Pearls and Pitfalls of Introducing Ketogenic Diet in Adult Status Epilepticus: A Practical Guide for the Intensivist

Jason B Katz; Kent Owusu; Ilisa Nussbaum; Rachel Beekman; Nicholas A DeFilippo; Emily J Gilmore; Lawrence J Hirsch; Mackenzie C Cervenka; Carolina B Maciel

doi:10.3390/jcm10040881

Pearls and Pitfalls of Introducing Ketogenic Diet in Adult Status Epilepticus: A Practical Guide for the Intensivist

J Clin Med. 2021 Feb 22;10(4):881. doi: 10.3390/jcm10040881.

Authors

Jason B Katz¹, Kent Owusu^{2

3}, Ilisa Nussbaum², Rachel Beekman², Nicholas A DeFilippo^{4

5}, Emily J Gilmore², Lawrence J Hirsch², Mackenzie C Cervenka⁶, Carolina B Maciel^{1

2}

Affiliations

¹ Department of Neurology, Neurocritical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL 32611, USA.
² Department of Neurology, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT 06520, USA.
³ Care Signature, Yale New Haven Health, New Haven, CT 06510, USA.
⁴ Department of Pharmacy Services, Yale New Haven Hospital, New Haven, CT 06510, USA.
⁵ School of Pharmacy, University of Connecticut, Storrs, CT 06269, USA.
⁶ Department of Neurology, Epilepsy Division, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.

Abstract

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.

Keywords: critical care; ketogenic diet; ketosis; new onset refractory status epilepticus; seizures; status epilepticus.

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Review

Abstract

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