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