Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane

Background: Refractory status epilepticus (RSE) is defined as continued seizures after 2 or 3 antiepileptic drugs have failed. Several intravenous agents have been used for RSE; however, problems occur with their toxicity and/or efiectiveness. Objective: To report our experience with inhalational anesthesia (IA) in patients who were refractory to other antiepileptic drugs. Design, Setting, and Participants: Retrospective review during a 4-year period of patients with RSE treated with isoflurane and/or desflurane. Main Outcome Measure: Efficacy of IA on therapy in terminating RSE. Results: Seven patients (4 mate) aged 17 to 71 years received 7 to 15 (mean, 10) antiepileptic drugs in addition to IAs. The IAs were initiated after 1 to 103 (mean, 19) days of RSE and were used for a mean +/-SD 11 +/- 8.9 days. All patients received isoflurane, and 1 patient in addition received desflurane anesthesia 21 days after the onset of RSE for a total of 19 days. Regardless of seizure type, isoflurane and desflurane consistently stopped epileptic discharges with adequate, sustained electroencephalographic burst suppression within minutes of initiating IA therapy. Four patients had good outcomes, 3 died (1 of acute hemorrhagic leukoencephalitis, 1 of bowel infarction, and 1 of toxic encephalopathy, who remained in a persistent vegetative state until death 5.5 months after the onset of seizures). Complications during IA therapy included hypotension (7/7), atelectasis (7/7), infections (5/7), paralytic ileus (3/7), and deep venous thrombosis (2/7). No patient developed renal or hepatic dysfunction. Conclusions: Isoflurane and desflurane adequately suppressed RSE in all cases. Complications were common, but mortality and long-term morbidity were related to the underlying disease and duration of RSE. Prolonged use of isoflurane and desflurane is well tolerated.