Pentobarbital treatment of refractory status epilepticus

Rashkin, Mitchell C.; Youngs, Charles; Penovich, Patricia

doi:10.1212/wnl.37.3.500

Cited by 117 publications

(56 citation statements)

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“…We also evaluated the efficacy of different treatment intensities as reflected in the EEG titration goal for continuous-infusion antiepileptic drug (cIV-AED) therapy, by comparing EEG background suppression (isoelectric or burst-suppression pattern) (22)(23)(24) with that of seizure suppression only (25).…”

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confidence: 99%

Treatment of Refractory Status Epilepticus with Pentobarbital, Propofol, or Midazolam: A Systematic Review

et al. 2002

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Summary:Background: New continuous infusion antiepileptic drugs (cIV-AEDs) offer alternatives to pentobarbital for the treatment of refractory status epilepticus (RSE). However, no prospective randomized studies have evaluated the treatment of RSE. This systematic review compares the efficacy of midazolam (MDL), propofol (PRO), and pentobarbital (PTB) for terminating seizures and improving outcome in RSE patients.Methods: We performed a literature search of studies describing the use of MDL, PRO, or PTB for the treatment of RSE published between January 1970 and September 2001, by using MEDLINE, OVID, and manually searched bibliographies. We included peer-reviewed studies of adult patients with SE refractory to at least two standard AEDs. Main outcome measures were the frequency of immediate treatment failure (clinical or electrographic seizures occurring 1 to 6 h after starting cIV-AED therapy) and mortality according to choice of agent and titration goal (cIV-AED titration to "seizure suppression" versus "EEG background suppression").Results: Twenty-eight studies describing a total of 193 patients fulfilled our selection criteria: MDL (n ‫ס‬ 54), PRO (n ‫ס‬ 33), and PTB (n ‫ס‬ 106). Forty-eight percent of patients died, and mortality was not significantly associated with the choice of agent or titration goal. PTB was usually titrated to EEG background suppression by using intermittent EEG monitoring, whereas MDL and PRO were more often titrated to seizure suppression with continuous EEG monitoring. Compared with treatment with MDL or PRO, PTB treatment was associated with a lower frequency of short-term treatment failure (8 vs. 23%; p < 0.01), breakthrough seizures (12 vs. 42%; p < 0.001), and changes to a different cIV-AED (3 vs. 21%; p < 0.001), and a higher frequency of hypotension (systolic blood pressure <100 mm Hg; 77 vs. 34%; p < 0.001). Compared with seizure suppression (n ‫ס‬ 59), titration of treatment to EEG background suppression (n ‫ס‬ 87) was associated with a lower frequency of breakthrough seizures (4 vs. 53%; p < 0.001) and a higher frequency of hypotension (76 vs. 29%; p < 0.001).Conclusions: Despite the inherent limitations of a systematic review, our results suggest that treatment with PTB, or any cIV-AED infusion to attain EEG background suppression, may be more effective than other strategies for treating RSE. However, these interventions also were associated with an increased frequency of hypotension, and no effect on mortality was seen. A prospective randomized trial comparing different agents and titration goals for RSE with obligatory continuous EEG monitoring is needed.

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confidence: 99%

Treatment of Refractory Status Epilepticus with Pentobarbital, Propofol, or Midazolam: A Systematic Review

et al. 2002

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“…Pentobarbital (PTB) infusion is a standard treatment for status epilepticus (SE) that does not respond to the usual initial anticonvulsant treatment, such as phenytoin (PHT), benzodiazepines (BZDs), and phenobarbital (PB) (1)(2)(3)(4)(5)(6). PTB treatment of such refractory status epilepticus (RSE) is almost uniformly effective but is often associated with significant morbidity, commonly ascribed to the underlying etiology of the SE (2,6).…”

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confidence: 99%

“…PTB treatment of such refractory status epilepticus (RSE) is almost uniformly effective but is often associated with significant morbidity, commonly ascribed to the underlying etiology of the SE (2,6).…”

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Depth of EEG Suppression and Outcome in Barbiturate Anesthetic Treatment for Refractory Status Epilepticus

1999

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Summary: Purpose: Barbiturate anesthetic treatment of patients with refractory status epilepticus (RSE) is often titrated to a burst-suppression record on the EEG. We sought to determine whether the depth of EEG suppression correlated with persistent seizure control in such patients.Methods: We reviewed the EEGs and clinical course of patients treated with pentobarbital (PTB) for RSE. Persistent seizure control or relapse to status epilepticus after the taper of PTB was determined with reference to the depth of EEG suppression during treatment.Results: Of 35 patients tapering PTB, persistent seizure control was achieved in six of 12 patients reaching a burstsuppression record at greatest depth of EEG suppression and in 17 of 20 patients reaching a "flat" record; three patients with neither pattern had persistent control. Survival also was somewhat better in the more suppressed group. Isolated epileptiform discharges during the barbiturate infusion did not correlate with outcome. Recurrence of electrographic status after PTB taper predicted clinical relapse.Conclusions: The EEG is important in managing PTB treatment for patients with RSE. Some period of intense seizure and EEG suppression may help in preventing relapse of status after the PTB taper. It is not necessary to suppress all epileptiform discharges, but persistent clinical and EEG monitoring is necessary to avoid relapses.

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“…For these reasons, many different protocols are used in treating RSE (4). One of the most frequently used and the best studied protocol in the United States involves use of high-dose barbiturates (9)(10)(11)(12)(13)(14)(15)(16). High-dose barbiturate treatment is associated with significant mortality ranging from 10 to 75 depending on the study.…”

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Treatment of Refractory Status Epilepticus with Propofol: Clinical and Pharmacokinetic Findings

et al. 1998

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Summary: Purpose:We compared propofol with high-dose barbiturates in the treatment of refractory status epilepticus (RSE) and propose a protocol for the administration of propofol in RSE in adults, correlating propofol's effect with plasma levels.Methods: Sixteen patients with RSE were included; 8 were treated primarily with high-dose barbiturates and 8 were treated primarily with propofol.Results: Both groups of patients had multiple medical problems and a subsequent high mortality. A smaller but not statistically significant fraction of patients had their seizures controlled with propofol (63%) than with high-dose barbiturate therapy (82%). The time from initiation of high-dose barbiturate therapy to attainment of control of RSE was longer (123 min) than the time to attainment of seizure control in the group receiving propofol (2.6 min, p = 0.002). Plasma concentrations of propofol associated with control of SE were 14 pM +. 4 (2.5 p,g/ml). Recurrent seizures were common when propofol infusions were suddenly discontinued but not when the infusions were gradually tapered.Conclusions: If used appropriately, propofol infusions can effectively and quickly terminate many but not all episodes of RSE. Propofol is a promising agent for use in treating RSE, but more studies are required to determine its true value in comparison with other agents.

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Pentobarbital treatment of refractory status epilepticus

Cited by 117 publications

References 0 publications

Treatment of Refractory Status Epilepticus with Pentobarbital, Propofol, or Midazolam: A Systematic Review

Treatment of Refractory Status Epilepticus with Pentobarbital, Propofol, or Midazolam: A Systematic Review

Depth of EEG Suppression and Outcome in Barbiturate Anesthetic Treatment for Refractory Status Epilepticus

Treatment of Refractory Status Epilepticus with Propofol: Clinical and Pharmacokinetic Findings

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