Treatment of Refractory Status Epilepticus with Pentobarbital, Propofol, or Midazolam: A Systematic Review.
Abstract number :
G.04
Submission category :
Year :
2001
Submission ID :
2728
Source :
www.aesnet.org
Presentation date :
12/1/2001 12:00:00 AM
Published date :
Dec 1, 2001, 06:00 AM
Authors :
J. Claassen, M.D., Neurology, Neurological Institute, Columbia University, New York, NY; L.J. Hirsch, M.D., Neurology, Neurological Institute, Columbia University, New York, NY; R.G. Emerson, M.D., Neurology, Neurological Institute, Columbia University, N
RATIONALE: New medications offer alternative treatment approaches to pentobarbital infusion for the treatment of refractory status epilepticus (RSE). These new medications are frequently recommended in review publications. However, no prospective randomized study has evaluated the treatment of RSE.
METHODS: We performed a literature search of studies published between January 1970 and March 2001, using MEDLINE, OVID, and manually searched bibliographies of articles identified. We included peer-reviewed studies of adult patients with status epilepticus refractory to at least 2 standard non-continuous infusion anticonvulsant drugs (ACDs), and that were then treated with either continuous IV midazolam (MDZ), propofol (PRO), or pentobarbital (PB). We reviewed studies for methods, treatment intensity (titration to [dsquote]no seizures[dsquote] vs. [dsquote]burst suppression or suppression[dsquote]), and outcomes.
RESULTS: Seventy nine studies were screened. Twenty eight studies with a total of 192 patients fulfilled our selection criteria: MDZ (n=54 patients), PRO (n=32), and PB (n=106). Forty eight percent of patients died, and 29% returned to their premorbid functional baseline. Functional outcome and mortality were not significantly associated with MDZ, PRO, or PB treatment or treatment intensity. Acute treatment failure was least frequent in patients treated with PB (8% vs. 23%, P[lt]0.01), breakthrough seizures least frequent with PB (12% vs. 42%, P[lt]0.001), hypotension was most frequently associated with PB (68% vs. 36%, P[lt]0.001), and a change to a different cIV-ACD least frequently reported in PB treatment (3% vs. 21%, P[lt]0.001).
CONCLUSIONS: These data do not support the hypothesis that any of the investigated ACDs leads to a better outcome after RSE. Within the limits of a systematic review, treatment responses appear to be better with PB; however, side effects are more likely to occur. A prospective randomized trial is needed to determine the preferential therapy for patients with RSE.