Anesthetics in status epilepticus: does one size fits it all?—A scoping review on titration goals, timing, and patient selection

Status epilepticus (SE) is a neurological emergency with significant morbidity and mortality. Refractory status epilepticus (RSE) occurs in 20-30% of cases and may require treatment escalation to continuously administered intravenous anesthetic drugs (CIVAD). Despite widespread use, fundamental questions remain unresolved regarding optimal anesthetic management. This narrative scoping review examines CIVAD use in non-anoxic adult SE, focusing on three critical questions: What is the optimal titration goal? When should CIVADs be initiated and discontinued? Which patients benefit from CIVAD therapy? Regarding titration targets, current evidence does not support burst suppression as superior to seizure cessation for most RSE patients. Regarding timing, studies examining first- or second-line CIVAD administration have shown conflicting results, although a delayed initiation when used as a third-line treatment is associated with worse outcomes. Patient selection remains particularly challenging, as limited evidence supports aggressive CIVAD use in refractory nonconvulsive SE (NCSE) without coma or focal motor SE, whereas individualized approaches appear necessary for high-risk populations, such as NCSE with coma. The available evidence consists primarily of observational studies with inherent limitations. CIVAD therapy requires individualized decision-making based on SE type, patient characteristics, and etiology rather than standardized protocols. Future research should focus on prospective studies, advanced EEG analytics, and identification of robust biomarkers to enable precision medicine approaches in RSE management.