Purpose: While protocols regarding how to treat status epilepticus (SE) has been universally accepted, management of refractory status epilepticus (RSE) is far from being evidence-based. Ketamine (KET), a NMDA-antagonist, may have a role in RSE when other conventional anesthetics fail due to its unique pharmacodynamic properties and good safety profile.
Methods: Exhaustive search of available medical literature was performed using MEDLINE-Ovid, MEDLINE-PubMed, Psych INFO, Web of Science, and CINAHL for relevant articles from 2012-2017 using keywords “ketamine” and “status epilepticus.” Additional criteria for consideration: articles applicable to the topic and published in the English language. Exclusion criteria includes all opinion articles, preclinical data, protocol articles, and case studies. Studies were then assessed for quality using GRADE criteria.
Results: The 4 studies reviewed found a good response rate ranging from 64-80% when KET was used as the first- or second-line agent in RSE. Furthermore, all studies found a good safety profile of KET at high doses and long duration of infusion. Although initial response rate of RSE to early administration of KET is high, all 4 studies have severe limitations.
Conclusion: Currently, RSE algorithms are inadequate and leave providers to choose the best course of action. Earlier introduction of KET after failure of first- and second-line agents shows promise to control RSE and avoid intubation and ventilation. This area of study needs larger, prospective, and randomized trials that clearly designate and follow a protocol to assess adequate efficacy of early administration of KET in RSE.
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