Super-refractory status epilepticus: A therapeutic challenge in paediatrics

A status epilepticus which persists for 24 hours or more after starting treatment with anaesthesia or has recurred inspite of general anesthesia is known as Super-Refractory Status Epilepticus (SRSE). It includes cases where status epilepticus recurs on reduction or withdrawal of anaesthesia. SRSE, though infrequently seen, constitutes a medical emergency due to the associated high morbidity and mortality. No clear cut guidelines are available till date for the management of SRSE. Most of the published literature was case reports and expert opinion. We hereby reported three cases of super refractory seizures as they posed a therapeutic challenge. All three children were aged 6-7 years with prior normal developmental history and no medical illness. Viral meningoencephalitis, fever induced refractory status epilepticus, and auto-immune encephalitis was the probable aetiology in the cases studied. Midazolam, pentobarbital, and ketamine are the most commonly used anaesthetic agents. Phenytoin, phenobarbitone, valproate and levetiracetam are the most commonly used antiepileptic agents. All three cases had residual neurological deficits and morbidities like pneumonia and sepsis. SRSE is associated with high rates of mortality and morbidity necessitating immediate treatment.