Ketamine versus GABAergic therapies for super refractory status epilepticus

Ketamine unquestionably controls super refractory status epilepticus by offering an alternative to GABAergic drugs through its potent neuroprotective effects and a substantial decline in vasopressor need.

This systematic review focused on evaluating the role of Ketamine in managing super refractory status epilepticus (SRSE).

The study systematically searched through PubMed, EMBASE, and Google Scholar databases and only included human studies irrespective of age and gender for treating SRSE with Ketamine.

Nineteen studies with 336 participants aged 9 months to 86 years were included in this review. Causes for SRSE often included infections, anoxia (total depletion of oxygen) and metabolic problems. In some instances, the origin was unknown and referred to as New Onset RSE (NORSE) or Febrile Infection-Related Epilepsy Syndrome (FIRESs).

SRSE cases were categorized as convulsive (N = 105) and non-convulsive (N = 197). The usage of Ketamine had a wide range of dosages: Adults received a bolus of 0.5 mg/kg and a maintenance dose of 0.2-15 mg/kg/hour, while children were given a bolus of 1-3 mg/kg and a maintenance dose of 0.5-3 mg/kg/hour. These dosages were administered over durations ranging from 1 to 30 days, and other medications like Propofol and Midazolam were concurrently used in 40-100% of cases.

Seizure resolution rates varied widely: from 53.3% to 91% in larger studies and 40-100% in smaller series. Seizure resolution was reported in every case report except one where the patient died. Burst suppression on EEG was observed in 12 patients across two series and two case reports. Recurrence of seizures was registered in 11 patients from 5 studies. All-cause mortality rates varied significantly: from 38.8% to 59.5% in larger studies and 0-36.4% in smaller series, with no direct correlation to Ketamine dosage or duration.

Ketamine is effective for SRSE, offering neuroprotection and reducing vasopressor needs by acting on NMDA receptors.