“We drove on towards death through the cooling twilight.” – F. Scott Fitzgerald
Paper aim: Investigate whether therapeutic hypothermia improves outcomes in status epilepticus
Methodology: This was an unblinded, multicentre, randomised control study in French ICUs. From 2011-2015, patients were randomised if their seizure activity was not halted after 5 minutes and they requiring mechanical ventilation. Patients in the intervention group were cooled to 32-34 degrees C for 24 hours, while control group received targeted normothermia.
Outcomes analysed: PRIMARY = Functional outcome at 90 days. Other outcomes analysed were mortality at 90 days, progression to EEG confirmed status and the presence of refractory status epilepticus
Paper population: The study included 268 patients with an average age 57. Half had previous diagnosis of epilepsy. At 90 days, half had moderate disability or worse, and 10% had died. The median time from seizure onset to first drug was 40 minutes and 43% of patients only received one anti-epileptic before intubation and propofol.
Paper findings: There was no significant difference in functional outcome at 90 days. There were higher rates of adverse outcomes in hypothermia group. However, in treatment group EEG progression to status epilepticus was halved. There is potential for data mining (bad) to show significantly better outcomes in those under 65, if this group is analysed separately.
Analysis of paper: This paper includes many cases who were sub-optimally treated according to UK guidelines. The cooling methods used were archaic and ineffective and there was a very mixed cohort of treatments used prior to intubation and ventilation. Only patients in the treatment group were paralysed and this could be a confounding factor. Overall the study too small, and the anticipated treatment effect was too ambitious.
Conclusion: Therapeutic cooling made no difference to functional outcome at 90 days. There is potential for helping certain subgroups, and the intervention does not appear to be harmful.
Summary by Dr Miles Gandolfi