Change in Management of Status Epilepticus With the Addition of Neurointensivist-Led Neurocritical Care Team at a Rural Academic Medical Center

Abstract

Learning Objective: Status epilepticus (SE) is continuous clinical and/or electrographic seizures lasting 5 minutes or more without recovery and carries a high mortality. Medication management varies by institution, as well as administration, combination of antiepileptic drugs (AEDs), and dosing. Methods: Single-center retrospective review of medication management of SE patients admitted to West Virginia University Hospital before and after neurointensivist implemented guidelines. Patients admitted between January 2012 and June 2014 were grouped in the prior to neurointensivist group (pre-NI) and patients admitted between July 2014 and June 2016 were grouped in the postneurointensivist group (post-NI). Baseline demographics, hospital, intensive care unit (ICU), and ventilator length of stay were recorded. Medications reviewed included number of AEDs and maximum dose of lorazepam, phenytoin, levetiracetam, and lacosamide. Outcomes included number of continuous infusions of either midazolam or propofol at seizure suppression doses as well as pentobarbital, phenobarbital, or ketamine, and need for vasopressor use. Results: Of the 74 patients included, the pre-NI group (n = 40) utilized more AEDs (6 vs 4) compared with the post-NI group (n = 34). The pre-NI group had less midazolam continuous infusions meeting seizure suppression doses (8 vs 9), but higher average doses (49 vs 27 mg/h) compared with the post-NI group. More patients in the pre-NI group were on propofol seizure suppression doses (15 vs 10) and phenobarbital continuous infusions (11 vs 2) than the post-NI group. Patients had less vasopressor use in the post-NI group than the pre-NI group (11 vs 23). Frequency and dosing of lorazepam, phenytoin, levetiracetam, and lacosamide were similar between the 2 groups. Ventilator use, hospital, and ICU length of stay were also similar between groups. Discussion: Implementation of a neurointensivist and medication guidelines resulted in fewer AEDs and less vasopressor use in the management of SE. Midazolam use was slightly higher in the post-NI group but at lower doses overall.