Status epilepticus...

Re: Status epilepticus...

vs0u — Sun, 06 Mar 2011 20:42:51 GMT

[quote user="Anthony Todd"]Um, the short action is the big, and only[?] disadvantage of diazepam isn't it??[/quote]

depends if the fitting restarts once it wears off 15 mins later which it often doesn't! in an ideal world, the fit stops after diazepam p.r. allowing time for a nice clean catheter placement, blood samples, drip, discussion of costs and signing of consent forms before it wears off...

[quote user="Anthony Todd"]And I/V in a SE dog isn't that difficult IMHO[/quote]

Not impossible, but in a large vigorously moving dog can be tricky, even more so in a cat especially if no nurse on hand (I think so anyway - others may have superior skills!)

Re: Status epilepticus...

Anthony Todd — Sun, 06 Mar 2011 10:21:49 GMT

[quote user="alison howell"]So there are 2 advantages over phenobarb I would say. [/quote]

Um, the short action is the big, and only[?] disadvantage of diazepam isn't it??

And I/V in a SE dog isn't that difficult IMHO.

Could give diazepam by rectum if you can't get I/V then phenobarb when it is wearing off??

Re: Status epilepticus...

jamie winstone — Sat, 05 Mar 2011 21:37:38 GMT

The In Practice article was good but I felt it was a pity that Pentobarbitone usage for Status Epilepticus was not even mentioned. It seems to be a treatment that has fallen out of favour and yet it is still advocated in the latest edition of Canine Medicine and Therapeutics as being suitable.

This discussion is surely not about informing what is the best product to use but to give alternatives for difficult and varied situations,(is there anything worse than a refractory case of SE at 11pm).

I am sure that if Sagatal was still available it would be seen as a very useful adjunct to the Diazepam approach which so often only has a temporary calming effect.

Re: Status epilepticus...

vs0u — Sat, 05 Mar 2011 20:00:13 GMT

But diazepam wears off a lot quicker so avoids a hangover, also it does work well and quickly rectally in a lot of cases, and it can be hard to get a drug in iv on a fitting patient, plus it's quicker to put it rectally than mess about preparing iv stuff. So there are 2 advantages over phenobarb I would say.

I agree the in practice article was very useful!

Re: Status epilepticus...

vs0u — Sat, 05 Mar 2011 19:55:30 GMT

Phenobarb works within a few seconds - but think it theoretically takes a while to reach max effect (not that you would leave the dog fitting for 30 mins so if it did take that long it would be totally pointless!)

Re: Status epilepticus...

Anthony Todd — Sat, 05 Mar 2011 12:13:30 GMT

[quote user="phipps"]IV Phenobarb takes about 30 mins to have an effect. [/quote]

I find this really odd; pentobarb works instantly, well, within 10seconds, as does any I/V anaesthetic or euthanasial drug or diazepam so I can't understand why I/v phenobarb to effect takes 30 mins??

Or is this with a bolus and waiting??

But I've never used it, always pentobarb.

Re: Status epilepticus...

Glen McIntosh — Sat, 05 Mar 2011 10:19:47 GMT

[quote user="Anthony Todd"]Can't see why phenobarb isn't the first line of treatment instead of up to 3 slugs of diazepam [and rectally wouldn't work very quickly] particularly when she intimates that diazepam mightn't stop the seizure?[/quote]

IV Phenobarb takes about 30 mins to have an effect. Diazepam, on the other hand, will have its effects immediately and rectal administration of diazepam works almost as quickly.

Re: Status epilepticus...

Anthony Todd — Sat, 05 Mar 2011 09:25:08 GMT

[quote user="Busybee"] 'Treatment and monitoring of epilepsy in dogs' with mention of treating SE.[/quote]

Can't see why phenobarb isn't the first line of treatment instead of up to 3 slugs of diazepam [and rectally wouldn't work very quickly] particularly when she intimates that diazepam mightn't stop the seizure?

No mention of ketamine??

Re: Status epilepticus...

Busybee — Sat, 05 Mar 2011 07:55:37 GMT

This month's In Practice has a nice article about 'Treatment and monitoring of epilepsy in dogs' with mention of treating SE. Bascially:

IV or rectal diazepam 0.5-1mg/kg immediately to stop seizures, place catheter, measure serum glucose + electrolytes
Maintain temperature between 37 and 39.5C
Fluid therapy to achieve normohydration + normotension
Diazepam 0.5-1mg/kg up to three times IV or rectally
If this fails to stop seizures, give phenobarbitone as a loading protocol - 3mg/kg IV q30mins until total dose of 20mg/kg has been given; reduce dose to 3mg/kg IV q6hrs for 24hrs; reduce dose to 3mg/kg orally BID for continued long term use.
If ineffective, use propofol CRI - 4-8mg/kg bolus initially then CRI 6-12mg/kg/hr.

Re: Status epilepticus...

Malcolm Ness — Tue, 01 Mar 2011 17:25:35 GMT

A bit off thread but Arlo said I could!!

Some of you may be interested in our CPD "Roadshow" which this year is a one-day seminar on SA neurology for practitioners. We are putting this on at three venues, Wetherby, Yorkshire (24/3/11); Penrith, Cumbria (12/5/11) and Dumfries (15/9/11). A full day of CPD for £75=00 and with your lunch and some free drinks thrown in!

Details are in the CPD calender.

Re: Status epilepticus...

Anthony Todd — Tue, 01 Mar 2011 07:32:42 GMT

[quote user="Kate Richardson"]No it was a diabetic dog who then developed hypoparathyroidism.[/quote]

Wow, definitely a feather in your cap. I remain suitably chastened for trying to be a smart ar5e.

Re: Status epilepticus...

Kate Richardson — Mon, 28 Feb 2011 10:46:01 GMT

[quote user="alison howell"]

So would you keep giving it till the fitting stops? Is there a point at which it kills the animal first? I've had some cases where it didn't work at the formulary dose (cats that had bob martins) and put them on propofol after that, but can you just keep on giving phenobarb? (or pentobarb which I've never tried...)

[/quote]

I give it in incremental doses until the maximum dose is reached, then if still fitting I would use propofol. But will now consider ketamine once I've read the previous posts in more detail.

[quote user="Anthony Todd"]PS. I assume the hypocalcaemic one wasn't a whelping bitch?][/quote]

No it was a diabetic dog who then developed hypoparathyroidism. Had a few fits prior to developing SE. Still going strong 3 years later on Vit D!

Re: Status epilepticus...

Anthony Todd — Mon, 28 Feb 2011 08:08:25 GMT

[quote user="alison howell"]So would you keep giving it till the fitting stops?[/quote]

I just gave it as above [pentobarb. though not phenobarb. or any of the others] . fits stopped usually in light anaesthesia as graded by normal reflex measurement. Never euthanasied one as far as I remember.

PS. I assume the hypocalcaemic one wasn't a whelping bitch?]

Re: Status epilepticus...

vs0u — Sun, 27 Feb 2011 19:27:03 GMT

[quote user="Kate Richardson"]

We use iv phenobarbitone to good effect in most cases.

[/quote]

Re: Status epilepticus...

Kate Richardson — Sun, 27 Feb 2011 15:52:25 GMT

One point I'd like to make is to double check your blood results if not responding to routine treatment for seizures (eg diazepam)- I had one non responder seen by a colleague, all bloods reported as normal, but after 3rd diazepam, double checked the bloods, and was significantly hpocalcaemic- iv calcium stopped the seizures immediately. Just worth mentioning, not suggesting anyone is incompetent!

We use iv phenobarbitone to good effect in most cases.

Re: Status epilepticus...

Anthony Todd — Sat, 26 Feb 2011 16:33:02 GMT

[quote user="Rob Davis"]If there were subsequent CNS signs, how would you differentiate between the effects of pentobarb and those of prolonged seizure activity?[/quote]

Touche, but if you'd been plotting blood gases you'd say it was the SE, and if you hadn't you'd be pigeoned by the eminenced of us.

[Some days you're the pigeon, some days you're the statue", as has been said somewhere]

But hey, in amongst all the set positions here I've discovered that maybe phenobarb I/v to effect and ketamine may be a veterinary alternative to diazepam so, as I pleaded, a lot more anecdotal evidence will do me.

Again I ask, has anyone seen post SE with apparent recovery result in permanent CNS damage and is this linked to the drugs used to treat and/or control the SE?

Re: Status epilepticus...

Rob Davis — Sat, 26 Feb 2011 09:16:52 GMT

[quote user="Anthony Todd"]Has anyone ever seen any adverse subsequent effects from pentobarb given to effect in SE, I'm talking about subsequent CNS signs.[/quote]

If there were subsequent CNS signs, how would you differentiate between the effects of pentobarb and those of prolonged seizure activity?

Re: Status epilepticus...

Anthony Todd — Sat, 26 Feb 2011 00:38:40 GMT

[quote user="Jane Dunnett"]I'm afraid that if anyone takes the attitude of 'it's always worked for me and I've never seen a problem with it' as their main reason for choosing a treatment they belong in the same bucket as the homeopaths, herbalists and reiki therapists.[/quote]

So what are you suggesting as an alternative, sorry, better say "different", attitude? "Alternative has a sort of homeopathic ring to it....

Whereas homeopathy etc. has the advantage of the placebo effect and the passage of time giving a response it's pretty hard to get that with SE.

What the humans use, even though it seems short acting and sometimes doesn't work at all?

What research says will work and they've trialled it on the required eight beagles?

Has anyone ever seen any adverse subsequent effects from pentobarb given to effect in SE, I'm talking about subsequent CNS signs.

However, and this is what I'm trying to find out, is phenobarb [a] effective in SE and [b] has less of these apparently important potential side effects of brain damage being quoted via blood gas measurement which none of the "it's always worked for me" dinosaurs seem to have ever seen.

If it works and has less side effects, by any criterion, then we should use it instead of the now discontinued and somewhat discredited pentobarb.

Re: Status epilepticus...

jamie winstone — Fri, 25 Feb 2011 13:51:33 GMT

Some of the responses have been interesting but only really applicable for those where constant supervision is possible and by inference the cost is not the major issue.

Often clients come in with a much loved dog that has been thrashing around for some time, on occasions having had previous I/V Diazepam treatment.

In many cases the owners are on the verge of putting the dog to sleep, funds are nearly always an issue.

These cases are offered Pentobarbitone to effect, at a cost that is affordable. I do accept that this approach is "living on the edge", but the relief and amazement of all concerned, 24 hours later when invariably the dog has recovered makes it worthwhile.

As for losing a few brain cells during the process this seems a price worth paying and an advantage in some cases! A bit like me having a few too many drinks!

Re: Status epilepticus...

Bob Russell — Fri, 25 Feb 2011 10:14:15 GMT

''Aha! Got it: Waiting room for the morgue. Perfect ''

Just like Eastbourne! (sorry local joke related to 'gods waiting room').

Re: Status epilepticus...

jd2008 — Fri, 25 Feb 2011 00:57:59 GMT

[quote user="Michael Woodhouse"] You start giving people or departments titles like "emergency and critical care" and they think they have to behave like they do on ER.[/quote]

I can honestly say I have never asked for anything "stat"

If I ever do I truly hope someone has the good sense to take me aside and give me a thorough beating.

By the way, you may have a point about our title. Maybe it is time to rename our department. We need a title that conveys accurately and succinctly what we do so as not to confuse or mislead the public and which doesn't give us ideas above our station. So how about 'Place where we treat the really sick animals that require intens..' oops, can't use that word. 'Place where we see emerge..' Nope, can't say that either.

Aha! Got it: Waiting room for the morgue. Perfect

Re: Status epilepticus...

Glen McIntosh — Fri, 25 Feb 2011 00:20:32 GMT

[quote user="Jane Dunnett"]Maybe the next cat spey I do I should eschew the fancy schmancy sterilised kit with its swanky metzenbaums and haemostats and use a blunt pair of kitchen scissors and my teeth. Job will still get done so where's the problem?[/quote]

Or perhaps use the urine taste test to diagnose and treat diabetes mellitus?

Re: Status epilepticus...

jd2008 — Thu, 24 Feb 2011 22:59:10 GMT

[quote user="Michael Woodhouse"]It's all well and good having all your fancy blood gasses and slowly exanguating your patients, but do more go home better? I worry that some of the ventilation/gasses etc are to utilise the expensive bit of kit rather than always for the benefit of the patient. You start giving people or departments titles like "emergency and critical care" and they think they have to behave like they do on ER.[/quote]

Umm. Not saying I'm any better than anyone else on here.

Do more go home better? That's what we don't know as we cannot assess cognitive function accurately in dogs. We can only extrapolate from our knowledge that prolonged hypercapnia and hypoxaemia has the potential to cause CNS damage so it seems a good idea to try and avoid it if we have the ability to do so.

I did say I had the luxury of having blood gas analysis available. I'm well aware (coming from 16 years in good ol' general practice - see, I'm just like you) that this is not available in your average practice.

What I'm clumsily trying to point out is that just because your patient looks good from the outside (pink, breathing, not seizuring anymore) we run the risk of assuming that the treatment we've given has caused no harm. Choosing a less globally neurodepressant drug (i.e. phenobarb rather than pentobarb) first makes much more sense for our patients' welfare.

I'm afraid that if anyone takes the attitude of 'it's always worked for me and I've never seen a problem with it' as their main reason for choosing a treatment they belong in the same bucket as the homeopaths, herbalists and reiki therapists.

I use my 'expensive bits of kit' because they allow me to more accurately tailor my treatment to provide the best possible outcome for my patient so no need to be worried, Michael. They help me spot problems at an early stage and take steps to rectify those problems.

Maybe the next cat spey I do I should eschew the fancy schmancy sterilised kit with its swanky metzenbaums and haemostats and use a blunt pair of kitchen scissors and my teeth. Job will still get done so where's the problem?

Re: Status epilepticus...

jd2008 — Thu, 24 Feb 2011 22:28:30 GMT

[quote user="phipps"] I did not know that ketamine lowered the seizure threshold, (in fact I thought it did the opposite). What is it's mechanism of action with regard to seizure control? [/quote]

Epilepsy Res. 2000 Dec;42(2-3):117-22.

Ketamine controls prolonged status epilepticus.

Borris DJ, Bertram EH, Kapur J.

Department of Neurology, Box 800394, University of Virginia Health Sciences Center, Charlottesville, VA, USA.

Abstract

New treatments are needed to control prolonged status epilepticus given the high failure rate of current therapies. In an animal model of status epilepticus based on electrical stimulation of the hippocampus, rats demonstrate at least 5 five-hours of seizure activity following stimulation. Phenobarbital (70 mg/kg) administered 15 min after stimulation effectively controlled seizures in 66% of animals (n=6). When phenobarbital (70 mg/kg) was administered 60 min after stimulation, seizures were controlled in 25% of animals (n=4). Ketamine (100 mg/kg) administered 15 min after stimulation did not control seizures in any animal (n=4). But when ketamine was administered one hour after stimulation it effectively controlled seizures in all animals (n=4). Increasing doses of ketamine were administered 60 min after stimulation to generate a dose-response curve. The ketamine dose response (fraction of seizure free rats) data were fit to a sigmoid curve to derive an ED(50) of 58 mg/kg. These findings suggest that prolonged status epilepticus becomes refractory to phenobarbital but can be effectively controlled by ketamine. For patients experiencing prolonged status epilepticus that is refractory to phenobarbital, ketamine may be an alternative to general anesthesia.

There's quite a bit more info on PubMed. Should have qualified my ketamine suggestion by saying that I've only used it in cases where nothing else seems to work. From current studies it also works best given alongside a diazepam CRI.

Can't remember the dose we use - it's written down at work and I haven't used it regularly enough to commit it to memory yet. Will dig it out when I'm back in next week.

Cheers,

Jane

Re: Status epilepticus...

Glen McIntosh — Thu, 24 Feb 2011 14:06:42 GMT

With an animal in status epilepticus I start with a few diazepam iv boluses and some phenobarb iv. If seizures recur I will usually start a diazepam cri with phenobarb top ups every 12 hours or phenobarb cri in some cases. I want these guys sedated and not seizing for a few hours. I don;t necessarily want them anaesthetised, with all the added care and risk that that requires, so propofol only comes out if the above fails, which is rarely.

I have never used pentobarb to treat seizures (or at least not recently enough to remember using it), but I cant see it being any more risky than propofol, so long as the user recognises that they are effectively anaethetising the animal and appropriate monitoring etc is provided (et tubing + oxygen is advocated by some).

Nor do I think there is any particular advantage of pentobarb over propofol, except that you only have to give a single injection of pentobarb to get several hours of seizure control/anaesthesia vs the need for a cri to acheive the same with propofol. But pentobarb is probably cheaper,

Haven't tried ketamine cri though. What are your dose rates for that Jane? I did not know that ketamine lowered the seizure threshold, (in fact I thought it did the opposite). What is it's mechanism of action with regard to seizure control?