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
1. CRAIGAVON AREA HOSPITAL
INTENSIVE CARE UNIT
COPPEL PRIZE PRESENTATION 2014
NORTHERN IRELAND INTENSIVE CARE SOCIETY
CATHERINE POOTS
CT1 ACCS 26/10/2014
2. 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
3. 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?
4. 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
5. 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
6. 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
13. 20
15
10
5
0
LENGTH OF TIME TO ICU ADMISSION
0-90 91-180 181-270 271-360 361-450 451-540
MINUTES
% OF CASES
14. 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
15. 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%
16. 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
17. 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
18. 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
19. Small sample
Retrospective
Biased selection of patients
Non-documentation / missing information
from case notes
Use of AEDs very individualised
20. 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
21. 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.
22. Dr G Browne
Dr C McAllister
Dr K McKnight
Dr R Forbes
Mrs H Renshaw
Mrs G Cullen
Ms E Johnston
Editor's Notes
The incidence of SE has been estimated at 4-27 cases per 100 000 per year however given that many cases of non-convulsive status often go unrecognised particularly in the learning disabled population, this may well be an underestimate. Mortality is approximately 3% if seizure duration is under 1 hour, up to 40% if seizure duration over one hour.
.
The definition of SE has changed over the years – currently (as defined by the Neurocritical Care Society in 2012) it is 5 min or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures. Spontaneous termination becomes less likely in seizures lasting > 5 min, and the longer the seizure continues, the more difficult it is to control the seizure with antiepileptic drugs (AEDs) and the greater the degree of neuronal damage
SE should be classified as either convulsive SE – tonic, clonic or tonic-clonic activity and is associated with a loss of consciouness or non-convulsive – ongoing seizure activity for at least 30mins without major motor signs but a change in cognition or behaviour. Diagnosis is on clinical suspicion and EEG confirmation.
RSE is defined as continuous or repetitive seizures lasting longer than 60 min despite treatment with a benzodiazepine (lorazepam) and another standard anticonvulsant (usually phenytoin/fosphenytoin) in adequate loading dose.
Aim – Overall aim was to examine the management of patients admitted to ICU with SE/uncontrolled seizures before, during and after admission.
Audit objectives
1. Was there a preventable reason for SE?
2. Was the local protocol for management of SE adhered to prior to ICU admission?
3. Were patients admitted to ICU within the recommended timeframe
3. What was the resource utilisation of patients admitted to ICU (including EEG)?
4. 30 day mortality and Neurology follow up
Local guidelines suggest
Premonitory - 10mg Diazepam PR or Midazolam 10mg PO repeated after 15minutes if needed.
Early - IV Lorazepam 0.07mg/kg repeated once after 10minutes.
Established Status (10-30mis) - Phenytoin IV at 15mg/kg or Fosphenytoin
Refractory (.>30mins) – Phenobarbitone 10mg/kg then if still seizing 30mins from onset propofol, midazolam, thiopentone general anaesthesia.
Recommended that patients still seizing 30minutes after admission should be admitted to ICU for management however local guidelines acknowledge that in practice it may take 60-90minutes before a patient is ready to be admitted to ICU.
A retrospective audit undertaken using the ICNARC database to identify all patients admitted to ICU between 01/08/10 and 31/07/13 who had a diagnosis of status epilepticus or uncontrolled seizures – 78 patients.
To minimise number of charts needed to be pulled accessed PAS and identified those patients who were seen at Neurology OPC either before or after admission – 26 patients included in the audit.
Data collected by single auditor from patient medical and neurology case notes and entered into Microsoft Excel worksheet
Number of patients: 26 (13 male, 13 female)
Age range: 19 – 82 (Av 44.538yrs)
All 15 patients known to have epilepsy (as diagnosed by a Consultant Neurologist) had been previously reviewed at Neurology Outpatient clinic.
The most common AEDs prior to admission were Keppra and Epilim.
7 patients were on a monotherapy regime and 9 patients were on a polytherapy regime with 4 taking 2 agents, 4 taking 3 agents and 1 taking 4 agents.
Only 5 patients known to have epilepsy had serum AED levels measured on admission, 2 of these had subtherapeutic levels.
92.3% of patients had serum alcohol level taken on admission. Other alcohol levels 70, 238, 363.
69.2% of patients had a potential provoking factor for their seizures.
30% of patients had documented receipt of Diazepam equivalent either with NIAS or in A&E.
73% of patients received IV Lorazepam at an appropriate dose.
69% of patients also received Pheyntoin, 4 of these patients received doses less than 1g.
1 DHH transfer received Thiopentone prior to transfer, 1 patient received IV Valproate and 1 received IV midazolam,
In 3 sets of case notes there was no record of treatment received prior to ICU admission.
Time to ICU admission ranged between 84minutes and 510 minutes.
There was insufficient documentation to calculate time between ICU referral and ICU admission in 7 sets of case notes.
Average length of ICU admission was 3.66 days (range 6 hours to 11 days).
92.3% of patients admitted to ICU required invasive ventilatory support, 11.5% required inotropic support an none required CRRT.1 patient was intubated due to respiratory depression following 20mg Diazepam and 4mg Lorazepam with NIAS/A&E.
2 patients with ongoing disability - 1 had increased cognitive dysfunction on a BG of previous embolisation of right sided AV malformation and 1 was subsequently diagnosed with a Grade 3 Glioma.
The patient who died was a 57year old male admitted with increased seizure activity on a BG of traumatic brain injury.
Of these three patients times to ICU admission were 90, 285 (DHH T/F) and 90 minutes respectively.
Reason for delayed ICU admission include 7 transfers from DHH – transfer times ranged between 180 and 510minutes with an average of 354minutes.
7 patients initially admitted to CAH also had CT Brain scans – their times to ICU admission ranged between 85 and 300minutes – average 157minutes.
In 1 set of case notes there was a documented delay whilst awaiting a bed to become available
7 sets of case notes there was insufficient documentation to establish the time course between referral to ICU and subsequent admission.
Local guidelines recommend checking anti-convulsant levels within 60minutes of admission to asses compliance with prior prescriptions. CAH guidelines also comment on the common practice of giving 1000mg without considering the weight of the patient and how this may result in suboptimal cerebral levels.