Role of anesthetics in treating status epilepticus

Status epilepticus (SE) is a medical emergency that can lead to serious sequelae if left untreated. Benzodiazepines have become established as the first treatment of choice.¹ Benzodiazepine-refractory SE is typically treated with a nonsedating IV antiepileptic drug (AED), most frequently fosphenytoin, valproic acid, or levetiracetam. When SE is refractory to the second-line AED, continuous IV anesthetic drugs are considered, and particularly recommended in generalized convulsive SE. The myriad systemic complications that can result from the various anesthetic drug choices have been well documented.² Hence, additional nonsedating IV AEDs are often considered before anesthesia, particularly for patients with nonconvulsive SE (NCSE) who are hemodynamically stable and have not required intubation.^3,4 The rationale behind early escalation to anesthetic drugs (so-called “therapeutic coma”) is to avoid development of neuronal injury from excitotoxicity⁵ and benzodiazepine resistance associated with prolonged seizures.⁶ This practice has been called into question following a series of studies documenting higher mortality with the use of anesthetic drugs.^7–9 This has led many to shift away from early anesthesia in favor of further trials of nonsedating IV AEDs. An aerial survey of the current landscape appears muddy, and studies are urgently needed to clarify the optimal level of treatment aggressiveness in SE.