Anesthetic agents in the management of status epilepticus: Current perspectives

Status epilepticus (SE) is a life-threatening neurological emergency characterized by prolonged or recurrent seizures without return to baseline consciousness. Failure to terminate seizure activity promptly can lead to neuronal injury, metabolic derangements, and long-term cognitive deficits. First-line treatment typically includes benzodiazepines, followed by intravenous antiepileptic drugs (AEDs); however, approximately 30 % of cases become refractory (RSE), necessitating the use of anesthetic agents. The evolving neurochemical profile of SE—including GABA-A receptor internalization and NMDA receptor upregulation—renders standard AEDs ineffective, highlighting the need for agents with broader mechanisms of action. Anesthetic agents such as midazolam, thiopental, propofol, and ketamine are critical in managing RSE and super-refractory SE. These agents enhance inhibitory neurotransmission, suppress excitatory pathways, and modulate cortical excitability, often titrated to achieve burst suppression on continuous EEG (cEEG) monitoring. Midazolam offers rapid onset and a favorable safety profile, whereas thiopental provides profound cortical suppression but carries risks of hypotension and delayed recovery. Propofol enables rapid titration and recovery but is associated with the rare but fatal propofol infusion syndrome. Ketamine's NMDA antagonism is particularly beneficial in late-stage SE. Inhalational agents like isoflurane and adjuncts like dexmedetomidine show promise but require further validation. cEEG plays a pivotal role in guiding anesthetic titration and monitoring for non-convulsive seizures. Despite advances, optimal agent selection, dosing strategies, and treatment duration remain inadequately defined. Further randomized controlled trials are essential to refine anesthetic protocols and improve outcomes in SE. This review explores the rationale, efficacy, and practical considerations for anesthetic use in SE management.