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Calorie Intake During Status Epilepticus and Outcome: A 5-Year Cohort Study

Rybitschka, Anja1; Semmlack, Saskia MD1; Kaplan, Peter W. MBBS, FRCP2; De Marchis, Gian Marco MD, MSc3,4; Rüegg, Stephan MD3,4; Marsch, Stephan MD1,4; Sutter, Raoul MD1,3,4

doi: 10.1097/CCM.0000000000003828
Neurologic Critical Care
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Objectives: Recommendations regarding nutrition during status epilepticus are lacking, and it is unclear whether restriction of calorie intake would result in beneficial effects or potential harm. We thus aimed to investigate associations between daily calorie intake and outcome in adult status epilepticus patients deriving from a 5-year cohort with a systematic and prospective collection of nutritional data.

Design: Retrospective observational study.

Setting: Medical ICUs at a tertiary academic medical care center.

Patients: Consecutive patients with status epilepticus treated at the ICUs from 2012 to 2016 were included.

Interventions: None.

Measurements and Main Results: All patients with status epilepticus were monitored regarding nutrition support provided according to the guidelines. Relative risks of no return to baseline were estimated by Poisson regression with robust error variance and adjusted for potential confounders. Of 203 patients, 86 (42%) had return to baseline. Metabolic characteristics of patients with and without return to baseline did not differ. Patients without return to baseline received more calories and proteins per status epilepticus day, and increasing nutritional support was associated with ventilator-associated pneumonia (relative risk, 1.19; 95% CI, 1.09–1.28). Multivariable regression analysis revealed significant increases in relative risks for no return to baseline with every percent of days with nutrition (relative risk, 1.35; 95% CI, 1.05–1.74), with every 100 kcal (relative risk, 1.01; 95% CI, 1.002–1.01), and gram of protein intake (relative risk, 1.01; 95% CI, 1.001–1.01) per status epilepticus day, independent of potential confounders (including fatal etiology, duration and severity of status epilepticus, Charlson comorbidity index, and treatment with anesthetics).

Conclusions: Our results indicate that increased calorie intake during status epilepticus is independently associated with unfavorable outcome. These findings require further validation and investigations into potential mediators, such as induction of ketogenesis, immunomodulating effects, and/or reduction of ICU-associated complications, such as infections.

1Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland.

2Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD.

3Department of Neurology, University Hospital Basel, Basel, Switzerland.

4Medical faculty of the University of Basel, Basel, Switzerland.

Drs. Rybitschka and Sutter planned the work, acquired and interpreted the data, and wrote the manuscript. Dr. Semmlack, Mr. Kaplan, Dr. De Marchis, Dr. Rüegg, and Dr. Marsch interpreted the data, revised the manuscript, and substantially contributed to the inaugural draft. All authors approved the final submitted version. Mr. Kaplan has provided unsponsored grand rounds, published books on EEG, status epilepticus, and epilepsy for which he received honoraria, has consulted for Cadwell, has been on the board of the ABCN, ICCN, and the ACNS.

Dr. Semmlack disclosed government work. Mr. Kaplan has provided unsponsored grand rounds; published books on electroencephalography (EEG), status epilepticus, and epilepsy for which he received honoraria; has consulted for Cadwell; and has been on the board of the ABCN, ICCN, and the ACNS. Dr. De Marchis is supported by the Swiss National Science Foundation; Science Funds of the University Hospital Basel and University of Basel; Bangerter-Rhyner Foundation; the Swisslife Jubiläumsstiftung for Medical Research; the Swiss Neurological Society; the Fondazione Dr. Ettore Balli; De Quervain research grant; and the Thermo Fisher GmbH. He received travel honoraria by Bayer and speaker honoraria by Medtronic and BMS/Pfizer. Dr. Rüegg received unconditional research grants from UCB-pharma. He received honoraria from serving on the scientific advisory boards of Desitin, Eisai, GlaxoSmithKline (GSK), and UCB-pharma; travel grants from GSK, Janssen-Cilag, and UCB-pharma; and speaker fees from UCB-pharma and from serving as a consultant for Eisai, GlaxoSmithKline, Janssen-Cilag, Pfizer, Novartis, and UCB-pharma. He does not hold any stocks of any pharmaceutical industries or manufacturers of medical devices. He received funding from Sandoz Switzerland; Novartis Oncology, Switzerland; Desitin GmbH, Switzerland; Editor Swiss EEG-Bulletin, support of UCB Switzerland and EGI USA Portland, currently Philips, Eindhoven, The Netherlands; and the Swiss Society of Clinical Neurophysiology and Swiss Neurological Society. He received funding from UCB-pharma, Novartis, and Swiss National Science Foundation Grants: grant number 320030_169379/1 and coapplicant for grants numbers 33CM30_125115/1 and 33CM30_140338/1; he disclosed that he is the president of the Swiss League against Epilepsy (no payments), Editor of EPILEPTOLOGIE (Journal of the Swiss League against Epilepsy) (no payments), and Editor of the Swiss EEG Bulletin (payments from UCB); he received honoraria from serving on the scientific advisory boards of Desitin, Eisai, GSK, and UCB-pharma; travel grants from GSK, Janssen-Cilag, and UCB-pharma; and speaker fees from UCB-pharma. Dr. Sutter received research grants from the Swiss National Foundation (No 320030_169379), the Research Fund of the University Basel, the Scientific Society Basel, and the Bangerter-Rhyner Foundation. He received personal grants from UCB-pharma and holds stocks from Novartis, Roche, and Johnson & Johnson. The remaining authors have disclosed that they do not have any potential conflicts of interest.

This work was performed at the University Hospital Basel, Basel, Switzerland.

The corresponding author had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

For information regarding this article, E-mail: raoul.sutter@usb.ch

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