Clinical Analysis Based on Midazolam and Phenytoin

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Material and Methods

This retrospective study was performed in the pediatric intensive care unit of the Erasmus Medical Center-Sophia Children's Hospital, a tertiary university pediatric hospital. All children diagnosed as having generalized convulsive status epilepticus who were admitted to the pediatric intensive care unit from January 1995 to December 2001 were eligible for inclusion in the study.

Generalized convulsive status epilepticus was defined as a single seizure lasting more than 30 minutes or multiple seizures relapsing within 30 minutes without recovery of consciousness between each seizure. Cessation of seizure activity was defined as no clinical evidence of seizures during at least 30 minutes. Children treated according to our protocol were included. Children who received initial rectal diazepam were not excluded. Patients treated with other initial antiepileptic medications were excluded from analysis. The treatment protocol consisted of a stepwise use of midazolam and phenytoin, with each subsequent step taken if seizures persisted. For the purpose of this study, we categorized the following levels of antiepileptic therapy:

Level 1: Rectal midazolam 0.5 mg/kg (diluted intravenous solution via short catheter) or 0.1 mg/kg intravenously. after 10 minutes: midazolam 0.1 mg/kg intravenously

Level 2: After 10 minutes: phenytoin 20 mg/kg intravenously in 20 minutes

Level 3: After phenytoin load: midazolam 0.2 mg/kg intravenously followed by midazolam 0.1 mg/kg/hour continuously, increased by 0.1 mg/kg/hour every 10 minutes, after extra loading of 0.1 mg/kg, to a maximum of 1 mg/kg/hour

Level 4: Phenobarbital 20 mg/kg intravenously or pentobarbital 2 to 5 mg/kg intravenous load, 1 to 2 mg/kg/hour continuously intravenously

Level 4 could be taken earlier by the attending physician if temporary cessation of seizures was not obtained after several steps of increasing midazolam with loading.

For each patient demographic variable, a history of seizures, underlying diseases, and use of antiepileptic medication were abstracted from patient files. Changes in vital parameters that needed intervention (eg, artificial ventilation) were recorded and described in relation to administration of medication. Patients were categorized using a previously described definition for etiology ( Table 1 ).^[31] The Pediatric Index of Mortality (PIM) was used as a measure of the severity of illness.^[32] Mortality was defined as death within 3 months after admission to the pediatric intensive care unit. Relationships between etiology, Pediatric Index of Mortality score, and level of therapy needed to control generalized convulsive status epilepticus were tested using a χ² test with a significance level of .05.

Cite this: Status Epilepticus: Clinical Analysis of a Treatment Protocol Based on Midazolam and Phenytoin - Medscape - Jun 01, 2005.

Classification of Generalized Convulsive Status Epilepticus
Etiology	Description
Idiopathic	Absence of an acute precipitating central nervous system insult or systemic metabolic dysfunction
	Neurologically normal individuals with an established seizure disorder
	Children with a first unprovoked seizure
Remote symptomatic	No acute provocation in a patient with a history of central nervous system insult known to be associated with an increased risk of seizures
Febrile	Acute provocation with fever (temperature greater than 38.4°C); the patient may be neurologically normal or abnormal
Acute symptomatic	An acute illness with a known central nervous system insult or systemic metabolic dysfunctioning within 1 week after abrupt discontinuation of antiepileptic drugs
Progressive encephalopathy	Progressive neurologic disorder; included are neurodegenerative diseases and malignancies not in remission

Etiology of Generalized Convulsive Status Epilepticus
Etiology	Frequency (%)
Idiopathic	46 (37.7)
Acute symptomatic	24 (19.7)
Progressive neurologic	3 (2.5)
Remote symptomatic	5 (4.0)
Febrile	44 (36.1)
Total	122 (100.0)

Level of Antiepileptic Therapy Needed for Cessation of Epileptic Activity Stratified for Initial Rectal Diazepam
Antiepileptic Therapy	Level				Total
Antiepileptic Therapy	1	2	3	4	Total
No diazepam	19	6	9	6	40
Diazepam	39	13	23	7	82
Total	58	19	32	13	122

Relationship Between Etiology of Generalized Convulsive Status Epilepticus and Level of Antiepileptic Therapy
Etiology	Level				Total
Etiology	1	2	3	4	Total
Idiopathic	23	9	11	3	46
Acute symptomatic	10	2	5	7	24
Progressive neurologic	1	1	0	1	3
Remote symptomatic	4	1	0	0	5
Febrile	20	6	16	2	44
Total	58	19	32	13	122

Cause of Death in Seven Patients
Patient	Cause of Death
1	Near-drowning
2	Brain death as complication of pneumococcal meningitis
3	Cardiac failure following cardiac surgery
4	Cardiac failure owing to mitochondrial respiratory chain deficiency
5	Hemorrhagic shock and encephalopathy
6	Brainstem tumor
7	Congenital defect of glycosylation complicated by pneumonia and sepsis

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Status Epilepticus: Clinical Analysis of a Treatment Protocol Based on Midazolam and Phenytoin

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