the feasibility of a randomized trial in this setting unfortunately appears very unlikely.