From the Guidelines
Treatment of Refractory Status Epilepticus in the ICU For the treatment of refractory status epilepticus in the ICU, a continuous infusion of midazolam (0.1-0.4 mg/kg/h) or propofol (2-4 mg/kg/h) is recommended, titrated to achieve a burst-suppression pattern on electroencephalogram (EEG) monitoring 1.
- Alternatively, pentobarbital (5-10 mg/kg loading dose, followed by 1-5 mg/kg/h) or thiopental (5-10 mg/kg loading dose, followed by 2-5 mg/kg/h) may be used, with a goal of achieving a burst-suppression pattern on EEG 1.
- Valproate has also been shown to be effective in refractory status epilepticus, with a loading dose of 30 mg/kg followed by an infusion of 1-2 mg/kg/h 1.
- Levetiracetam may also be considered, with a loading dose of 20-30 mg/kg followed by an infusion of 1-2 mg/kg/h, although more studies are needed to confirm its efficacy 1.
Key Considerations
- Treatment duration is typically 24-48 hours, after which the infusion is gradually tapered to assess for seizure recurrence.
- The choice of medication should be based on the patient's individual needs and medical history, as well as the potential side effects of each medication.
- Close monitoring of the patient's EEG and clinical status is essential to adjust the treatment as needed.
- It is also important to note that the evidence for these treatments is not always strong, and the choice of medication may depend on the specific clinical context and the availability of medications 1.
From the FDA Drug Label
Propofol injectable emulsion was found to be effective in status epilepticus which was refractory to the standard anticonvulsant therapies. The median maintenance propofol dose was 146 mcg/kg/min (range: 68 mcg/kg/min to 425 mcg/kg/min). The maintenance infusion rates required to maintain adequate sedation ranged from 2.8 mcg/kg/min to 130 mcg/kg/min.
Pentobarbital Sodium should not be admixed with any other medication or solution The rate of IV injection should not exceed 50 mg/min for Pentobarbital Sodium. A commonly used initial dose for the 70 kg adult is 100 mg. At least one minute is necessary to determine the full effect of intravenous pentobarbital If necessary, additional small increments of the drug may be given up to a total of from 200 to 500 mg for normal adults.
Treatment options for refractory status epilepticus in the ICU include:
- Propofol: with a median maintenance dose of 146 mcg/kg/min and a range of 68-425 mcg/kg/min 2
- Pentobarbital: with an initial dose of 100 mg and a maximum rate of 50 mg/min, up to a total of 200-500 mg for normal adults 3
From the Research
Treatment Options for Refractory Status Epilepticus
- Refractory status epilepticus in the Intensive Care Unit (ICU) can be treated with intravenous (IV) medication drips, including midazolam 4.
- Midazolam is a potent short-acting benzodiazepine that has been shown to be safe and highly effective in controlling status epilepticus 4.
- The dosage of midazolam for continuous intravenous infusion can range from 0.1-0.4 mg/kg/h, and it can be administered for 1 to 3 days 4.
Efficacy of Midazolam
- Midazolam has been shown to control seizures in neonates with refractory status epilepticus, with seizures being controlled in all six neonates within 1 hour of initiation of midazolam 4.
- Electroencephalographic seizures were abolished in four of six neonates, and the remaining two neonates continued to have electrographic seizures without clinical accompaniment for a further 12 hours 4.
Other Treatment Options
- There is no relevant evidence from the provided studies regarding other IV medication drips for refractory status epilepticus in the ICU.
- One study investigated the use of continuous intravenous terbutaline infusions, but it was for adult patients with status asthmaticus, not status epilepticus 5.