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Refractory status epilepticus in children: role of continuous diazepam infusion
S Singhi1, S Banerjee, P Singhi
1Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Insights
Continuous diazepam infusion effectively controls refractory status epilepticus in children, with a high success rate and fewer complications than thiopental. This treatment is a valuable option for pediatric intensive care units.
Area of Science:
- Pediatric Neurology
- Critical Care Medicine
- Pharmacology
Background:
- Refractory status epilepticus (RSE) in children poses significant management challenges.
- Established treatment protocols often involve continuous infusions of sedatives.
- Limited data exists on the comparative efficacy and safety of specific agents like diazepam in pediatric RSE.
Purpose of the Study:
- To evaluate the efficacy and safety of continuous diazepam infusion for treating pediatric refractory status epilepticus.
- To compare outcomes of diazepam infusion with thiopental infusion in RSE management.
- To assess the need for ventilatory and vasopressor support with each treatment modality.
Main Methods:
- Retrospective analysis of 62 pediatric patients with RSE admitted to a Pediatric Intensive Care Unit.
- Standard treatment protocol involved continuous diazepam infusion; thiopental infusion was used if diazepam failed.
- Data collected included patient demographics, etiology of RSE, treatment details, seizure control, and adverse events.
Main Results:
- Diazepam infusion controlled seizures in 86% of 57 patients, with a mean time to control of 40 minutes.
- Adverse events with diazepam included hypotension (1 patient) and respiratory depression (12%), with a 14% mortality rate.
- Thiopental infusion, used in 9 patients (8 after diazepam failure), controlled seizures but required mechanical ventilation in all and vasopressors in 77%, with a 44% mortality rate.
Conclusions:
- Continuous diazepam infusion is a reasonably effective first-line treatment for pediatric refractory status epilepticus.
- Diazepam infusion is associated with a lower incidence of mechanical ventilation and vasopressor support compared to thiopental.
- Diazepam infusion offers a potentially safer alternative for managing RSE in children, despite a significant mortality rate.
Abstract:
To determine efficacy of continuous diazepam infusion in the treatment of refractory status epilepticus in a retrospective study, we analyzed data of 62 children admitted consecutively to our Pediatric Intensive Care Unit with a diagnosis of refractory status epilepticus. The unit followed a standard treatment protocol for diazepam infusion; if it failed, thiopental infusion was used. The mean age of patients was 2.80 years (range, 1.5 to 11.5 yr). Thirty-six patients (60%) had acute infections of the central nervous system and 10 (16%) had idiopathic epilepsy. Diazepam infusion was used in 57 patients. This treatment controlled seizures in 86% of patients (49/57), on average within 40 minutes (median, 30 min; range, 10-120 min), at a mean infusion rate of 0.017 mg/kg/min (range, 0.01-0.03 mg/kg/min). The mean total duration of infusion was 68 hours (range, 12-220 hr). Diazepam infusion was associated with hypotension in one patient, respiratory depression requiring ventilatory support in 12% of patients (6/49), and death in 14% of patients (7/49). Thiopental infusion was used in nine patients, including eight in whom diazepam infusion had failed. Thiopental infusion controlled seizures in all nine patients, but all of them needed mechanical ventilation, and seven needed vasopressor support for hypotension; four patients (44%) died. We conclude that continuous diazepam infusion is a reasonably effective modality to control refractory status epilepticus in children and is associated with reduced need for ventilatory and vasopressor support.