Department of Neurology, Erasme Hospital, Université Libre de Bruxelles, Bruxelles, Belgium.
Department of Neurology, Erasme Hospital, Université Libre de Bruxelles, Bruxelles, Belgium -
Minerva Anestesiol. 2017 Aug;83(8):878-887. doi: 10.23736/S0375-9393.17.11884-5. Epub 2017 May 11.
Seizures and status epilepticus (SE), both clinical and subclinical, are frequent in critically ill patients. The list of available antiseizure medications (ASMs) is expanding and now includes older and widely used drugs as well as more recent medications with a better safety and pharmacokinetics profile.
We review a selection of recent publications about the indications and administration of ASMs in critical care for the prophylaxis and treatment of seizures and SE, focusing on recent ASMs available as intravenous formulation and emphasizing pharmacokinetics and safety issues in relation to several aspects of critical illness.
Levetiracetam, lacosamide and more recently brivaracetam, represent interesting alternatives to older ASMs, mostly due to a more favorable safety and pharmacokinetic profile. Low-quality studies suggest that this profile results in better tolerability in treated patients. Ketamine might represent a useful addition in our anesthetic armamentarium for refractory SE, due to its different mechanism of action and cardiovascular properties. Little evidence is available however to support the prophylactic use of ASMs in critically ill patients, except in specific settings (traumatic brain injury and subarachnoid hemorrhage). Head-to-head studies comparing recent and older ASMs in the treatment of acute seizures and SE are ongoing or awaiting publication. Administration of ASMs to critically ill patients needs to be adapted to organ dysfunction, and especially to renal dysfunction for recent drugs.
Recent ASMs and could represent better treatment choices in critically ill patients than older ones but this needs to be confirmed in randomized controlled studies. In general, further studies are required to clarify the indications and optimal use of ASMs in the critical care setting.
无论是临床发作还是亚临床发作，癫痫发作和癫痫持续状态（SE）在重症患者中都很常见。可供选择的抗癫痫药物（ASMs）的清单正在不断扩大，现在包括了更老的、广泛使用的药物以及具有更好安全性和药代动力学特征的更新药物。
我们回顾了一些关于 ASMs 在重症监护中用于预防和治疗癫痫发作和 SE 的最新出版物，重点介绍了最近可作为静脉制剂使用的 ASMs，并强调了与重症疾病的几个方面相关的药代动力学和安全性问题。
左乙拉西坦、拉考沙胺和最近的溴维曲坦代表了对老一代 ASMs 的有趣替代，主要是由于它们具有更有利的安全性和药代动力学特征。低质量的研究表明，这种特征在治疗患者中可提高耐受性。氯胺酮可能因其不同的作用机制和心血管特性而成为难治性 SE 治疗中有用的附加药物。然而，除了在特定情况下（创伤性脑损伤和蛛网膜下腔出血）外，目前几乎没有证据支持在重症患者中预防性使用 ASMs。比较最近和老一代 ASMs 在急性癫痫发作和 SE 治疗中的头对头研究正在进行或等待发表。对重症患者给予 ASMs 的治疗需要适应器官功能障碍，尤其是最近的药物对肾功能障碍的适应。
与老一代 ASMs 相比，最近的 ASMs 可能代表了重症患者更好的治疗选择，但这需要在随机对照研究中得到证实。一般来说，需要进一步的研究来阐明 ASMs 在重症监护环境中的适应症和最佳使用方法。
