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Purpose of Review <p>To enhance awareness of practice guidelines for the treatment of established convulsive status epilepticus (CSE) and to recommend their use wherever possible. To critically review the literature on the use of standard non-anesthetizing antiseizure medications (ASMs) versus continuous infusion anesthetizing drugs (CIVADs) for the treatment of refractory SE (RSE).</p> Recent Findings <p>A 2026 French national study reported a hospitalization rate for SE of 15.6/100,000 persons and a 1-year mortality rate of 36%. Many new studies, including a randomized, controlled trial (RCT), support the American Epilepsy Society’s treatment guideline for children and adults with established CSE. Numerous new reports show that full, weight-based doses of benzodiazepines should be administered per CSE guidelines to avoid patient harm. Multiple observational studies have documented benefits and harms with the use of CIVADs in 3<sup>rd</sup> phase treatment of convulsive RSE and non-convulsive SE (NCSE) with coma. Although many clinicians favor CIVADs, equipoise exists as to whether standard ASMs might suffice as the initial treatment of convulsive RSE for many patients. Convulsive RSE often evolves to NCSE with coma, and both are commonly treated with CIVADs despite the lack of class I RCTs comparing CIVADs to standard non-anesthetizing ASMs. Continuous EEG monitoring is highly desirable, but not available in many countries and hospitals, for diagnosis and to assist with CIVAD dosing and weaning decisions. Many healthcare disparities exist globally in the diagnosis and treatment of SE. Two new class I RCTs are underway, as are new clinical practice guidelines.</p> Summary <p>Prompt first-phase treatment of CSE should include full doses of an IV or IM benzodiazepine. Recommended second phase treatment is a full loading dose of IV levetiracetam, fosphenytoin, or valproate (or if none of these are available, phenobarbital) per evidence-based guidelines. For convulsive RSE, third-phase treatment could include IV bolus fosphenytoin, lacosamide, levetiracetam, or valproate, or IV infusion ketamine, midazolam, pentobarbital (thiopental, in Europe), or propofol based on the clinical situation, the ASM used in the second phase, drug and intubation availability, availability of continuous EEG monitoring, and the health care provider’s experience and comfort using these non-anesthetizing or anesthetizing drugs. Lacosamide and the CIVADs have shown efficacy in convulsive RSE. CIVADs are often used in the treatment of nonconvulsive RSE with coma which may occur from the onset or may follow convulsive RSE. Complete or marked reduction of electrographic seizure patterns on EEG is probably a useful efficacy outcome indicating that it is reasonable to begin weaning CIVADs. A large, prospective, randomized trial of standard ASMs versus CIVADs for the treatment of convulsive RSE is needed.</p>

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Continuous Infusions of IV Anesthetizing Antiseizure Medications for the Treatment of Refractory Status Epilepticus: A Critical Review

  • 期刊论文

  • 发表日期：

    2026年7月13日

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  • DG Vossler,
  • M. Raghavan

摘要

Purpose of Review

To enhance awareness of practice guidelines for the treatment of established convulsive status epilepticus (CSE) and to recommend their use wherever possible. To critically review the literature on the use of standard non-anesthetizing antiseizure medications (ASMs) versus continuous infusion anesthetizing drugs (CIVADs) for the treatment of refractory SE (RSE).

Recent Findings

A 2026 French national study reported a hospitalization rate for SE of 15.6/100,000 persons and a 1-year mortality rate of 36%. Many new studies, including a randomized, controlled trial (RCT), support the American Epilepsy Society’s treatment guideline for children and adults with established CSE. Numerous new reports show that full, weight-based doses of benzodiazepines should be administered per CSE guidelines to avoid patient harm. Multiple observational studies have documented benefits and harms with the use of CIVADs in 3rd phase treatment of convulsive RSE and non-convulsive SE (NCSE) with coma. Although many clinicians favor CIVADs, equipoise exists as to whether standard ASMs might suffice as the initial treatment of convulsive RSE for many patients. Convulsive RSE often evolves to NCSE with coma, and both are commonly treated with CIVADs despite the lack of class I RCTs comparing CIVADs to standard non-anesthetizing ASMs. Continuous EEG monitoring is highly desirable, but not available in many countries and hospitals, for diagnosis and to assist with CIVAD dosing and weaning decisions. Many healthcare disparities exist globally in the diagnosis and treatment of SE. Two new class I RCTs are underway, as are new clinical practice guidelines.

Summary

Prompt first-phase treatment of CSE should include full doses of an IV or IM benzodiazepine. Recommended second phase treatment is a full loading dose of IV levetiracetam, fosphenytoin, or valproate (or if none of these are available, phenobarbital) per evidence-based guidelines. For convulsive RSE, third-phase treatment could include IV bolus fosphenytoin, lacosamide, levetiracetam, or valproate, or IV infusion ketamine, midazolam, pentobarbital (thiopental, in Europe), or propofol based on the clinical situation, the ASM used in the second phase, drug and intubation availability, availability of continuous EEG monitoring, and the health care provider’s experience and comfort using these non-anesthetizing or anesthetizing drugs. Lacosamide and the CIVADs have shown efficacy in convulsive RSE. CIVADs are often used in the treatment of nonconvulsive RSE with coma which may occur from the onset or may follow convulsive RSE. Complete or marked reduction of electrographic seizure patterns on EEG is probably a useful efficacy outcome indicating that it is reasonable to begin weaning CIVADs. A large, prospective, randomized trial of standard ASMs versus CIVADs for the treatment of convulsive RSE is needed.