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Summary of Anti-Epileptic Drugs (AED) for Status Epilepticus
| Drug | Route of Administration and Corresponding Dose | Adverse Effects | Pearls |
| Phenytoin or Fosphenytoin | Intravenous:Phenytoin: 20 mg/kg,maximum infusion rate: 50 mg/minFosphenytoin: 20 mg/kg PE IV, maximum infusion rate: 150 mg/min, may add 5-10 mg/kg for persistent seizures Maintenance Dose:5-7 PE/kg/day in 2-3 divided doses | Hypotension, bradycardia, Steven-Johnsons syndrome, Pancytopenia, Delirium | Avoid combination with Valproate Not the first agent for second-line therapy for SE with its numerous contraindications and adverse effects |
| Levitiracetam (Keppra) | Intravenous: 20-60 mg/kg, maximum infusion rate of 4.5g over 10 minutes Maintenance Dose:1 – 1.5g q12hr | Syndrome of Inappropriate AdH (SIADH), Mood Disturbance | Preferred AED as second-line therapy for SE Avoid combination with Fosphenytoin Renally cleared |
| Valproic Acid | Intravenous: 40 mg/kg, maximum infusion rate up to 3000mg over 5-10 minutes, may add 20 mg/kg over 5 minutes Maintenance Dose:30-60 mg/kg daily, divided TID | Hyperammonemia, Encepalopathy, Steven-Johnson syndrome, SIADH, Pancreatitis, Hepatotoxicity, Thrombocytopenia | Used for patients with agitated delirium or known psychiatric disorders Interferes with pharmacokinetics of Phenytoin and Phenytoin equivalents and Phenobarbital Contraindicated to pregnant patients |
| Lancomide (Vimpat) | Intravenous: 400mg IV over 5 minutes Maintenance Dose:200 mg IV q12hr | Atrioventricular block, Hypotension | Minimal drug interactions |
| Phenobarbital | Intravenous: 15-20 mg/kg IV, maximum infusion rate of 50-70 mg/min | Somnolence, Respiratory Suppression | Increased risk for prolonged sedation due to long half-life Preferred anti-epileptic for alcohol withdrawal seizures Useful for patients off a barbiturate coma |
Summary of Anaesthetic Drugs for Refractory Status Epilepticus (RSE)
| Drug | Route of Administration and Corresponding Dose | Adverse Effects | Pearls |
| Midazolam | Intravenous: 0.2 mg/kg over 2-5 minutes, repeat 0.2 to 0.4 mg/kg bolus every 5 minutes until seizure stops, maximum loading dose of 2 mg/kg Maintenance Dose: 0.05 to 2.9 mg/kg/h | CNS Depression, Hypotension, Extended half-life with prolonged use | Prolonged administration is associated with decrease in drug response Tachyphylaxis with prolonged infusions |
| Propofol | Intravenous: 1 to 2 mg/kg IV over 3 – 5 minutes, repeat boluses every 3 – 5 minutes until seizure stops, maximum loading dose of 10 mg/kg Maintenance Dose:30 to 200 μg/kg/min | Occasional bradycardia, Hypertriglyceridemia, and life-threatening Propofol Infusion Syndrome (PRIS) that may ultimately lead to death | Best induction drug given its potent anti-epileptic activity Pharmacologic effect is maintained only for 10 minutes if discontinued therefore may cause abrupt seizure if drug therapy is stopped |
| Pentobarbital | Intravenous: 5 – 15 mg/kg, may repeat 5 mg/kg doses until seizure lyses Maintenance Dose:0.5 – 5 mg/kg/h | Myocardial Depression, Hypotension, Ileus, Persistent Coma due to long half-life (up to 60 hours), Allergic reactions such as angioedema and Steven-Johnson syndrome | Prolonged mechanical ventilation Must be used in caution in patients with hepatic or renal impairments Increase risk for nosocomial infections for high-dose barbiturates |
| Ketamine | Intravenous: 1 – 2 mg/kg, may repeat to maximum dose of 10 mg/kg Maintenance Dose:5 to 125 μg/kg/min | Dissociative psychosis, Hypertension, Airway complications | Synergistic effect with benzodiazepine Combine with Midazolam to reduce risk of Dissociative Psychosis |
References
- Rossetti AO, Reichhart MD, Schaller MD, Despland PA, Bogousslavsky J. Propofol treatment of refractory status epilepticus: A study of 31 episodes. Epilepsia 2004;45:757-63
- Parviainen I, Uusaro A, Kalviainen R, Mervaala E, Ruokonen E. Propofol in the treatment of refractory status epilepticus. Intensive Care Med 2006;32:1075-9
- van Gestel JP, Blusse van Oud-Alblas HJ, Malingre M, Ververs FF, Braun KP, van Nieuwenhuizen O. Propofol and thiopental for refractory status epilepticus in children. Neurology 2005;65:591-2
- Claassen J, Hirsch LJ, Emerson RG, Mayer SA. Treatment of refractory status epilepticus with pentobarbital, propofol, or midazolam: A systematic review. Epilepsia 2002;43:146-53.
- Gilbert DL, Gartside PS, Glauser TA. Efficacy and mortality in treatment of refractory generalized convulsive status epilepticus in children: A meta-analysis. J Child Neurol 1999;14:602-9.
- Kim SJ, Lee DY, Kim JS. Neurologic outcomes of pediatric epileptic patients with pentobarbital coma. Pediatr Neurol 2001;25: 217-20.
- Holmes GL, Riviello JJ Jr. Midazolam and pentobarbital for refractory status epilepticus. Pediatr Neurol 1999;20:259-64.
- Mewasingh LD, Sekhara T, Aeby A, Christiaens FJ, Dan B. Oral ketamine in paediatric non-convulsive status epilepticus. Seizure 2003;12:483-9
- Ubogu EE, Sagar SM, Lerner AJ, Maddux BN, Suarez JI, Werz MA. Ketamine for refractory status epilepticus: A case of possible ketamine-induced neurotoxicity. Epilepsy Behav 2003;4:70-5.
- Ben Yehuda Y, Watemberg N. Ketamine increases opening cerebrospinal pressure in children undergoing lumbar puncture. J Child Neurol 2006;21:441-3.
- Himmelseher S, Durieux ME. Revising a dogma: Ketamine for patients with neurological injury? Anesth Analg 2005;101:524-34.