Alvarez Vincent, Lee Jong Woo, Westover M Brandon, Drislane Frank W, Novy Jan, Faouzi Mohamed, Marchi Nicola A, Dworetzky Barbara A, Rossetti Andrea O
From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland.
Neurology. 2016 Oct 18;87(16):1650-1659. doi: 10.1212/WNL.0000000000003224. Epub 2016 Sep 24.
Our aim was to analyze and compare the use of therapeutic coma (TC) for refractory status epilepticus (SE) across different centers and its effect on outcome.
Clinical data for all consecutive adults (>16 years) with SE of all etiologies (except postanoxic) admitted to 4 tertiary care centers belonging to Harvard Affiliated Hospitals (HAH) and the Centre Hospitalier Universitaire Vaudois (CHUV) were prospectively collected and analyzed for TC details, mortality, and duration of hospitalization.
Two hundred thirty-six SE episodes in the CHUV and 126 in the HAH were identified. Both groups were homogeneous in demographics, comorbidities, SE characteristics, and Status Epilepticus Severity Score (STESS); TC was used in 25.4% of cases in HAH vs 9.75% in CHUV. After adjustment, TC use was associated with younger age, lower Charlson Comorbidity Index, increasing SE severity, refractory SE, and center (odds ratio 11.3 for HAH vs CHUV, 95% confidence interval 2.47-51.7). Mortality was associated with increasing Charlson Comorbidity Index and STESS, etiology, and refractory SE. Length of stay correlated with STESS, etiology, refractory SE, and use of TC (incidence rate ratio 1.6, 95% confidence interval 1.22-2.11).
Use of TC for SE treatment seems markedly different between centers from the United States and Europe, and did not affect mortality considering the whole cohort. However, TC may increase length of hospital stay and related costs.
This study provides Class III evidence that for patients with SE, TC does not significantly affect mortality. The study lacked the precision to exclude an important effect of TC on mortality.
我们的目的是分析和比较不同中心对难治性癫痫持续状态（SE）使用治疗性昏迷（TC）的情况及其对预后的影响。
前瞻性收集并分析了隶属于哈佛附属医院（HAH）和沃州大学中心医院（CHUV）的4家三级医疗中心收治的所有连续成年（>16岁）SE患者（病因不限，缺氧后除外）的临床数据，以获取TC详情、死亡率和住院时间。
在CHUV识别出236例SE发作，在HAH识别出126例。两组在人口统计学、合并症、SE特征和癫痫持续状态严重程度评分（STESS）方面具有同质性；HAH中25.4%的病例使用了TC，而CHUV中为9.75%。调整后，TC的使用与年龄较小、Charlson合并症指数较低、SE严重程度增加、难治性SE以及中心有关（HAH与CHUV相比优势比为11.3，95%置信区间为2.47 - 51.7）。死亡率与Charlson合并症指数增加、STESS、病因和难治性SE有关。住院时间与STESS、病因、难治性SE和TC的使用相关（发病率比为1.6，95%置信区间为1.22 - 2.11）。
美国和欧洲中心之间对SE治疗使用TC的情况似乎明显不同，并且考虑整个队列时对死亡率没有影响。然而，TC可能会增加住院时间和相关费用。
本研究提供了III类证据，表明对于SE患者，TC不会显著影响死亡率。该研究缺乏排除TC对死亡率重要影响的精确性。
