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Propofol and thiopental for refractory status epilepticus in children

Introduction

Thiopental is commonly used as a last treatment modality in case of refractory status epilepticus (RSE). Its side effects are well known, but there is little information about the frequency in which they occur and the impact they have on clinical practice. Because of the adverse effects of thiopental, several guidelines recommend propofol as an alternative therapy before thiopental is started. However, propofol is associated with potentially fatal outcome, and its efficacy in the treatment of RSE is almost exclusively based on small case series and case reports.

Objective

The purpose of this study was to assess safety and efficacy of propofol and thiopental in the treatment of RSE in children.

Setting

A pediatric intensive care unit of a tertiary teaching hospital.

Methods

Retrospective data collection of all patients treated with propofol or thiopental for RSE between January 1993 and January 2004. Before 1999, patients were treated with thiopental, when phenytoin and high doses of midazolam had failed to terminate the status. After 1999, propofol was administered systematically to all children before thiopental was started, reserving thiopental for those who suffered from side effects of propofol or did not respond to it. The maximum dose of propofol never exceeded 5 mg/kg/hour. Success and adverse effects of treatment were noted and short-term seizure control and neurological outcome were assessed.

Results

Thirty-three patients were treated for 34 episodes of RSE. The effects of propofol and thiopental on seizure activity and short-term neurological outcome are shown in Fig. 1. Propofol was used on 22 occasions. Side effects were infrequent, of limited severity and fully reversible. Mortality was low and attributed to the severity of the underlying disorder. Twenty children were treated with thiopental. Hemodynamic instability occurred in most patients, but could be adequately managed with extra fluids and vasoactive medication. The majority of patients developed fever, pleural effusions and infiltrates on their chest X-ray, suggestive of pneumonia. Bacterial cultures, however, often remained negative.

figure1

Figure 1

Conclusions

Propofol is a safe and effective treatment option for RSE in children. When treatment with propofol fails and thiopental is indicated, a broad range of complications can be encountered. We advise using propofol before thiopental is started.

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van Gestel, S., van Oud-Alblas, H.B., Malingre, M. et al. Propofol and thiopental for refractory status epilepticus in children. Crit Care 9, P273 (2005). https://doi.org/10.1186/cc3336

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Keywords

  • Midazolam
  • Status Epilepticus
  • Neurological Outcome
  • Pediatric Intensive Care Unit
  • Thiopental