Abstract
Objective
To assess the efficacy of high-dose midazolam in the treatment of refractory status epilepticus in children.
Setting
Paediatric intensive care unit (PICU).
Design
Audit of clinical experience.
Subjects
Seventeen consecutive patients treated for episodes of refractory status epilepticus.
Interventions
Algorithm-driven administration of intravenous midazolam to control RSE. Regular, mandatory, patient evaluation to avoid delay in the appropriate escalation of therapy. Our target was the abolition of clinical seizures within 30 min of initiating treatment and early confirmation of cessation of all seizure activity using EEG. The algorithm had failed if clinical seizures persisted beyond 30 min despite the administration of midazolam at 24 μg/kg/min or if administration of a further acute anti-epileptic drug was required to achieve seizure control.
Measurements
The midazolam infusion rate, cumulative midazolam dose and duration of midazolam therapy at time of clinical seizure control were recorded. Haemodynamic parameters were recorded continuously. Episodes of algorithm failure, breakthrough seizures and seizure relapses were identified. Patient outcome was measured in terms of survival to PICU discharge.
Results
In 13 patients (76%) midazolam achieved clinical seizure control within 30 min of treatment initiation. Midazolam was eventually successful in treating 15 seizure episodes (88%). Breakthrough seizures occurred in 8 patients (47%). Relapse after discontinuation of therapy occurred in 1 patient (6%). No significant adverse effects attributable to the use of midazolam occurred. There were 3 deaths (18%) related to underlying CNS pathology.
Conclusions
Midazolam can offer control of refractory status epilepticus without significant morbidity.
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Acknowledgements
We would like to thank all the PICU nurses and doctors who helped implement the midazolam treatments and bedside data capture. We also thank especially Dr George Rylance, Consultant General Paediatrician and Paediatric Clinical Pharmacologist, then at Birmingham Children's Hospital, and Prof Stefano Seri, Consultant in Paediatric Clinical Neurophysiology, Birmingham Children's Hospital for their help and support in the design of the midazolam treatment algorithm. We also thank Dr P. Sender, Dr J. Armstrong, and Dr A. Schwerin, paediatric neurology trainees, who helped with the literature review and data collection.
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This article is discussed in the editorial available at: http://dx.doi.org/10.1007/s00134-006-0363-7
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Morrison, G., Gibbons, E. & Whitehouse, W.P. High-dose midazolam therapy for refractory status epilepticus in children. Intensive Care Med 32, 2070–2076 (2006). https://doi.org/10.1007/s00134-006-0362-8
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DOI: https://doi.org/10.1007/s00134-006-0362-8