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The article by Alvarez et al.1 compared the use of therapeutic coma (TC) for status epilepticus (SE) in tertiary care centers belonging to Harvard Affiliated Hospitals (HAH) and the Centre Hospitalier Universitaire Vaudois (CHUV). TC for SE was used more in HAH hospitals as compared to CHUV, and did not affect mortality, but resulted in increased length of stay and related costs.1 I frequently advise residents to avoid a shotgun approach (hasty use of wide-ranging, nonselective, and haphazard techniques) to SE treatment. Evidence-based standardized protocols need to be followed, but treatment must be tailored to the patient. Benzodiazepines (first-line) and nonsedating antiseizure drugs (ASD) should be dosed based on weight and at the recommended rate to rapidly achieve therapeutic CNS concentrations. A second loading dose of the initial nonsedating ASD, such as phenytoin (usually half the initial loading dose), or a second ASD (i.e., levetiracetam, valproic acid, levetiracetam, lacosamide) sometimes terminates SE. The decision to use TC in patients who are in electrographic partial SE or displaying electrographic patterns thought to be in the interictal to ictal continuum, such as periodic lateralized discharges and generalized epileptiform discharges, needs to be individualized after carefully considering the risk–benefit profile.
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Author disclosures are available upon request (journal{at}neurology.org).
- © 2017 American Academy of Neurology
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