Super-refractory status epilepticus (SRSE) is defined as status epilepticus that continues or recurs 24 hours or more after the administration of anesthetic therapy.

Clinical Presentation

A 45-year-old male with a history of post-traumatic epilepsy was admitted following multiple generalized tonic-clonic seizures that failed to respond to lorazepam and fosphenytoin.

Management Strategy

  • First-line Anesthetics: Continuous infusions of propofol and midazolam were initiated, but burst-suppression on EEG could not be maintained without seizure recurrence.
  • Adjunctive Treatment: A ketogenic diet (4:1 lipid-to-non-lipid ratio) was introduced via nasogastric tube on day 3.
  • Outcome: The addition of ketosis led to a rapid decrease in epileptiform discharges, allowing for successful weaning of anesthetics by day 7 with no further clinical seizures.