The Science Journal of the American Association for Respiratory Care

2009 OPEN FORUM Abstracts

PROLONGED USE OF ISOFLURANE IN A CHILDWITH STATUS EPILEPTICUS

Christopher Fawcett1, Stefanie Gauguet2, Brian K.Walsh1,2, JohnH. Arnold2,1; 1Respiratory Care, Children’s Hospital Boston, Boston, MA; 2Division of Critical Care, Children’s Hospital Boston, Boston, MA

Introduction: Isoflurane is a commonly used inhalational anesthetic, but it is rarely used in the ICU setting, except for cases of severe status asthmaticus or status epilepticus refractory to conventional medical management. Historically, many of the anesthetic ventilators have performed appropriately at delivering and conserving anesthetic agents, but were unable to properly ventilate the spontaneously breathing child. We report the prolonged use of isoflurane in the ICU for management of a patient with intractable seizures. In this case, the desired effect of isoflurane was to achieve and maintain burst suppression while minimizing adverse effects. Case Summary: A 3 year old previously healthy male with a 2 week history of intractable seizures progressing to uncontrollable status epilepticus. Treatment for this patient was complicated by severe allergic and idiosyncratic hypersensitivity to most antiepileptic drugs. In an attempt to achieve seizure control, he was electively intubated and sedated with escalating doses of midazolam, which became progressively less effective. He was then switched to a Servo 900c ventilator with an attached isoflurane vaporizer and isoflurane was titrated to achieve burst suppression successfully (Figure 1). By day 13, however, the length of treatment and the continuously escalating dose of isoflurane required to maintain seizure control was concerning to elicit potential adverse effects (Figure 2). A ketamine infusion was added which allowed weaning of the inhaled isoflurane to lower levels. Ultimately, the patient was diagnosed with cortical dysplasia per brain biopsy and subsequently underwent a successful temporal lobe resection with resulting post operative neurological deficits. The isoflurane was weaned off after a total course of 26 days and the patient was discharged to a rehabilitation hospital. He suffered no adverse effects clearly attributable to the prolonged isoflurane use. Discussion: The delivery of isoflurane at reliable, titratable doses while allowing appropriate ventilation over a several week course was challenging due to technical difficulties using a Servo 900c anesthesia machine, which is more difficult to trigger than modern ventilators and has difficulty with the conservation of anesthetic agents. We recommend the use of closed-loop anesthetic work stations, such as the Draeger Apollo for patients requiring treatment with prolonged inhaled anesthetics and ventilator support in the ICU setting. Sponsored Research - None

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