Super-Refractory Status Epilepticus Diagnosis, Management, and Prognostication

Guidelines for super-refractory status epilepticus (SRSE) evaluation, management, and prognostication are lacking. Characterization of practice patterns could identify trends and potential areas for future inquiry. We surveyed clinicians who manage SRSE to better understand practice approaches to SRSE evaluation, management, and prognostication. We conducted an international cross-sectional 66-question, web-based survey of clinicians who manage SRSE, distributed through 4 scientific societies from August 3, 2023, through January 25, 2024. We collected data regarding SRSE diagnostics and management. We examined prognostic approaches based on 2 clinical vignettes. We characterized responses using descriptive statistics and developed logistic regression models to identify key factors associated with prognostication. Of 245 participants, 36 were excluded because of no clinical involvement with SRSE and 209 were included; 41 (20%), 66 (32%), and 84 (40%) participants were neurologists, neurointensivists, and general intensivists, respectively, 83% of whom practiced in the United States. For IV anesthetic treatment, midazolam (n = 47, 38%) and propofol (n = 42, 34%) were most often selected as first line while ketamine was most often 2nd (n = 34, 26%) or 3rd (n = 52, 41%) line. Regarding electroencephalography targets for IV treatment, burst suppression (n = 96, 47%) or seizure suppression (n = 70, 34%) was most popular. This goal was maintained for a median of 49.5 hours (interquartile range 29.8-74 hours) before weaning. Regarding prognostication, of 147 respondents, 75 (51%) reported an ability to predict favorable prognosis, which was associated with neurology (OR: 4.4, 95% CI 1.5-13.5) or general intensivist (OR: 4.6, 95% CI 1.6-14) practice vs neurocritical care (reference, fewer than 5 years of experience (OR: 3.9, 95% CI 1.6-10); higher annual SRSE case load (OR: 2.9, 95% CI 1.7-7.3); and use of clinical severity scores (OR: 4.7, 95% CI 2-11.4). Time to determine futility and recommendations for withdrawal of life-sustaining therapy (WLST) followed bimodal distributions, with early (0-4 weeks) and delayed (26 weeks) modes. Prognostic optimism was associated with delayed determination of futility and recommendation for WLST (OR: 6.2, 95% CI 2.2-19.3). There is significant variability in the evaluation and management of SRSE, including treatment preferences, targets, and duration of therapy. Prognostication is associated with multiple clinician-related factors. The timing of prognostication is highly variable and is associated with clinician optimism.