Abstracts

Rationale: Given the high risk of morbidity and mortality in super refractory status epilepticus (SRSE), there is a critical need for new therapies to halt ongoing seizure activity. We investigated the feasibility, tolerability and efficacy of the ketogenic diet (KD) in critically ill adults with SRSE. Methods: We performed a retrospective case review at four medical centers (Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Mayo Clinic-Rochester, Rush University Medical Center) in patients over age 17 years with SRSE treated with KD. SRSE was defined as SE (convulsive and/or nonconvulsive) that continued 24 hours or more after the initiation of general anesthetic medications, or SE that recurred following wean or discontinuation of the general anesthetic drug. Data collected included demographic features; clinical presentation; diagnosis; electroencephalography data; anticonvulsant treatment (AEDs) before, during, and after KD; and timing and duration of KD. Outcome measures included hospital and intensive care unit (ICU) length of stay, EEG at discharge, number of AEDS on discharge, and Glasgow Coma Scale (GCS) on discharge. Data were confirmed by review of the electronic medical record including physicians notes, laboratory results, neuroimaging studies and other supporting data. Medians and interquartile ranges (IQR) were calculated for all continuous variables and proportions were determined for all categorical variables.Results: Ten adult patients at four medical centers were started on KD for SRSE. The median age was 33 years (IQR 21), 4 patients were male and 7 had encephalitis. Median admission GCS was 4.5 (IQR 8), with 7 patients having a GCS<8. Median duration of SE prior to initiation of KD was 21.5 days (IQR 28) and median number of AEDs used before initiation of KD was 7 (IQR 7). Three patients had minor complications of KD including transient acidosis and hypertriglyceridemia, and two patients ultimately died of causes unrelated to KD. Ninety percent of patients achieved ketosis within a median of 3 days (IQR 5). SE ceased in all within a median of 3 days (IQR 8). The median days on anesthetic agents after KD initiation were 5 (IQR 4). On discharge, 6 patients had a GCS >12. The median number of AEDs prescribed at discharge was 4 (IQR 2.5). Seven patients had clinical and/or electrographic seizure resolution within one week of diet initiation, and nine within one month.Conclusions: We describe the safe and effective treatment of adults with SRSE with KD, with 90% of patients achieving resolution of SE within one month. This series suggests that the diet is safe and feasible in ICU patients and may lead to resolution and clinical improvement in SRSE. Further prospective studies are needed to determine the applicability of KD and long-term outcome after treatment.