Midazolam coma for refractory status epilepticus in children

OBJECTIVE:To implement and retrospectively evaluate a therapeutic algorithm for the treatment of refractory status epilepticus with midazolam coma. METHODS:Eight consecutive patients with refractory status epilepticus were mechanically ventilated. Their arterial and central venous blood pressures were continuously monitored by indwelling vascular catheters. These patients were also continuously monitored by a 16-channel video electroencephalogram (EEG). A midazolam bolus of 0.15 mg/kg was administered, and a continuous infusion of 1-2 μg/kg/min was started. If seizures continued, the infusion was increased every 15 mins by 1-2 μg/kg/min. If seizures stopped and/or burst suppression was achieved, the patients continued to receive that dose for 48 hrs and were then weaned by decrements of 1-2 μg/kg/min every 15 mins. RESULTS:The patients' ages ranged from 17 days to 16 yrs, and they had various underlying diseases. In five of the eight patients, cessation of seizures occurred before achieving burst suppression on EEG, in two patients, cessation occurred during burst suppression, and in one patient, no response before or during burst suppression was encountered. The maximal midazolam doses required to achieve cessation of seizures and/or burst suppression, whichever came first, ranged from 4-24 μg/kg/min, with a mean of 14 ± 6 μg/kg/min. The patients maintained stable cardiovascular function while receiving the maximal dose of midazolam and did not require inotropic support. CONCLUSION:Midazolam infusion, as per our described algorithm, is effective in terminating refractory status epilepticus. This treatment is not associated with cardiovascular instability, even at doses resulting in burst suppression. In the majority of cases, cessation of seizures occur before burst suppression is achieved on EEG.