High-dose midazolam therapy for refractory status epilepticus in children

Objective: To assess the efficacy of high- dose midazolam in the treatment of refractory status epilepticus in children. Setting: Paediatric intensive care unit (PICU). Design: Audit of clinical experience. Subjects: Seventeen consecutive patients treated for episodes of refractory status epilepticus. Interventions: Algorithm-driven administration of intravenous midazolam to control RSE. Regular, mandatory, patient evaluation to avoid delay in the appropriate escalation of therapy. Our target was the abolition of clinical seizures within 30 min of initiating treatment and early confirmation of cessation of all seizure activity using EEG. The algorithm had failed if clinical seizures persisted beyond 30 min despite the administration of midazolam at 24 mu g/kg/min or if administration of a further acute anti- epileptic drug was required to achieve seizure control. Measurements: The midazolam infusion rate, cumulative midazolam dose and duration of midazolam therapy at time of clinical seizure control were recorded. Haemodynamic parameters were recorded continuously. Episodes of algorithm failure, breakthrough seizures and seizure relapses were identified. Patient outcome was measured in terms of survival to PICU discharge. Results: In 13 patients (76%) midazolam achieved clinical seizure control within 30 min of treatment initiation. Midazolam was eventually successful in treating 15 seizure episodes (88%). Breakthrough seizures occurred in 8 patients (47%). Relapse after discontinuation of therapy occurred in 1 patient (6%). No significant adverse effects attributable to the use of midazolam occurred. There were 3 deaths (18%) related to underlying CNS pathology. Conclusions: Midazolam can offer control of refractory status epilepticus without significant morbidity.