Status epilepticus: refractory: propofol was not clearly as good as high-dose barbiturates.

Clinical bottom line (level 2b-)

  1. Propofol was not clearly as good as high-dose barbiturates in terminating seizures or reducing death in patients with refractory status epilepticus.
Stecker et al: Epilepsia 1998; 39 (1): 18-26
Expires November 2003

The study

Unblinded ?concealed un-randomised trial with intention-to-treat
Setting: university hospital, USA

16 patients (aged mean 54 years, 63% female) refractory status epilepticus, defined as:
  • acute seizures persisting for > 2 hours despite treatments with phenytoin 15 to 30 mg/kg iv and lorazepam 0.05 to 0.1 mg/kg iv, or phenobarbital iv
  • altered mental status
  • seizures occurring at rate of = 2 per hour without recovery to baseline between seizures


Excluded if
  • simple partial seizures


    • Control Group: (n = 8, 8 analysed): phenobarbital :loading dose 10-30 mg/kg followed by boluses to a maximum of 50 mg/min until seizure activity stopped. Patients were then started on an infusion 1 to 10 mg/kg/hour, which was gradually tapered over the next 24 hours while therapeutic levels of phenytoin and phenobarbital were achieved
    Experimental Group: (n = 8, 8 analysed): propofol : bolus 1 mg/kg over 5 minutes, with further 1 mg/kg boluses until seizure activity stopped. Patients were then started on an infusion at 2-4 mg/kg/hour and titred between 1 to 15 mg/kg/hr. If seizures were not controlled within 40 minutes, high-dose barbiturates were used.
    All patients were intubated and had continuous EEG monitoring.
    100% followed for 12 hours

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNH
    (95% CI)
    no elimination of seizures 12 hours 1
    (12.5%)    		 3
    (37.5%)    		 -200%
    (-2207% to 61%)    		 -25.0%
    (-65.6% to 15.6%)    		 4
    (NNT = 6 to infinity;
    NNH = 2 to infinity)
    death unknown 4
    (50.0%)    		 7
    (87.5%)    		 -75%
    (-267% to 17%)    		 -37.5%
    (-79.0% to 4.04%)    		 3
    (NNT = 25 to infinity;
    NNH = 1 to infinity)

    Comments

    1. The study is too small to indicate whether propofol is a safe alternative to barbiturates.

    Citation

    1. Stecker MM, Kramer TH, Raps EC, et al: Treatment of refractory status epilepticus with propofol: clinical and pharmacokinetic findings. Epilepsia 1998; 39 (1): 18-26
    Search Terms: reference in review article
    Contributor: Chris Ball and Clare Wotton, November 2000
    Reviewer:

    Clinical Question.
    Patient status epilepticus
    Intervention or Exposure propofol
    Comparison pentobarbital
    Outcome elimination of seizures, death