ICU‑Smart Keto in November 2025: The New Adult Status Epilepticus SOP—and a Safe, Step‑by‑Step Protocol You Can Use

What’s new this week—and why it’s a big deal

• First adult ICU SOP for KD in (S)RSE: published November 12, 2025, with explicit indications, contraindications, a stepwise enteral protocol, and safety flowcharts. ^[3]
• Prospective ICU data (2025): in a 12‑patient series, KD resolved SRSE in 75% a median of 3 days after initiation; adverse events were manageable with monitoring. ^[4]
• The evidence base remains limited (mostly small cohorts and Class IV evidence), but feasibility and rapid ketosis are consistently reported—even in multicenter work. ^[5]

Evidence at a glance

“We advocate for early KD initiation in all SRSE patients without contraindications.” ^[10]

Translate the SOP to the bedside: a practical, step‑by‑step pathway

1) Indications and timing

• Consider KD when RSE persists >72 hours despite appropriate antiseizure therapy, or in SRSE early after ICU admission; initiate within 24 hours when SRSE is anticipated. ^[11]

2) Contraindications and cautions

• Absolute: severe hepatic failure (e.g., AST/ALT >5× ULN or ammonia >5× ULN), triglycerides >400 mg/dL, acute pancreatitis, ileus/malabsorption, type 1 diabetes or pancreoprivic diabetes, pregnancy. ^[12]
• Relative: concurrent propofol infusion (lipid load), severe electrolyte derangements, high‑dose vasopressors, ongoing GI intolerance, septic shock; use extra caution with topiramate/zonisamide (acidosis, nephrolithiasis risk). ^[13]

3) Start the diet (enteral, classical 4:1)

4) Monitoring that keeps patients safe

• Baseline labs: CMP, lipids, electrolytes, glucose/ketones, pancreatic enzymes; consider continuous EEG before and during initiation. ^[16]
• Daily during induction: glucose, serum β‑hydroxybutyrate (BHB), electrolytes/acid–base, triglycerides, LFTs; track GI tolerance and fluid balance. Urine ketones are less reliable for seizure control than serum BHB. ^[17]
• Watch for: hypoglycemia, metabolic acidosis, hypertriglyceridemia, electrolyte shifts, and GI intolerance—then adjust formula/MCT rate, add bicarbonate if needed, and correct deficits per ICU standards. ^[18]

5) Drug–nutrition interactions to manage

• Hidden carbs (dextrose in IVs, suspending agents, elixirs) can abort ketosis—convert to carb‑free equivalents where possible; coordinate pharmacy/dietary reviews. ^[19]
• Propofol: treat as a “relative contraindication” due to cumulative lipid load; if used, intensify triglyceride and acid–base monitoring and consider tapering as ketosis is achieved. ^[20]
• Topiramate/zonisamide: higher risk of acidosis and stones—ensure hydration, consider urinary alkalinization if indicated. ^[21]

ICU “recipe” you can copy and tailor

Troubleshooting and stop rules

What this means for patients and families

• Speed: When KD works, seizure control and anesthetic weaning can follow within days, not weeks. Evidence quality is still limited but encouraging. ^[31]
• Safety: Side effects are common but usually correctable with labs and protocolized adjustments; the diet is reversible at any time. ^[32]
• Teamwork: Success hinges on a coordinated ICU team (neurology, critical care, dietetics, pharmacy, nursing) and rigorous monitoring. ^[33]

What’s proven vs. what’s emerging

• Proven/established in 2025: Feasibility of rapid ketosis and protocolized ICU delivery; standardized adult SOP now available. ^[34]
• Promising but limited: Effectiveness signals (e.g., 75% resolution in a small prospective series) need confirmation in larger, controlled trials. ^[35]
• Consensus need: Surveys highlight demand for better practice guidelines—the new SOP answers many of those gaps. ^[36]

For outpatient keto followers (not in the ICU)

This ICU protocol is not for home use. If you follow a ketogenic diet for other health goals, the takeaways are general: minimize hidden carbs, prioritize electrolyte balance, and coordinate care with your clinician—especially if you use medications that influence acid–base status. The new SOP is designed for critically ill adults and should be implemented by trained teams only. ^[37]

Actionable summary (print‑and‑post)

• When: Start KD early in SRSE or after >72 h RSE unresponsive to meds.
• How: 4:1 classical KD, staged to 90% fat by Day 3; add emulsified MCT from Day 4 as needed. ^[38]
• Monitor: Daily BHB, glucose, electrolytes/ABG, lipids, LFTs; rely on serum—not urine—ketones for decision‑making. ^[39]
• Avoid: Dextrose‑containing meds/flushes; high propofol lipid loads without close TG/acid–base checks. ^[40]
• Stop or step back if: Uncontrolled acidosis, rapidly rising triglycerides, pancreatitis, or intolerance despite adjustments. ^[41]

References (selected)

1. Feil K, Schweikert D, Adolph M, et al. Ketogenic diet for status epilepticus in adult ICU patients: a standard operating procedure. Neurol Res Pract. Published November 12, 2025. ^[42]
2. Ren Y, Zhang M, Fu X, et al. Ketogenic diet treatment for super‑refractory status epilepticus in the ICU: feasibility, safety and effectiveness. Front Neurol. 2025;15:1517850. ^[43]
3. Wusthoff CJ, et al. Phase I/II multicenter ketogenic diet study for adult SRSE. Neurology. 2017. ^[44]
4. Utilization of the ketogenic diet for adults with status epilepticus: barriers and needs. Epilepsy Behav. 2023. ^[45]

Note on recency: We prioritized the November 12, 2025 SOP (published 4 days ago) and the most recent peer‑reviewed ICU data available as of Sunday, November 16, 2025. No additional peer‑reviewed adult ICU KD studies were published in the past 24–48 hours beyond the SOP; the sources above represent the latest verified evidence. ^[46]