Ketamine Infusion in the Management of Refractory Status Epilepticus Following Cardiac Arrest: A Case Report

Abstract

Objective: Refractory status epilepticus (RSE) is a neurological emergency characterized by high morbidity and mortality, defined as the failure of first- and second-line antiepileptic drugs. RSE occurring in the post-cardiac arrest period poses additional therapeutic challenges due to hemodynamic instability. This case report aims to present a patient who developed RSE after cardiac arrest and achieved successful seizure control with ketamine infusion and to discuss the efficacy and safety of ketamine in this context with a review of the literature. Case: In the emergency department, he had a second cardiac arrest and underwent CPR, and during this period, generalized tonic-clonic seizures were observed, prompting intravenous diazepam administration. The patient was sedated with midazolam and fentanyl infusions in the intensive care unit. Neurology consultation led to the initiation of levetiracetam and valproate. Despite these treatments, focal myoclonic seizures persisted and increased in frequency. Anesthesiology recommended propofol infusion, but due to hypotension (related to underlying sepsis), propofol was contraindicated. On the 4th day of admission, ketamine infusion was started at 1 mg/kg/h; after minimal reduction in seizure frequency, the dose was increased to 1.5 mg/kg/h. Seizure frequency, hemodynamic parameters, and adverse effects were monitored. Conclusion: In this case, ketamine infusion provided effective seizure control without significant adverse effects. The effective dose of 1.5 mg/kg/h was consistent with the literature, supporting ketamine as a safe and effective alternative in RSE. Early consideration of ketamine infusion may be beneficial in preventing neuronal damage when other anesthetic agents cannot be used.

Keywords

• Refractory status epilepticus
• Ketamine
• Post-cardiac arrest period

Kardiyak Arrest Sonrası Gelişen Refrakter Status Epileptikus Yönetiminde Ketamin İnfüzyonu: Olgu Sunumu

Abstract

Amaç: Refrakter status epileptikus (RSE), birinci ve ikinci basamak antiepileptik tedavilere yanıt vermeyen, yüksek morbidite ve mortalite ile seyreden nörolojik bir acildir. Özellikle postkardiyak arrest dönemde gelişen RSE’de hemodinamik instabilite tedavi seçeneklerini kısıtlamaktadır. Bu vaka sunumunda, kardiyak arrest sonrası gelişen ve konvansiyonel tedavilere dirençli nöbetlerin ketamin infüzyonu ile başarılı şekilde kontrol altına alındığı bir olgu sunularak, ketaminin bu hasta grubundaki etkinliği ve güvenilirliğinin literatür eşliğinde tartışılması amaçlanmıştır. Olgu: Acil serviste ikinci kez kardiyak arreste giren hastaya yeniden KPR uygulandı ve bu sırada jeneralize tonik-klonik nöbet gözlenmesi üzerine intravenöz diazepam uygulandı. Hastanın izleminde midazolam ve fentanil infüzyonu ile sedasyon sağlanırken, nöroloji konsültasyonu ile levetirasetam ve valproat tedavisi başlandı. Ancak nöbetler (fokal miyoklonik) devam etti ve sıklığı arttı. Anestezi kliniği propofol infüzyonu önerdi, ancak hasta hipotansif olduğu için propofol başlanamadı. Bunun üzerine izlemin 4. gününde ketamin infüzyonu (1 mg/kg/saat) başlandı, nöbetlerde kısmi azalma olunca doz 1,5 mg/kg/saat’e yükseltildi. Nöbet sıklığı, hemodinamik parametreler ve olası yan etkiler kaydedildi. Sonuç: Bu vakada, ketamin infüzyonu ile başarılı nöbet kontrolü sağlanmış ve ciddi bir yan etki gözlenmemiştir. Literatürde bildirilen etkili doz aralığıyla uyumlu olarak 1,5 mg/kg/saat dozunda ketamin, güvenli ve etkili bir seçenek olarak değerlendirilebilir. RSE tedavisinde, özellikle diğer anestezik ajanların kullanılamadığı durumlarda, ketamin infüzyonunun erken dönemde düşünülmesi nöronal hasarı önlemede önemli olabilir.

Keywords

• Refrakter status epileptikus
• Ketamin
• Postkardiyak arrest dönem

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