Refractory Status Epilepticus

The standard regimens of benzodiazepines, phenytoin, and phenobarbital suffice to control status epilepticus within 30 min of presentation in most patients. In a few cases (generally patients with structural lesions or CNS infections), seizures continue even after such treatment. Various approaches have been advocated, including

IV infusions of midazolam, propofol, or barbiturates to induce anesthesia (see Fig 224-1). These modalities are best used in an intensive care setting, as advanced respiratory and cardiovascular support, as well as continuous EEG and invasive hemodynamic monitoring, may be needed. Consultation from an anesthesiologist and neurologist should be obtained.

Anesthesia may be induced to treat refractory status epilepticus by administering infusions of midazolam or propofol for 12 to 24 h. 2 23,2.4 and 25 General anesthesia may also be obtained with IV barbiturates such as thiopental and pentobarbital. Midazolam and propofol have the advantage over barbiturates of having a short half-life and rapid clearance, allowing for earlier extubation and earlier clinical assessment; midazolam also causes less hypotension.

Neuromuscular blocking agents (usually pancuronium or vecuronium) are sometimes helpful. These drugs will abolish tonic-clonic movements and may facilitate ventilation and other measures; they have no effect on abnormal neuronal activity. EEG monitoring is necessary to assess the effectiveness of anticonvulsant therapy when neuromuscular blockers are utilized.

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