Phenytoin Administration Protocol in Pediatric Status Epilepticus
For pediatric status epilepticus, phenytoin should be administered intravenously at a loading dose of 15-20 mg/kg, infused at a rate not exceeding 1-3 mg/kg/min or 50 mg/min (whichever is slower), with continuous cardiac and blood pressure monitoring. 1
Dosing Protocol
- The recommended loading dose for phenytoin in pediatric status epilepticus is 15-20 mg/kg intravenously 1
- The infusion rate should not exceed 1-3 mg/kg/min or 50 mg/min, whichever is slower, to avoid cardiovascular complications 1
- The loading dose should be followed by maintenance doses of 5-7 mg/kg/day divided every 8-12 hours 1
- Therapeutic serum concentrations should be maintained between 10-20 mcg/mL (unbound phenytoin concentrations of 1-2 mcg/mL) 1
Administration Guidelines
- Administer phenytoin directly into a large peripheral or central vein through a large-gauge catheter 1
- Test patency of the IV catheter with a flush of sterile saline before administration 1
- Follow each injection with a flush of sterile saline to avoid local venous irritation due to the alkalinity of the solution 1
- Phenytoin can be diluted with normal saline (not dextrose solutions) with final concentration no less than 5 mg/mL 1
- Use an in-line filter (0.22 to 0.55 microns) when administering diluted phenytoin 1
Monitoring Requirements
- Continuous monitoring of electrocardiogram and blood pressure is essential during administration 1
- Observe the patient for signs of respiratory depression 1
- Monitor for hypotension, which occurs more frequently with phenytoin than with alternatives like valproate 2
- Determination of phenytoin serum levels is advised when using phenytoin for status epilepticus management 1
Important Considerations and Precautions
- Phenytoin has only shown 56% success in terminating status epilepticus when used after benzodiazepines 2
- Cardiac monitoring is crucial as phenytoin can cause hypotension and cardiac arrhythmias 1
- Reduce the rate of administration or discontinue if cardiovascular adverse reactions occur 1
- Phenytoin should not be mixed with dextrose-containing solutions due to precipitation 1
- Intramuscular administration should not be used for status epilepticus due to erratic absorption and risk of tissue necrosis 1
Alternative Considerations
- Valproate (30 mg/kg IV) has shown similar or better efficacy than phenytoin with fewer cardiovascular side effects 2
- Levetiracetam (40 mg/kg IV) is a potential alternative with a more favorable side effect profile, though recent studies show it is not superior to phenytoin in efficacy 3, 4, 5
- If phenytoin fails to terminate seizures, consider additional anticonvulsants or anesthetic agents 1, 6
Remember that benzodiazepines remain the first-line treatment for status epilepticus, with phenytoin typically used as second-line therapy after benzodiazepine failure 2, 6.