Abstracts

Refractory Status Epilepticus (RSE) refers to a subgroup of Status Epilepticus (SE) with continuous seizure activity persisting for 60 minutes or more despite the first and/or second line medical and anticonvulsant therapy. We review clinical features, treatment response, seizure recurrence and EEG findings in children with RSE., Retrospective chart review of patients [lt]18 y.o who were admitted to a pediatric Intensive Care Unit with a diagnosis of RSE between 2001 and 2005 to determine demographic features, clinical course, treatment response and short term outcome., Twenty-four episodes of RSE were identified in 23 patients (age 13d-194m). Etiology was cryptogenic in 1, symptomatic in 23 (14 acute, 4 remote, 5 progressive). Specific causes included CNS infection in 7 (30%), progressive encephalopathy in 3 (13%), toxic metabolic in 3 (13%), CNS tumor in 2 (8.6%), change in AED dose in 2 (8.6%), other causes in 2. Duration of seizures until the 1st AED was [lt]30 min in 5; 30-60 min in 5; [gt]60 min in 1; repetitive clusters of seizures in 10 and missing in 3.
First AED administered at the time of diagnosis included lorazepam (LRZ) in 14 (58%), diazepam (DZP) in 5 (20.8%) and phenytoin (PHT) in 3 (12.5%). Twenty-three children received a 2nd AED: LRZ in 12 (52%), DZP in 2 (8.6%), PHT in 4 (17.3%), and phenobarbital (PB) in 3 (13%). A third AED was administered to 18: PHT 9 (50%), DZP in 6 (33%) and PB in 3 (16.6%). A Fourth AED was used in 12 (50%), a 5th AED in 4( 16.6%). All patients ultimately received continuous infusion of midazolam (MDZ) 23/24 or pentobarbital (PTB) 9/24. MDZ was effective in 15, maximum dose 0.06-1.2 mg/kg/hr and average duration of 4.4 days. PTB was effective in 6, maximum dose was 3-15mg/kg/h with average duration of 18 days. RSE was controlled only with ACTH in 1 and high dose PB in 1 after failing MDZ and PTB infusion.
In 20 patients, EEG was obtained within 24 hrs. Burst suppression was noted in 11 (45%) with MDZ or PTB infusion. Non-convulsive seizures were seen in 7 RSE cases (29%) during the course of treatment.
RSE was controlled in all but one patient, 14 responded in [lt]2 days, 6 in 2-4d, 3 in [gt]15d. Seizures recurred in 7 cases within 1 week of discontinuation of infusion. At discharge, mild neurological deficit was seen in 12, and severe disability in 9. Thirteen patients were released home, 5 to rehabilitation, 3 to the local hospital, and 2 expired during the course of RSE., This study demonstrates that etiology, recurrence of seizures and mortality rate are different in children with RSE compared to adults with RSE. CNS infection was the most common single cause, and mortality was lower than in adults. Further studies are needed to identify risk factors and optimal treatment for RSE in children.,