During the coronavirus disease 2019 (COVID-19) pandemic, clinicians will be challenged by a lack of ICU resources and ventilators to manage patients with status epilepticus (SE), according to authors of an editorial in Epilepsy and Behavior. In their editorial, the authors provide some recommendations for clinicians who are faced with treating patients with COVID-19 and/or SE.

To make room for patients with the infection, the authors of this editorial emphasize the need for shorter ICU stays, proactive neurologic decision-making, and thorough assessment of the appropriateness of SE referrals to the ICU. Ways to accomplish these goals would be to increase education related to diagnostics, supply appropriate rescue medication to patients with SE and their caregivers, and use benzodiazepines or second-line parenteral non-sedating therapies in cases of ambulatory forms of non-convulsive SE.

Current tools to identify prognosis in patients with SE are somewhat limited because of their moderately good positive predictive value for poor outcomes. According to the authors of the editorial, the epidemiology-based mortality score in SE (ESME) was capable of predicting 90% of deaths in a cohort of patients with SE and was superior to the SE Severity Score (STESS) in a previous study. The ESME accounts for etiology, age, comorbidity, electroencephalogram findings, and consciousness impairment.

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In regard to patients who present with COVID-19 and concomitant SE, the editorial’s authors suggest a significant challenge will be potential drug-drug interactions between anti-seizure drug (ASD) and trial drug agents. Some agents, they argue, may increase the risk of cardiac arrythmia. They advise careful monitoring of patients with SE and COVID-19, particularly since extracorporeal membrane oxygenation, if used, may lead to unpredictable pharmacokinetics.

Considering SE and COVID-19 are both associated with significant morbidity and mortality and both conditions share similar ICU care durations, the authors of this editorial state that patients presenting with either condition should receive fair consideration for ICU care. They suggest palliative care should be consulted early in cases where a terminal prognosis is likely. Overall, a multidisciplinary team-based approach is recommended for ICU care of patients with SE in the COVID-19 era, rather than reliance on individual choices made by a single clinician.

These multi-disciplinary teams should “use creative solutions, non-sedating ASDs, and risk-benefit calculations when embarking on emergency SE management in this resource-constrained time,” the editorial’s authors concluded.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Kinney MO, Brigo F, Kaplan PW, et al. Optimizing status epilepticus care during the COVID-19 pandemic [published online April 14, 2020]. Epilepsy Behav. doi: 10.1016/j.yebeh.2020.107124