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O estado de mal epilético é uma emergência neurológica ocasionalmente diagnosticada e tratada fora do ambiente de unidades especializadas em cuidados neurocríticos e cuja abordagem por vezes requer a aplicação de procedimentos intensivos. Com este trabalho pretende-se descrever a casuística de estado de mal epilético num serviço de Medicina Intensiva polivalente, quanto a número de casos, demografia e comorbilidades dos doentes, forma de estado de mal, diagnóstico etiológico, métodos de monitorização e tratamento, assim como os resultados vitais e funcionais. Para o efeito, foi realizado um estudo transversal e retrospetivo englobando todos doentes adultos diagnosticados e tratados por estado de mal epilético na Unidade de Cuidados Intensivos do Centro Hospitalar Cova da Beira ao longo dos últimos 10 anos.
Obtiveram-se dados referentes a 30 processos clínicos de doentes com idades compreendidas entre os 24 e 92 anos, sendo 70% deles do sexo masculino. Os principais fatores desencadeantes de estado de mal epilético identificados foram a lesão cerebral pós-anóxica (33.3%), as doenças cerebrovasculares (10.0%) e os distúrbios hidroeletrolíticos (10.0%). Em termos semiológicos, o estado de mal epilético convulsivo generalizado foi a forma de apresentação mais frequente, tendo ocorrido em 50% dos casos. Em 56.7% dos doentes a duração do episódio ictal foi superior a 60 minutos.
Na abordagem direcionada à cessação da atividade epilética destacou-se uma elevada heterogeneidade na escolha das opções terapêuticas. De entre as diversas estratégias medicamentosas adotadas, verificou-se que os doentes a quem o diazepam foi administrado como primeira linha de tratamento, associado a outros fármacos antiepiléticos, apresentaram uma evolução clínica mais favorável quando comparados com os doentes a quem este medicamento não foi administrado. Por outro lado, a administração de fenitoína, sobretudo de forma isolada como primeira linha, esteve associada a pior prognóstico e a uma maior mortalidade. A percentagem de doentes refratários às duas primeiras linhas de tratamento foi de 40%.
Constatou-se que o estado de mal epilético está associado a uma elevada mortalidade, estimada em 43.3% durante o internamento na Unidade de Cuidados Intensivos ou em 50% se considerado o intervalo até à alta hospitalar. Relativamente aos fatores de prognóstico, este estudo estabeleceu uma relação estatisticamente significativa entre o tipo de evolução clínica com a idade, etiologia e duração do estado de mal epilético. Apurou-se ainda que o indicador SAPS II (Simplified Acute Physiology Score), sobrestimou a mortalidade, ao passo que o indicador STESS (Status Epilepticus Severity Score) subestimou o prognóstico. Verificou-se também que os doentes permaneceram internados em média 11.6 dias na Unidade de Cuidados Intensivos e que a duração total do internamento hospitalar foi de 29.2 dias.
Na sequência deste trabalho, deve ser equacionada uma reavaliação da abordagem de primeira linha a implementar nos casos de estado de mal epilético que dão entrada no Centro Hospitalar Cova da Beira e deve ser considerada a criação de um protocolo interno de forma a uniformizar os procedimentos.
Status epilepticus is a neurological emergency occasionally diagnosed and treated outside the departments specialized in neurological care and whose approach often requires the application of intensive procedures. This work aims to describe status epilepticus case-by-case in an intensive care unit, as the number of cases, demographics and comorbidities of patients, semiology, etiology, monitoring and treatment methods as well as the vital and functional outcomes. To this purpose, we designed a cross-sectional and retrospective study encompassing all adult patients diagnosed and treated by status epilepticus in the Intensive Care Unit of Cova da Beira Hospital Center over the past 10 years. Data were obtained regarding 30 medical records of patients aged between 24 and 92 years. Among them, 70% of them were male. The main triggering factors identified were anoxic brain injury (33.3%), cerebrovascular disease (10.0%) and electrolyte disturbances (10.0%). Generalized convulsive status epilepticus was the most frequent form of presentation, occurring in 50% of the cases. In 56.7% of the patients, the ictal episode duration was greater than 60 minutes. In the approach directed to cease seizures it was found a high heterogeneity when selecting the therapeutic option. Among the various therapeutic strategies adopted, it was found that patients who received diazepam as first the line-therapy in combination with other antiepileptic drugs, showed a more favorable clinical outcome when compared with the patients to whom this drug was not administered. On the other hand, phenytoin administration, especially as first-line therapy, was associated with poor prognosis and increased mortality. The percentage of refractory patients to the first two lines of treatment was 40%. It was noted that the status epilepticus is associated with a high mortality rate, estimated at 43.3% during the Intensive Care Unit stay or 50% if considered the time interval until discharge. In what concerns to prognostic factors, this study established a statistically significant relationship between the type of clinical evolution and age, etiology and duration of status epilepticus. It was also found that the score SAPS II (Simplified Acute Physiology Score) overestimated the mortality and the score STESS (Status Epilepticus Severity Score) underestimated the prognosis. Patients remained hospitalized an average of 11.6 days in the Intensive Care Unit and that the total duration of hospitalization was 29.2 days. Following this study, the first-line therapy to treat status epilepticus in the Cova da Beira Hospital Center should be re-evaluated and it should be considered the creation of an internal protocol to standardize procedures.
Status epilepticus is a neurological emergency occasionally diagnosed and treated outside the departments specialized in neurological care and whose approach often requires the application of intensive procedures. This work aims to describe status epilepticus case-by-case in an intensive care unit, as the number of cases, demographics and comorbidities of patients, semiology, etiology, monitoring and treatment methods as well as the vital and functional outcomes. To this purpose, we designed a cross-sectional and retrospective study encompassing all adult patients diagnosed and treated by status epilepticus in the Intensive Care Unit of Cova da Beira Hospital Center over the past 10 years. Data were obtained regarding 30 medical records of patients aged between 24 and 92 years. Among them, 70% of them were male. The main triggering factors identified were anoxic brain injury (33.3%), cerebrovascular disease (10.0%) and electrolyte disturbances (10.0%). Generalized convulsive status epilepticus was the most frequent form of presentation, occurring in 50% of the cases. In 56.7% of the patients, the ictal episode duration was greater than 60 minutes. In the approach directed to cease seizures it was found a high heterogeneity when selecting the therapeutic option. Among the various therapeutic strategies adopted, it was found that patients who received diazepam as first the line-therapy in combination with other antiepileptic drugs, showed a more favorable clinical outcome when compared with the patients to whom this drug was not administered. On the other hand, phenytoin administration, especially as first-line therapy, was associated with poor prognosis and increased mortality. The percentage of refractory patients to the first two lines of treatment was 40%. It was noted that the status epilepticus is associated with a high mortality rate, estimated at 43.3% during the Intensive Care Unit stay or 50% if considered the time interval until discharge. In what concerns to prognostic factors, this study established a statistically significant relationship between the type of clinical evolution and age, etiology and duration of status epilepticus. It was also found that the score SAPS II (Simplified Acute Physiology Score) overestimated the mortality and the score STESS (Status Epilepticus Severity Score) underestimated the prognosis. Patients remained hospitalized an average of 11.6 days in the Intensive Care Unit and that the total duration of hospitalization was 29.2 days. Following this study, the first-line therapy to treat status epilepticus in the Cova da Beira Hospital Center should be re-evaluated and it should be considered the creation of an internal protocol to standardize procedures.
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Keywords
Anestesia Geral. Cuidados Intensivos Estado de Mal Epilético