Refractory and super-refractory status epilepticus in pediatric patients

Abstract

Refractory status epilepticus (RSE) and super-RSE (SRSE) are life-threatening neurologic emergencies associated with substantial morbidity, mortality, and long-term neurologic sequelae in children. Despite advances in antiseizure therapies and critical care, optimal management remains challenging because of heterogeneous etiologies, limited pediatric-specific evidence, and the absence of standardized treatment algorithms beyond first-line therapy. Early recognition, monitoring, and comprehensive diagnostic evaluation for infectious, structural, metabolic, genetic, or inflammatory causes are essential. Treatment strategies, including continuous anesthetic infusions such as midazolam, ketamine, and barbiturates, and immunomodulatory therapies for patients with suspected inflammatory etiologies, focus on rapid seizure termination while minimizing secondary brain injury. This approach requires multidisciplinary coordination from pediatric neurologists, intensivists, and other specialists in order to optimize long-term neuropsychological outcomes. This review highlights current evidence, recent advances in treatment strategies, and gaps in knowledge regarding management of pediatric RSE and SRSE.