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Presentation given by Dr Catherine Poots from Craigavon Area Hospital at the 2014 Northern Ireland Intensive Care Society annual Coppel Prize on Wednesday November 26th
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CRAIGAVON AREA HOSPITALINTENSIVE CARE UNIT
COPPEL PRIZE PRESENTATION 2014NORTHERN IRELAND INTENSIVE CARE SOCIETY
CATHERINE POOTS CT1 ACCS 26/10/2014
Incidence of Status Epilepticus in adults: 4-27/100 000/year1,2
Definition of Status Epilepticus (SE)3
5 minutes or more of continuous clinical seizure activity OR
Recurrent seizure activity without recovery in between
Classification of SE4
Convulsive
Non-convulsive
Refractory SE5
SE that does not respond to standard treatment regimes
Aim To investigate the management of patients admitted to ICU
with SE/uncontrolled seizures before, during and after their admission
Objectives Was there a preventable reason for SE?
Was local protocol adhered to prior to ICU admission?
Were patients admitted to ICU within the recommended timeframe?
What was the resource utilisation of patients admitted to ICU (including EEG)?
Were patients followed up by a Neurology service and what was 30 day mortality?
100% of patients to be initially managed
according to Southern Trust protocol (in
line with NICE clinical guidelines) 7,8
100% of patients admitted to ICU within
30-90 minutes7,8
STAGE EMERGENCY AED THERAPY
PREMONITORY (PRE-HOSPITAL) DIAZEPAM 10-20mg PR (x2) or
MIDAZOLAM 10mg PO
EARLY STATUS LORAZEPAM 0.1mg/kg IV (x2)
ESTABLISHED STATUS PHENYTOIN INFUSION (15-18mg/kg)
or FOSPHENYTOIN or
PHENOBARBITAL
REFRACTORY STATUS
(60-90 MINUTES AFTER INITIAL
THERAPY)
GENERAL ANAESTHESIA
(PROPOFOL / MIDAZOLAM /
THIOPENTAL SODIUM)
ANAESTHESIA CONTINUED FOR
12-24 HOURS AFTER THE LAST
SEIZURE
Retrospective
ICNARC – all patients admitted to CAH ICU between 01/08/10 and 31/07/13 with a diagnosis of SE or uncontrolled seizures (78)
PAS used to identify those patients seen at Neurology OPC either before or after admission (26)
Single auditor
Medical & Neurology case notes and NIECR
GENDER
MALE (13)
FEMALE (13)
0
1
2
3
4
5
6
7
16-25 26-35 36-45 46-55 56-65 66-75 76-85
AGE RANGES
NUMBER OF CASES
STATEMENT PATIENT KNOWN TO HAVE EPILEPSY % (n)
YES 57.7% (15)
NO / NOT DOCUMENTED 42.3% (11)AEDS TAKEN PRIOR TO ADMISSION
PATIENTS WITH EPILEPSY% (n)
PATIENTS WITHOUT STATEMENT OF EPILEPSY % (n)
LEVETIRACETAM/KEPPRA 38.5% (10) 3.8% (1)
VALPROATE/EPILIM 23.0% (6) 3.8% (1)
LAMOTRIGINE/LAMICTAL 15.4% (4) 0
OTHER AED 15.4% (4) 0
PHENYTOIN/EPANUTIN 11.5% (3) 0
CARBAMAZEPINE/TEGRETOL 3.8% (1) 0
CLOBAZAM/FRISIUM 0 3.8% (1)
NO AED 0 38.5% (10)
PATIENTS KNOWN TO HAVE EPILEPSY % (n)
SERUM AED CHECKED 33.3% (5)
SERUM AED NOT CHECKED 66.7% (10)
SERUM C2H5OH CHECKED ON ADMISSION
% (n)
MEASURED 92.3% (24)
LEVEL <10 80.8% (21)
LEVEL >10 11.5% (3)
0
5
10
15
20
25
30
35
Rx PRIOR TO ICU % (n) DOSE RANGE (AVERAGE)
DIAZEPAM/DIAZEMULS 30.7% (8) 10-20mg (12.5)
LORAZEPAM 73.1% (19) 2-12mg (4.6)
PHENYTOIN 69.2% (18) 0.3-2g (0.95)
THIOPENTONE 3.8% (1) 1mg
VALPROATE 3.8% (1) 800mg
MIDAZOLAM 3.8% (1) 5mg
NO/MISSING DOCUMENTATION
11.5% (3) N/A
0
5
10
15
20
0-90 91-180 181-270 271-360 361-450 451-540
MINUTES
LENGTH OF TIME TO ICU ADMISSION
% O
F C
AS
ES
ORGAN SUPPORT % (n) RANGE (AVERAGE) DAYS
RESP (INVASIVE) 92.3% (24) 1-9 (2.7)
CVS 11.5% (3) 2-6 (3.6)
CRRT 0 0
EEG
Performed in 7 patients
• 2 non-convulsive status
• 2 no evidence of epileptiform discharges
• 1 alpha coma
• 1 hypoxic encephalopathy
• 1 sharp activity likely related to previous head injury and
neurosurgery
Addition of Phenytoin – 42.3%
30.7% continued on hospital discharge
Addition of Levetiracetam – 11.5%
Addition of Clobazam – 7.7%
Addition of Sodium Valproate – 3.8%
Increased dose of usual AED – 19.2%
15 patients subsequently reviewed at a
SHSCT Neurology OPC
2 patients reviewed within other NI trusts
2 patients had ongoing disability at time of
ICU discharge
25/26 patients alive at 30 days
Patients with known epilepsy under the review of a Neurologist
Serum alcohol/drugs of abuse levels checked in 92.3% of patients
Potential provoking factor identified in 69.2% of patients
Protocol generally well followed
EEG performed
Majority of patients followed up by Neurology post discharge with low rates of ongoing morbidity and mortality
Serum AED levels checked in 33.3%
Weight rarely recorded - ?sub-therapeutic
doses of Lorazepam / Phenytoin prior to
ICU admission
Only 15.4% of patients admitted to ICU
within recommenced timeframe of 90
minutes
Small sample
Retrospective
Biased selection of patients
Non-documentation / missing information from case notes
Use of AEDs very individualised
Results shared with colleagues locally at M&M meeting
Review local protocol – highlight recommendation to check serum AED levels
Record estimated / actual weight of all patients admitted with seizures
Re-audit
1. Sander JW The epidemiology of epilepsy revisited. Current Opinion in Neurology, 16, 165–70 (2003)
2. National Audit of Seizure Management in Hospitals (April 2014) 3. Brophy G et al. Guideleines for the Evaluation and Management of
Status Epilepticus. Neurocritical Care Society Status Epilepticus Guideline Writing Committee. April 2012.
4 .Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med 1998;338:970-6
5. Shorvon S. Status epilepticus: Its clinical features and treatment in children and adults. Cambridge, England: Cambridge University Press; 1994
6. Chin RFM, Neville BGR & Scott RC (2004) A systematic review of the epidemiology of status epilepticus. European Journal of Neurology, 11, 800–10.
7. SHSCT Status Epilepticus In Adults. January 2006 8. The epilepsies: the diagnosis and management of the epilepsies in
adults and children in primary and secondary care. NICE Clinical Guideline 137, 2012.
Dr G Browne
Dr C McAllister
Dr K McKnight
Dr R Forbes
Mrs H Renshaw
Mrs G Cullen
Ms E Johnston
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