The Unease When Using Anesthetics for Treatment-Refractory Status Epilepticus: Still Far Too Many Questions

Status epilepticus (SE), treatment-refractory status epilepticus (RSE), and super-treatment-refractory status epilepticus (SRSE) are associated with increased morbidity, mortality, and high socioeconomic burden and pose significant treatment challenges for intensivists and neurologists. To optimize and streamline emergency treatment, current practice guidelines recommend the use of continuously delivered intravenous anesthetic drugs such as midazolam, propofol, or barbiturates as the third-line therapy after first-line and second-line treatments have failed. Although the rationale for these third-line drugs seems intuitive at first glance, there is a clear paucity of evidence-based data on risks, benefits, and even on the choice of a third-line agent. Recent studies into safety and efficacy reveal disturbing results, such as a poor outcome and higher mortality associated with the use of intravenous anesthetic drugs, especially in patients with nonconvulsive SE without coma and in patients with out-of-hospital SE onset. Clinicians should deliberately weigh the advantages and disadvantages of intravenous anesthetic drug therapy in patients with different types of SE usually linked to a favorable outcome (i.e., simple partial, complex partial, or absence seizures). The lack of data to support evidence-based medicine prompts a careful balance of individual risks and benefits of intravenous anesthetic drug therapy in patients with SE, treatment-refractory SE, and super-RSE.