Status epilepticus: refractory:: midazolam stopped seizures.

Clinical bottom line (level 5)

  1. In patients with refractory status epilepticus, intravenous midazolam stopped seizures refractory to diazepam, lorazepam and phenytoin.
Kumar and Bleck: Critical Care Medicine 1992; 20 (4): 483-488
Expires December 2001

The study

Case series with unblinded, unobjective outcomes, not adjusted for confounding factors, not validated in an independent set of patients.
Setting: intensive care units of two university hospitals, Canada and USA

7 patients (aged range 4 weeks to 40 years, ?% male) with refractory status epilepticus, who failed treatment with diazepam, lorazepam and phenytoin, with or without phenobarbital
Control Group: (n = , analysed):
Experimental Group: (n = 7, 7 analysed): midazolam iv by bolus, followed by infusion
All patients underwent mechanical ventilation before they received midazolam.
100% followed for ?

The evidence

  • patient 1: 40 year old female with amitriptyline overdose.
    • total loading dose 0.18 mg/kg
    • maximum infusion rate 0.11 mg/kg.hr
    • duration of infusion 13 hours
    • seizures stopped and did not recur
  • patient 2: 21 year old female with theophylline overdose.
    • total loading dose 0.20 mg/kg
    • maximum infusion rate 0.10 mg/kg.hr
    • time to termination of seizures 1.5 min
    • duration of infusion 12 hours
    • seizures did not recur
  • patient 3: 29 year old male with second and third degree burns, who had sequential respiratory and cardiac arrests and was not effectively ventilated for 25 minutes.
    • total loading dose 0.20 mg/kg
    • maximum infusion rate 0.08 mg/kg.hr
    • time to termination of seizures 1.0 min
    • duration of infusion 10 hours
    • eliptiform seizures stopped, but patient died.
  • patient 4: 4 week old child with closed cerebral trauma.
    • total loading dose 0.38 mg/kg
    • maximum infusion rate 0.15 mg/kg.hr
    • time to termination of seizures 0.8 min
    • duration of infusion 29 hours
    • seizure-free on phenobarbital 6 months later
  • patient 5: 19 year old female developed status epilepticus during and episode of encephalitis.
    • total loading dose 0.42 mg/kg
    • maximum infusion rate 0.28 mg/kg.hr
    • time to termination of seizures 1.3 min
    • duration of infusion 70 hours
    • at discharge, she remained on phenobarbital with rare seizures and a mild, short-term memory loss
  • patient 6: 8 year old female with cerebral palsy, mental retardation and seizures.
    • total loading dose 0.15 mg/kg
    • maximum infusion rate 0.06 mg/kg.hr
    • time to termination of seizure 1.4 min
    • duration of infusion 44 hours
    • returned to premorbid condition
  • patient 7: 2.5 year old male who developed seizures at 12 months old as part of an undiagnosed degenerative central nervous system disorder.
    • total loading dose 0.02 mg/kg
    • maximum infusion rate 0.39 mg/kg.hr
    • time to termination of seizures 1.2 min
    • duration of infusion 38 hours
    • returned to premorbid condition

    • Comments

    1. The problems of a simple case series are numerous. This data requires confirmation in controlled, preferably randomised studies.

    Citation

    1. Kumar A, and Bleck TP: Intravenous midazolam for the treatment of refractory status epilepticus. Critical Care Medicine 1992; 20 (4): 483-488
    Contributor: Clare Wotton and Bob Phillips, December 2000
    Reviewer:

    Clinical Question.
    Patient refractory status epilepticus
    Intervention or Exposure midazolam
    Outcome termination of seizures