Eight-Year Study of Childhood Status Epilepticus: Midazolam Infusion in Management and Outcome

Abstract

Sixty-eight children 2 months to 14 years of age were admitted with status epilepticus to Sultan Qaboos University Hospital from November 1993 to December 2001. Thirty-eight children (55.9%) had refractory status epilepticus and 30 (44.1%) had established status epilepticus. The children with refractory status epilepticus had received intravenous or per rectal diazepam and intravenous phenytoin/phenobarbital (either or both) before continuous infusion of midazolam was given. Fifty-one children received continuous midazolam infusion. In 38 children with refractory status epilepticus, the midazolam infusion was given in addition to the long-acting antiepilepsy drug, whereas 13 (18.8%) children needed only midazolam to control the established status epilepticus. Seventeen (25%) children were controlled with phenytoin sodium alone. Midazolam was given 0.15 mg/kg/minute initially as bolus in 1 minute, followed by 1 to 7 μgram/kg/minute as continuous infusion. The status could not be controlled in one child (1.5%) suffering from neurodegenerative disease. Two children needed mechanical ventilation following prolonged apnea after diazepam administration in one and diazepam plus phenobarbital in the other. No metabolic derangements or compromise of vital functions was noted on midazolam infusion. All children made a complete recovery. There was one death related to meningoencephalitis. ( J Child Neurol 2002;17:907—909).

Aborted and refractory status epilepticus in children: A comparative analysis

“…Ten to 25% of children with epilepsy will develop SE in their life time (Shorvon, 2001). However, SE occurs mostly in patients without a previously existing seizure disorder (Hesdorffer et al, 1998a, 1998b; Koul et al, 2002; Garzon et al, 2003). SE is either aborted with antiepileptic drugs (AEDs), i.e., aborted status epilepticus (ASE) or refractory to drugs, i.e., refractory status epilepticus (RSE).…”

“…The data regarding SE and RSE in children are derived predominantly from studies that combine adult and pediatric patients (DeLorenzo et al, 1996; Logroscino et al, 1997; Hesdorffer et al, 1998a; Lowenstein & Alldredge, 1998; Treiman et al, 1998; Logroscino et al, 2001; Mayer et al, 2002; Riviello & Holmes, 2004; Logroscino et al, 2005; Lowenstein, 2006; Rossetti et al, 2005). Relatively few studies are limited to children only (Maytal et al, 1989; Gilbert et al, 1999; Kim et al, 2001; Sahin et al, 2001; Koul et al, 2002; Kwong et al, 2004; Maegaki et al, 2005; Ozdemir et al, 2005; Chin et al, 2006). A wide range in mortality (3.6%–50%) is described in those pediatric studies.…”

“…This could reflect the use of different study designs and definitions (Raspall‐Chaure et al, 2006). Only two studies exclusively in children (Sahin et al, 2001; Koul et al, 2002) report the frequency of RSE in a cohort of children with SE; at 26% and 59%, respectively. These two studies did not further compare the children that were refractory to initial treatment to those who were not.…”

Status Epilepticus and Refractory Status Epilepticus Management

“…The Neurocritical Care Society guideline states that “a period of 24–48 hours of electrographic control is recommended prior to slow withdrawal of continuous infusion anticonvulsants for RSE” 4 and a survey of experts in SE management across all age groups reported they would continue pharmacologic coma for 24 hours. 93 Electrographic or electro-clinical seizures frequently recur during weaning of pharmacologic coma medications 95,96,103,104 indicating that pharmacologic coma should be considered as a temporizing measure, and during this period other anticonvulsants should be initiated which may provide seizure control as coma inducing medications are weaned. Often coma inducing medications are weaned over 1–2 days, although this is not evidence based.…”

Midazolam inhibits IgE production in mice via suppression of class switch recombination

“…The maximum dose is 6 to 10 mg/kg (11,12). Therefore, each mouse (five mice/group) was administered different intraperitoneal (i.p.)…”