Universidad de Especialidades Espiritu Santo

Super-refractory status epilepticus (SRSE) is an extremely serious neurological emergency. Risk factors and mechanisms involved in transition from refractory status epilepticus (RSE) to SRSE are insufficiently studied.

This was a multicenter retrospective cohort study of consecutive patients diagnosed and treated for RSE at two reference hospital over 5 years in Ecuador. A total of 140 patients were included. Potential demographic, clinical, and treatment variables that may predict progression from refractory to SRSE were analyzed.

Super-refractory status epilepticus was identified in 67/140 (48%) of patients. In univariate analyses, level of consciousness on hospital admission (Glasgow Coma Score < 12, odds ratio [OR] 2.9, p < 0.01), traumatic brain injury (OR 2.3, p = 0.05), acute etiology (OR 3.0, p = 0.04), higher Status Epilepticus Severity Score (STESS) (OR 1.7, p < 0.01), and new clinical or electrographic seizure within 6 h (OR 4.2, p < 0.01) of starting anesthetic infusion were important factors related to super-refractory disease. The best independents predictors of SRSE when the presence of other potential factors were considered for multivariate analysis. Two models were calculated to avoid interactions between similar variables. Glasgow Coma Score on hospital admission < 12 (OR 3.1 [95% confidence interval {CI} 1.16-8.29], p = 0.02) and new clinical or electroencephalography (EEG) seizure after first 6 h of starting anesthetic infusion (OR 3.1 [95% CI 1.36-7.09], p = 0.01) were associated with higher risk of progression to SRSE in model 1. In contrast, model 2 indicated that patients with STESS ≥ 3 points (OR 2.9 [95% CI 1.24-6.65], p = 0.01) and new clinical or EEG seizure after 6 h starting anesthetic infusion (OR 3.0 [95% CI 1.32-6.97], p = 0.01) were the factors independently related to super-refractory disease.

The rate of patients with RSE admitted to intensive care units developing SRSE was high. Low level of consciousness on admission, higher STESS scores, and patients who did not achieve total control of clinical or EEG seizure in the first 6 h of starting intravenous anesthetic infusion may be early indicators of SRSE.

Background Simulation-based training plays a critical role in the acquisition of airway management skills in undergraduate medical education. Peyton's Four-Step Approach (PFSA) and Rapid Cycle Deliberate Practice (RCDP) are two structured, evidence-based methodologies used in simulation training. While both have shown educational benefits, few studies have directly compared their effectiveness across both basic procedures, such as laryngeal mask airway (LMA) placement and endotracheal intubation (ETI), and complex procedures, such as fiberoptic intubation (FOI), especially in time-limited massed practice formats. Methods Fifty-nine third-year medical students with no prior experience in airway management participated in this simulation-based study. They were divided into two cohorts: one trained using RCDP and the other using PFSA. Each cohort received three weekly sessions focused on LMA, ETI, and FOI, respectively, with individualized hands-on training. Final evaluations were conducted using the Objective Structured Assessment of Technical Skills (OSATS) for LMA and ETI, a Global Rating Scale (GRS) for bronchoscope handling, and a 10-item checklist for FOI. Statistical analysis included t-tests, Mann-Whitney U, chi-squared or Fisher's exact tests, and Cronbach's alpha for instrument reliability. Results PFSA resulted in significantly higher OSATS scores for LMA placement (38.06 ± 6.67 vs. 31.93 ± 7.70, p = 0.0017), with a higher proportion of non-competent participants in the RCDP group (p = 0.009). In contrast, RCDP outperformed PFSA in ETI OSATS scores (67.00 ± 12.32 vs. 58.93 ± 11.87, p = 0.012) and in the proportion of students achieving mastery (p = 0.013). For FOI, RCDP led to significantly better results on the GRS (14.73 ± 4.65 vs. 9.66 ± 2.79, p < 0.0001) and the procedural checklist (median: 6.0, interquartile range (IQR): 5-7 vs. median: 4.0, IQR: 3-6, p = 0.0021). No participants reached mastery in FOI, but the RCDP group had significantly more moderately competent students (p = 0.0194) and fewer non-competent participants (p = 0.0003). Reliability of assessment instruments was confirmed with Cronbach's alpha values above 0.70. Conclusion PFSA was more effective for teaching basic skills such as LMA placement, likely due to its stepwise instructional design. RCDP showed superior outcomes in ETI and FOI, supporting its use in complex procedures that benefit from iterative practice and immediate feedback. These findings highlight the importance of tailoring simulation-based training methods to the complexity of the procedure and the learners' needs, particularly in programs with limited training time, and underscore the value of incorporating follow-up assessments to evaluate long-term retention and the durability of training effects.