What to give a patient with active seizures and hypotension (low blood pressure) on pressors (vasopressors)?

From the Guidelines

For a patient with active seizures and hypotension on vasopressors, I recommend administering intravenous levetiracetam 60 mg/kg (max 4500 mg) IV as the preferred second-line treatment after benzodiazepines, due to its lower incidence of hypotension compared to other options, as seen in the study by Kapur et al 1. This approach is based on the most recent and highest quality evidence available, which prioritizes the management of seizures while minimizing the risk of worsening hypotension. The primary outcome of cessation of status epilepticus and improvement in the level of consciousness at 60 minutes was reached in 47% of patients who received levetiracetam, with a frequency of life-threatening hypotension of only 0.7% 1. Key considerations in the management of such patients include:

• Administering intravenous benzodiazepines as first-line treatment, specifically lorazepam 4 mg IV or midazolam 10 mg IV
• Avoiding propofol for seizure control in hypotensive patients as it can worsen hypotension
• Continuing vasopressor support (norepinephrine 0.05-0.5 mcg/kg/min is preferred) and addressing the underlying cause of both conditions
• Ensuring adequate oxygenation, considering intubation for airway protection if consciousness is impaired, and maintaining continuous EEG monitoring if available
• Fluid resuscitation with crystalloids (10-20 ml/kg) may help support blood pressure if the patient is hypovolemic, but use caution to avoid fluid overload, as noted in various studies 1. The goal is to balance the need to terminate seizure activity while supporting cardiovascular function, as ongoing seizures increase metabolic demands and can worsen hemodynamic instability, creating a dangerous cycle that requires prompt intervention.

From the FDA Drug Label

The provided drug labels do not directly address the management of a patient with active seizures and hypotension on pressors.

The FDA drug label does not answer the question.

From the Research

Management of Active Seizures with Hypotension on Pressors

• For patients with active seizures and hypotension on pressors, the primary goal is to control the seizures while managing the hypotension.
• According to a study published in the Journal of Neurology 2, levetiracetam (LEV) is an effective alternative to lorazepam (LOR) for the treatment of status epilepticus, especially in patients with respiratory compromise and hypotension.
• LEV has been shown to be as effective as valproic acid or phenytoin for the cessation of status epilepticus in adults, with a comparable safety profile 3.
• In terms of managing hypotension, push-dose vasopressin has been used as an alternative vasoactive medication to improve hemodynamics in patients with vasodilatory septic shock 4.

Treatment Options

• Levetiracetam (LEV) can be considered as a treatment option for patients with active seizures and hypotension on pressors, due to its efficacy and safety profile 2, 3.
• Sodium valproate (SVP) is also an effective treatment option for generalized convulsive status epilepticus, with comparable efficacy to LEV 5.
• The choice of antiepileptic drug should be individualized, taking into account the patient's specific needs and medical history.

Important Considerations

• Patients with hypotension on pressors require close monitoring and management to prevent further complications.
• The use of push-dose vasopressin or other vasoactive medications should be considered in patients with hypotension that is refractory to fluid resuscitation 4.
• Levetiracetam has a unique mechanism of action and is associated with a favorable safety profile, making it a suitable option for patients with active seizures and hypotension on pressors 6.