Clinical Progressionto SRSE

Understanding the complex puzzle of super-refractory status epilepticus (SRSE)

Early diagnosis of super-refractory status epilepticus (SRSE) and rapid treatment are crucial to terminate seizure activity.1,2

SRSE is a complex neurological crisis

"Time equals brain – we want to move in quickly and terminate that process [seizures] before it really gets out of control."

– Stephan Mayer, MD, FCCM

Ongoing, uncontrolled seizure activity1-3

Seizure Starts

Multiple underlying causes
MULTIPLE seizure types and underlying conditions
Status epilepticus
1st-/2nd-line treatment
(benzodiazepines and antiepileptic drugs [AEDs])
(5 minutes – 30 minutes)
Refractory status epilepticus
3rd-line treatment
(burst or seizure suppression with anesthetics + AEDs)
(30 minutes – 24 hours)
Super-refractory status epilepticus
3rd-line adjunctive treatment
(repeated rounds of burst or seizure suppression)
(>24 hours)
Increasing severity

Patients with SRSE are at risk of
additional complications due to
prolonged immobility within the ICU1

Systemic complications can occur in every stage of the evolution from SE to SRSE.4

Systemic complications associated with SRSE are complex1 and primarily relate to2,5,6:

Prolonged Immobility
Anesthetic Use
Exposure to an intensive care unit (IC) environment

Complications of prolonged ICU care can include2,4:

Pulmonary complications

Ventilator-associated pneumonia

Skin complications

Other infectious complications (e.g., catheter-associated urinary tract infections, sepsis, blood stream infections, pseudomembranous colitis)

ICU-acquired weakness (e.g., critical illness myopathy, critical illness neuropathy)

Venous thromboembolic

Further complications may be avoided by limiting the amount of time the patient is immobilized and exposed to the ICU environment.4

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SRSE Patient Management: The Nurse’s Perspective

Learn about the role of the neurocritical care nurse in the
care of a SRSE patient from Katelyn Sparks, BSN, RN, CNRN

Treating patients with SRSE
requires a multidisciplinary team

A diverse team of medical professionals plays a critical role in the treatment and management of SRSE. It is
critical that patients have access to an interdisciplinary team of experts to consult and care for SRSE.

Emergency room
(ER) physician

Status epilepticus patients arriving at the hospital are likely admitted to the ER first and evaluated and treated by ER physicians. Upon further evaluation of symptoms and/or lack of first-line treatment efficacy, other specialized medical personnel become involved in the diagnosis, treatment, and management of these patients.


With specialized training in the study and treatment of disorders of the nervous system, neurologists are key players in making treatment decisions, including the use of intravenous general anesthetics and weaning, for SRSE patients in the intensive care unit (ICU). Often, the neurologist is called in as a consult.

Critical care

Critical care and neurocritical care physicians (intensivists) are responsible for managing the broad care of a SRSE patient in the ICU. The intensivist and the ICU medical team (which includes, but is not limited to, physicians, nurses, EEG technicians, social workers, rehabilitation support, pharmacists, etc) provide close observation and monitoring of the SRSE patient’s vital signs and offer support for the patient’s holistic care.


Also known as electroneurodiagnostic technologists, these professionals are trained to operate and interpret electroencephalographs (EEGs), which are crucial for the diagnosis and monitoring of SRSE. Read more about the important role of continuous EEGs (cEEG).


Nurses play an interdisciplinary role in SRSE patient care. They are important for coordinating diagnostic testing and providing medical attention to patients with SRSE. Nurses may offer vitals support, assisting with cEEGs and other diagnostic devices, administration of drugs, monitoring wean attempts, and communicating with the patient’s family members.

Critical care

With advanced knowledge of and expertise in various pharmacologic medications and drug interactions, critical care pharmacists assist the medical team in the evaluation of clinical data and decision-making about pharmacological interventions. They play a vital role in proper administration of drugs and reducing medication errors.

Quick Quiz

How familiar are you with managing SRSE? See how your answers compare to key thought leaders.

  1. Hocker S, Tatum WO, LaRoche S, Freeman WD. Refractory and super-refractory status epilepticus – an update. Curr Neurol Neurosci Rep. 2014;14:452.
  2. Shorvon S, Ferlisi M. The treatment of super-refractory status epilepticus: a critical review of available therapies and a clinical treatment protocol. Brain. 2011;134(10):2802-2818.
  3. Novy J. Refractory status epilepticus: a prospective observational study. Epilepsia. 2010;51(2):251-256.
  4. Hocker S. Systemic complications of status epilepticus – an update. Epilepsy Behav. 2015;49:83-87.
  5. Hocker SE, Britton JW, Mandrekar JN, Wijdicks EF, Rabinstein AA. Predictors of outcome in refractory status epilepticus. JAMA Neurol. 2013;70(1):72-77.
  6. Wijdicks EF. The multifaceted care of status epilepticus. Epilepsia. 2013;54 Suppl 6:61-63.