845: DOES EARLY USE OF DEXMEDETOMIDINE IMPACT ICU OUTCOMES IN PATIENTS WITH ALCOHOL WITHDRAWAL?

Learning Objectives: We report a case of seizures following therapeutic plasma exchange (TPE) in a patient receiving lacosamide, levetiracetam, phenobarbital, and clobazam for newonset refractory status epilepticus (NORSE). Methods: A 43-year-old man presented with acute encephalopathy and myoclonus. On hospital day 2, he developed convulsive status epilepticus (CSE) and was started on levetiracetam, valproic acid, methylprednisolone, and anesthetic agents for burst suppression. His CSE was eventually controlled on a regimen of lacosamide 200 mg every 12 hours, levetiracetam 1500 mg every 12 hours, phenobarbital 100 mg every 12 hours, and clobazam 20 mg twice daily. All medications were given as oral suspensions via gastric tube. On hospital day 16, a course of TPE was initiated for presumed etiology of autoimmune encephalitis. Following two sessions of TPE, long-term video-electroencephalographic monitoring (LTM) showed evidence of recurrent non-convulsive status epilepticus, which raised concern for removal of antiepileptic drugs (AEDs). Serum AED levels were measured before and immediately following the third session of TPE. The serum lacosamide level remained relatively unchanged, increasing from 6.8 mg/L to 6.9 mg/L, serum levetiracetam level decreased from 19.2 mg/L to 16.3 mg/L, and serum phenobarbital level remained unchanged at 27.4 mg/L. Serum clobazam levels were not measured. He was treated with another course of midazolam for seizure control. A second course of TPE was completed during the hospitalization without recurrent seizures. He was eventually discharged from the hospital on a regimen of lacosamide, levetiracetam, and clobazam. Results: Consideration of drug removal via TPE is an important factor that should be accounted for in all patients when initiating this therapy. We believe this is the first case report describing the measurement of preand post-TPE levels of lacosamide. These findings demonstrate that TPE did not significantly affect serum lacosamide or phenobarbital concentrations. There was a 15% decrease in serum levetiracetam levels that may have been attributed to endogenous drug clearance or potentially resulted from TPE. The reason for recurrence of status epilepticus was not identified, but was not attributed to TPE.