Pearls and Pitfalls of Introducing Ketogenic Diet in Adult Status Epilepticus: A Practical Guide for the Intensivist.
Pearls and Pitfalls of Introducing Ketogenic Diet in Adult Status Epilepticus: A Practical Guide for the Intensivist.
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DOI：
10.3390/jcm10040881
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发表时间：
2021-02-22
影响因子：
3.9
通讯作者：
Maciel CB
中科院分区：
文献类型：
--
作者：
Katz JB;Owusu K;Nussbaum I;Beekman R;DeFilippo NA;Gilmore EJ;Hirsch LJ;Cervenka MC;Maciel CB
背景：癫痫持续状态（SE）具有极高的死亡率和发病率，通常需要积极的治疗方法。最近，生酮饮食（KD）在难治性和超难治性SE成人中的实施已被证明是可行和有效的。研究方法：我们描述我们的经验，包括实现和维持酮症的挑战，在成人新发难治性癫痫持续状态（NORSE）。案例简介：一名先前健康的29岁女性在发热性疾病后因不明原因的NORSE入院;病程因长期超难治性SE而复杂化。一个全面的工作是值得注意的，只有轻微的脑脊液（CSF）白细胞增多，升高的非特异性血清炎症标志物，和水肿的腰肌与相关的磁共振成像（MRI）的扩散限制。重复CSF检测正常，系列MRI显示水肿和扩散受限消退，伴进行性海马和弥漫性萎缩。她需要长时间的治疗昏迷，高麻醉输注率，16抗癫痫药物（ASD）试验，经验性免疫抑制和部分双侧卵巢切除术。在住院第28天开始肠内生酮配方。然而，在全面调整护理计划后，仅在37天后才实现持续的β-羟基丁酸水平>2 mmol/L。KD难以在重症监护室（ICU）中维持，由于营养状况差和压疮而停药。KD在非ICU病房再次重新开始，促进ASD逐渐减少，没有再次出现SE。讨论内容：在SE的常用药物中存在不明显的碳水化合物，包括抗生素、电解质补充制剂、同一药物的不同制剂（即，肠外、片剂或混悬剂），甚至用于口腔护理的溶液-所有这些都对住院患者使用KD提出了挑战。定制全面的护理和对KD可能并发症的认识对于酮症的成功实施和维持至关重要。
Background: Status epilepticus (SE) carries an exceedingly high mortality and morbidity, often warranting an aggressive therapeutic approach. Recently, the implementation of a ketogenic diet (KD) in adults with refractory and super-refractory SE has been shown to be feasible and effective. Methods: We describe our experience, including the challenges of achieving and maintaining ketosis, in an adult with new onset refractory status epilepticus (NORSE). Case Vignette: A previously healthy 29-year-old woman was admitted with cryptogenic NORSE following a febrile illness; course was complicated by prolonged super-refractory SE. A comprehensive work-up was notable only for mild cerebral spinal fluid (CSF) pleocytosis, elevated nonspecific serum inflammatory markers, and edematous hippocampi with associated diffusion restriction on magnetic resonance imaging (MRI). Repeat CSF testing was normal and serial MRIs demonstrated resolution of edema and diffusion restriction with progressive hippocampal and diffuse atrophy. She required prolonged therapeutic coma with high anesthetic infusion rates, 16 antiseizure drug (ASD) trials, empiric immunosuppression and partial bilateral oophorectomy. Enteral ketogenic formula was started on hospital day 28. However, sustained beta-hydroxybutyrate levels >2 mmol/L were only achieved 37 days later following a comprehensive adjustment of the care plan. KD was challenging to maintain in the intensive care unit (ICU) and was discontinued due to poor nutritional state and pressure ulcers. KD was restarted again in a non-ICU unit facilitating ASD tapering without re-emergence of SE. Discussion: There are inconspicuous carbohydrates in commonly administered medications for SE including antibiotics, electrolyte repletion formulations, different preparations of the same drug (i.e., parenteral, tablet, or suspension) and even solutions used for oral care―all challenging the use of KD in the hospitalized patient. Tailoring comprehensive care and awareness of possible complications of KD are important for the successful implementation and maintenance of ketosis.
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