What is the administration protocol for phenytoin (antiepileptic medication) in pediatric status epilepticus?

Phenytoin Administration Protocol in Pediatric Status Epilepticus

In pediatric status epilepticus, phenytoin should be administered intravenously at a loading dose of 15-20 mg/kg at a rate not exceeding 1-3 mg/kg/min or 50 mg/min (whichever is slower), with continuous cardiac, blood pressure, and respiratory monitoring. 1

Dosing Protocol

• The recommended loading dose for phenytoin in pediatric status epilepticus is 15-20 mg/kg intravenously 1
• Administration rate should not exceed 1-3 mg/kg/min or 50 mg/min (whichever is slower) to minimize cardiovascular adverse effects 1
• This loading dose typically produces serum concentrations within the therapeutic range of 10-20 mcg/mL (unbound phenytoin concentrations of 1-2 mcg/mL) 1
• After the loading dose, maintenance doses should be administered every 6-8 hours either orally or intravenously 1

Administration Requirements

• Phenytoin should be administered directly into a large peripheral or central vein through a large-gauge catheter 1
• Test catheter patency with sterile saline flush before administration 1
• Follow each injection with a sterile saline flush to avoid local venous irritation due to the alkalinity of the solution 1
• Phenytoin can be diluted with normal saline but should not be mixed with dextrose-containing solutions due to precipitation risk 1
• If diluted, the final concentration should be no less than 5 mg/mL, and administration must be completed within 1-4 hours 1
• An in-line filter (0.22 to 0.55 microns) should be used for infusion administration 1

Monitoring Requirements

• Continuous monitoring of electrocardiogram and blood pressure is essential during administration 1
• The patient should be observed for signs of respiratory depression 1
• Determination of phenytoin serum levels is advised when using phenytoin for status epilepticus management 1
• Hypotension is a significant risk with phenytoin administration, occurring more frequently than with alternatives like valproate 2

Important Considerations

• Intramuscular administration should NOT be used for status epilepticus due to erratic absorption and potential for tissue necrosis 1
• Phenytoin has shown only 56% success in terminating status epilepticus when used after benzodiazepines 2
• Other measures, including concomitant administration of an intravenous benzodiazepine (e.g., diazepam) or an intravenous short-acting barbiturate, will usually be necessary for rapid seizure control due to phenytoin's required slow administration rate 1
• If phenytoin administration does not terminate seizures, consider other anticonvulsants, intravenous barbiturates, general anesthesia, or other appropriate measures 1

Alternative Considerations

• Valproate (30 mg/kg IV) has shown similar or better efficacy than phenytoin with fewer cardiovascular side effects 2
• Recent studies have evaluated levetiracetam as an alternative to phenytoin, showing comparable efficacy with potentially fewer adverse effects and easier administration 3, 4, 5

Contraindications

• Hypersensitivity to phenytoin, its ingredients, or other hydantoins 1
• Sinus bradycardia, sino-atrial block, second and third degree A-V block, and Adams-Stokes syndrome 1
• History of prior acute hepatotoxicity attributable to phenytoin 1
• Coadministration with delavirdine 1