From the Guidelines
Propofol is preferred over Midazolam for seizure control due to its anticonvulsant properties and effectiveness in suppressing post-anoxic myoclonus 1.
Key Points
- Propofol has anticonvulsant properties and is effective in treating seizures, including post-anoxic myoclonus 1.
- Midazolam is not mentioned as a preferred treatment for seizures in the provided evidence, whereas propofol is specifically mentioned as an effective treatment 1.
- Propofol's mechanism of action involves binding to multiple receptors in the central nervous system, including GABAA, glycine, nicotinic, and M1 muscarinic receptors, which contributes to its anticonvulsant effects 1.
- However, propofol administration can be associated with significant side effects, including dose-dependent respiratory depression, hypotension, and hypertriglyceridemia 1.
- The use of propofol for seizure control should be carefully considered, taking into account the potential risks and benefits, and monitoring for signs of propofol infusion syndrome (PRIS) 1.
Treatment Considerations
- Propofol can be used to treat seizures, including post-anoxic myoclonus, at a dose that is effective for the individual patient, while minimizing the risk of adverse effects 1.
- Other treatment options, such as sodium valproate, levetiracetam, phenytoin, benzodiazepines, or a barbiturate, may also be considered, depending on the specific clinical scenario and patient characteristics 1.
The FDA Drug Labels for propofol (IV), midazolam (IV) do not address this question.
From the Research
Seizure Control with Propofol and Midazolam
- Both propofol and midazolam have been used for seizure control in patients with refractory status epilepticus (RSE) 2, 3.
- A study comparing the two found that propofol and midazolam achieved 64% and 67% complete clinical seizure suppression, and 78% and 67% electrographic seizure suppression, respectively 2.
- Another study found that target-controlled propofol infusion was equal in efficacy to midazolam for the treatment of RSE, with overall seizure control noted in 34.8% of patients 3.
Comparison of Efficacy and Safety
- A study comparing the anticonvulsant effects of propofol and midazolam against picrotoxin-induced seizures in rats found that midazolam was more effective than propofol against tonic seizures 4.
- A prospective, randomized study found that mortality was similar in both propofol and midazolam groups, but the duration of hospital stay was significantly shorter in the propofol group 3.
- A study comparing midazolam and propofol for long-term sedation in the ICU found that midazolam allowed better maintenance of sedation and yielded complete amnesia at a lower cost, while propofol caused more cardiovascular depression during induction 5.
Clinical Implications
- The choice of anesthetic agent does not seem to affect the overall outcome in RSE and super RSE, and target-controlled propofol infusion was found to be equal in efficacy to midazolam for the treatment of RSE 3.
- However, midazolam may be more effective than propofol against tonic seizures, and propofol may cause more cardiovascular depression during induction 4, 5.
- A large multicenter, prospective, randomized comparison is needed to clarify the data and determine the best choice of agent for seizure control in patients with RSE 2.