Refractory Status Epilepticus in Children: Intention to Treat With Continuous Infusions of Midazolam and Pentobarbital.
Publication/Presentation Date
10-1-2016
Abstract
OBJECTIVE: To describe pediatric patients with convulsive refractory status epilepticus in whom there is intention to use an IV anesthetic for seizure control.
DESIGN: Two-year prospective observational study evaluating patients (age range, 1 mo to 21 yr) with refractory status epilepticus not responding to two antiepileptic drug classes and treated with continuous infusion of anesthetic agent.
SETTING: Nine pediatric hospitals in the United States.
PATIENTS: In a cohort of 111 patients with refractory status epilepticus (median age, 3.7 yr; 50% male), 54 (49%) underwent continuous infusion of anesthetic treatment.
MAIN RESULTS: The median (interquartile range) ICU length of stay was 10 (3-20) days. Up to four "cycles" of serial anesthetic therapy were used, and seizure termination was achieved in 94% by the second cycle. Seizure duration in controlled patients was 5.9 (1.9-34) hours for the first cycle and longer when a second cycle was required (30 [4-120] hr; p = 0.048). Midazolam was the most frequent first-line anesthetic agent (78%); pentobarbital was the most frequently used second-line agent after midazolam failure (82%). An electroencephalographic endpoint was used in over half of the patients; higher midazolam dosing was used with a burst suppression endpoint. In midazolam nonresponders, transition to a second agent occurred after a median of 1 day. Most patients (94%) experienced seizure termination with these two therapies.
CONCLUSIONS: Midazolam and pentobarbital remain the mainstay of continuous infusion therapy for refractory status epilepticus in the pediatric patient. The majority of patients experience seizure termination within a median of 30 hours. These data have implications for the design and feasibility of future intervention trials. That is, testing a new anesthetic anticonvulsant after failure of both midazolam and pentobarbital is unlikely to be feasible in a pediatric study, whereas a decision to test an alternative to pentobarbital, after midazolam failure, may be possible in a multicenter multinational study.
Volume
17
Issue
10
First Page
968
Last Page
975
ISSN
1529-7535
Published In/Presented At
Tasker, R. C., Goodkin, H. P., Sánchez Fernández, I., Chapman, K. E., Abend, N. S., Arya, R., Brenton, J. N., Carpenter, J. L., Gaillard, W. D., Glauser, T. A., Goldstein, J., Helseth, A. R., Jackson, M. C., Kapur, K., Mikati, M. A., Peariso, K., Wainwright, M. S., Wilfong, A. A., Williams, K., Loddenkemper, T., … Pediatric Status Epilepticus Research Group (2016). Refractory Status Epilepticus in Children: Intention to Treat With Continuous Infusions of Midazolam and Pentobarbital. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 17(10), 968–975. https://doi.org/10.1097/PCC.0000000000000900
Disciplines
Medicine and Health Sciences | Pediatrics
PubMedID
27500721
Department(s)
Department of Pediatrics
Document Type
Article