The intensive care treatment of convulsive status epilepticus in the UK

Walker, Matthew C.; Smith, S. J. M.; Shorvon, Simon

doi:10.1111/j.1365-2044.1995.tb15095.x

Cited by 63 publications

(30 citation statements)

References 43 publications

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“…Many intensive-care units in Britain continue to prefer phenobarbitone as the barbiturate for children 25 . Pentobarbital tends to be the barbiturate of choice in USA.…”

Section: Barbituratesmentioning

confidence: 99%

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Pharmacological management of convulsive status epilepticus in children

Scott

Neville

1999

Develop Med Child Neuro

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Convulsive status epilepticus (CSE) is the most common medical neurological emergency and continues to be associated with significant morbidity and mortality. The two primary determinants of outcome from CSE are underlying aetiology and seizure length. It is unclear whether a prolonged seizure worsens the prognosis of an underlying aetiology or whether a more severe underlying disorder is more likely to result in CSE 1 . Acceptance of the former hypothesis means that seizures need rapid treatment as their early termination could potentially reduce brain damage and morbidity. Pathophysiology, epidemiology, and outcomes from CSE have recently been reviewed elsewhere 2 .Treatment of acute seizures is most effectively carried out by parents/carers or paramedics in the prehospital setting. In the hospital setting, management of CSE may be considered to be analogous to management of cardiac arrest in that a structured series of interventions is likely to be more successful than a haphazard approach. Our enquiries suggest that hospitals lack structured guidelines. Thus guidelines on prehospital and hospital management are required and should contain general and child-specific points. Locally generated clinical guidelines on the hospital management of CSE are likely to improve treatment. (A proposed protocol is shown in Figure 1.) It is essential that appropriate doses of the chosen anticonvulsant are administered; inadequate dosage is the most common reason for seizures continuing after an initial dose of medication. It is important for all acute units to have access to ITU facilities as a small proportion of children will have CSE associated with a severe systemic or neurological disorder, CSE refractory to firstline anticonvulsant agents, or respiratory depression as a consequence of treatment.This article aims to provide adequate information for the development of clinical guidelines as well as providing an update on newer medications used in the treatment of CSE. Prehospital treatmentSeizures treated early in their course are more likely to stop than those treated later, but most seizures begin some way from a hospital 3,4 . As the systemic changes associated with CSE (hypertension, hypoxia, and tachycardia) are usually a direct result of the seizure, termination of the seizure will usually correct these abnormalities. Children usually have normal cardiorespiratory function and so pharmacological treatment of seizures without monitoring cardiorespiratory parameters is justified in the prehospital setting. As parenteral administration of anticonvulsants is not feasible, rectal diazepam has been introduced into clinical practice. Rapid absorption through the haemorrhoidal veins and then across the blood-brain barrier occurs, therapeutic levels are reached within 5 minutes and peak levels within 20 minutes after administration 4 . Approximately 80% of seizures will stop if the treatment is administered within 15 minutes of the start of the seizure compared with approximately 60% if the drug is administered after this ...

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“…Many intensive-care units in Britain continue to prefer phenobarbitone as the barbiturate for children 25 . Pentobarbital tends to be the barbiturate of choice in USA.…”

Section: Barbituratesmentioning

confidence: 99%

“…Thiopentone is the favoured barbiturate in the treatment of refractory CSE but needs to be used in the ITU and with particular care in patients with impaired myocardial function 25 . Many intensive-care units in Britain continue to prefer phenobarbitone as the barbiturate for children 25 .…”

Section: Barbituratesmentioning

confidence: 99%

Pharmacological management of convulsive status epilepticus in children

Scott

Neville

1999

Develop Med Child Neuro

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“…Propofol has been reported to have antiepileptic activity in humans (20)(21)(22)(23)(24)(25)(26)(27), and several case reports describing its use in SE have been published (20)(21)(22)(23)(24)(25)(26)(27)(28)(29). In a study (4) of members of the Intensive Care Society in the United Kingdom, 12% indicated that propofol was their second-line choice for management of SE despite suggestions that propofol may have a proconvulsant effect (30,3 1).…”

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confidence: 99%

“…Third, many patients with RSE manifest only subtle signs of seizure activity and thus are not diagnosed. For these reasons, many different protocols are used in treating RSE (4). One of the most frequently used and the best studied protocol in the United States involves use of high-dose barbiturates (9)(10)(11)(12)(13)(14)(15)(16).…”

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confidence: 99%

Treatment of Refractory Status Epilepticus with Propofol: Clinical and Pharmacokinetic Findings

et al. 1998

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Summary: Purpose:We compared propofol with high-dose barbiturates in the treatment of refractory status epilepticus (RSE) and propose a protocol for the administration of propofol in RSE in adults, correlating propofol's effect with plasma levels.Methods: Sixteen patients with RSE were included; 8 were treated primarily with high-dose barbiturates and 8 were treated primarily with propofol.Results: Both groups of patients had multiple medical problems and a subsequent high mortality. A smaller but not statistically significant fraction of patients had their seizures controlled with propofol (63%) than with high-dose barbiturate therapy (82%). The time from initiation of high-dose barbiturate therapy to attainment of control of RSE was longer (123 min) than the time to attainment of seizure control in the group receiving propofol (2.6 min, p = 0.002). Plasma concentrations of propofol associated with control of SE were 14 pM +. 4 (2.5 p,g/ml). Recurrent seizures were common when propofol infusions were suddenly discontinued but not when the infusions were gradually tapered.Conclusions: If used appropriately, propofol infusions can effectively and quickly terminate many but not all episodes of RSE. Propofol is a promising agent for use in treating RSE, but more studies are required to determine its true value in comparison with other agents.

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“…midazolam (MDL) (1,8,9) or continuous i.v. propofol (PRO) (10,11) as alternatives to phenobarbital (PB) or continuous i.v. pentobarbital (PTB), evidence for this treatment practice is largely anecdotal.…”

mentioning

confidence: 99%

Treatment of Refractory Status Epilepticus with Pentobarbital, Propofol, or Midazolam: A Systematic Review

et al. 2002

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Summary:Background: New continuous infusion antiepileptic drugs (cIV-AEDs) offer alternatives to pentobarbital for the treatment of refractory status epilepticus (RSE). However, no prospective randomized studies have evaluated the treatment of RSE. This systematic review compares the efficacy of midazolam (MDL), propofol (PRO), and pentobarbital (PTB) for terminating seizures and improving outcome in RSE patients.Methods: We performed a literature search of studies describing the use of MDL, PRO, or PTB for the treatment of RSE published between January 1970 and September 2001, by using MEDLINE, OVID, and manually searched bibliographies. We included peer-reviewed studies of adult patients with SE refractory to at least two standard AEDs. Main outcome measures were the frequency of immediate treatment failure (clinical or electrographic seizures occurring 1 to 6 h after starting cIV-AED therapy) and mortality according to choice of agent and titration goal (cIV-AED titration to "seizure suppression" versus "EEG background suppression").Results: Twenty-eight studies describing a total of 193 patients fulfilled our selection criteria: MDL (n ‫ס‬ 54), PRO (n ‫ס‬ 33), and PTB (n ‫ס‬ 106). Forty-eight percent of patients died, and mortality was not significantly associated with the choice of agent or titration goal. PTB was usually titrated to EEG background suppression by using intermittent EEG monitoring, whereas MDL and PRO were more often titrated to seizure suppression with continuous EEG monitoring. Compared with treatment with MDL or PRO, PTB treatment was associated with a lower frequency of short-term treatment failure (8 vs. 23%; p < 0.01), breakthrough seizures (12 vs. 42%; p < 0.001), and changes to a different cIV-AED (3 vs. 21%; p < 0.001), and a higher frequency of hypotension (systolic blood pressure <100 mm Hg; 77 vs. 34%; p < 0.001). Compared with seizure suppression (n ‫ס‬ 59), titration of treatment to EEG background suppression (n ‫ס‬ 87) was associated with a lower frequency of breakthrough seizures (4 vs. 53%; p < 0.001) and a higher frequency of hypotension (76 vs. 29%; p < 0.001).Conclusions: Despite the inherent limitations of a systematic review, our results suggest that treatment with PTB, or any cIV-AED infusion to attain EEG background suppression, may be more effective than other strategies for treating RSE. However, these interventions also were associated with an increased frequency of hypotension, and no effect on mortality was seen. A prospective randomized trial comparing different agents and titration goals for RSE with obligatory continuous EEG monitoring is needed.

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The intensive care treatment of convulsive status epilepticus in the UK

Abstract: Summary Six hundred and ninety-four members of the Intensive

Cited by 63 publications

References 43 publications

Pharmacological management of convulsive status epilepticus in children

Pharmacological management of convulsive status epilepticus in children

Treatment of Refractory Status Epilepticus with Propofol: Clinical and Pharmacokinetic Findings

Treatment of Refractory Status Epilepticus with Pentobarbital, Propofol, or Midazolam: A Systematic Review

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