Abstracts

Rationale: Refractory status epilepticus (RSE) is a neurological emergency with high mortality and morbidity. There is no evidence-based consensus or randomized controlled study to guide therapy. To review the clinical evolution, response to treatment, safety profile and outcome of RSE in children treated in a tertiary pediatric centre from Jan 1, 2005 to Dec 31, 2010.Methods: This was a retrospective review of a cohort of 154 children with status epilepticus who had video-EEG monitoring. RSE was defined as persistent seizures (convulsive or non-convulsive) unresponsive to benzodiazepines, Phenytoin and/or Phenobarbital.Results: 64 children (aged 1 month to 16.5 years) met the criteria for RSE. Patients were classified as outlined in Table 1. Status epilepticus was convulsive in 64 children and in 10 patients, evolved to non-convulsive status. Details of therapy are described in Table 2. All patients received a midazolam (MDZ) infusion. Midazolam was effective in achieving seizure control in 42 patients (65%). The infusion ranged from 0.6-12 mcg/kg min. 7 patients had worsening of seizures with MDZ and 4 developed reversible tonic status. Hypotension was observed in 20 % of patients. The addition of Levetiracetam to the midazolam infusion in 9 patients resulted in resolution of RSE. Breakthrough seizures occurred in 51% of those treated with MDZ and responded to an increase in the dose of MDZ. The mean time to control status was one day, except in the epileptic encephalopathy group. MDZ + steroids were effective in 2 patients. The addition of propofol to MDZ was used in 5 patients, and it was effective in 4 patients. 3 patients developed hypotension that responded to inotropics and fluids. A Thiopental infusion was used in 5 patients, achieving a burst suppression pattern on EEG but seizures recurred upon decreasing the dose in 4 patients, thus thiopental was effective in only 1 patient. The ketogenic diet (KD) was effective in 1 patient. 3 patients had urgent resective surgery with resolution of RSE. The overall mortality in this population was 16 (25%), 6 patients died during their hospitalization. No deaths occurred in the febrile status group. New neurological impairment was observed in 52% of the patients in the acute symptomatic group at discharge or in the follow up.Conclusions: MDZ was effective and safe in 65% of patients with RSE; however it caused reversible tonic status in a subgroup of patients. The addition of Levetiracetam to MDZ was effective but was used in only a small number of patients. Propofol was effective and thiopental was not effective but the number of patients in each group was small. Urgent resective surgery may be considered in selected patients with RSE.