Status epilepticus propofol

Midazolam, propofol, and pentobarbital infusions can be used for refractory status epilepticus but may require intensive monitoring and supportive care. 

Claassen J, Hirsch LJ, Emerson RG, et al. Treatment of refractory status epilepticus with pentobarbital, propofol, or midazolam a systemic review. Epilepsia 2002 43 146-153. 

Refractory status epilepticus that has failed to respond to one of these treatments, and has continued for more than 20-30 min, requires urgent action. The accepted strategy is to paralyze and ventilate the patient and administer an antiepileptic drug in sufficient dosage to suppress EEG evidence of seizure activity. The barbiturate anaesthetic thiopental (thiopentone), the benzodiazepine midazolam, and the anaesthetic propofol have all been used. What little comparative evidence there is remains inconclusive. Such treatment can only be carried out with facilities for artificial ventilation and intensive care, and effects can only be monitored by EEG recording. 

A 10-year-old child had status epilepticus controlled with a combination of valproate, oxcarbazepine, and 48 hours of propofol infusion in a dose of 5.5 mg/kg/ hour. After weaning from propofol, a classic ketogenic diet was instituted in an attempt to provide long-term control of the seizures. A day later status epilepticus recurred and propofol was restarted at a rate of 6-9 mg/ kg/hour to suppress seizure activity (the diet, valproate, and oxcarbazepine were also continued). Shortly thereafter, he developed the classical constellation of malignant ventricular arrhythmias, hyperlipidemia, rhabdomyolysis, lactic acidosis, and biventricular cardiac failure. He did not survive. 

Two men, aged 7 and 17 years, presented with refractory status epilepticus. Both were treated with high-dose propofol infusions to achieve burst suppression on the electroencephalogram. During the second day of propofol infusion there was progressive severe lactic acidosis, hypoxia, pyrexia, and rhabdomyolysis, followed by hypotension, bradydysrhythmias, and renal dysfunction, leading to death. The total doses of propofol were 1275 mg/ kg over 2.7 days and 482 mg/kg over 2 days. 

Convulsions have been reported in two patients with no history of epilepsy after induction of anesthesia with propofol (44). However, in a crossover comparison in 20 epileptic patients undergoing cortical resection, in which the effects on the electrocorticogram of either propofol or thiopental during isoflurane + nitrous oxide anesthesia were studied, propofol caused no greater proconvulsive effect than thiopental, which is used to treat status epilepticus (45). In spite of occasional reports, a true epileptogenic effect of propofol remains to be proven. 

Status epilepticus i.s defined as continuou.s seizure.s lasting at least 30 minute.s or a state in which fits follow each other without consciousness being fully regained. Urgent treatnient with intravenous agents (bottom left) is neccs.sary to Stop the fits, which, if unchecked, result 111 exhaustion and cerebral damage. Lorazepam or diazepam is used initially followed hy phenyloin if necessary, [f the fits are not controlled, the patient is anaesthetized with propofol or thiopental. 

In a retrospective study of 32 patients who had been given intravenous levetiracetam for status epilepticus, there was arterial hypotension after intravenous levetiracetam in four patients during co administration of propofol and during rapid infusion of phenytoin in one patient [210 ]. There... 

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