Abstracts

Rationale: Sustained refractory status epilepticus (SRSE) is the persistence of seizures for more than 24 hours despite appropriate therapy. Large institutional treatment variability exists for SRSE but barbiturate coma is often utilized. However, the dose required to achieve barbiturate coma as well as its safety and efficacy are not well documented in children. Methods: A retrospective single centre review of all children who received treatment with thiopental (TP), pentobarbital (PTB) or high dose phenobarbital (HD-PHB) for SRSE between 2005 and 2013. All patients concomitantly received continuous video EEG (cEEG) monitoring in our ICU. Detailed data abstraction pertaining to patient demographics, etiology, barbiturate dosing, safety and efficacy were collected. The cEEG was carefully evaluated for the degree of background suppression and seizure cessation. Results: Twenty-nine children (13 females) were identified. Mean age was 6.5 years (range: 1 month - 17 years) and 12 (41%) had prior epilepsy. Ten patients received TP, 5 received PTB, and 21 received HD-PHB. Seven patients received HD-PHB and either TP or PTB. All patients had failed treatment with multiple antiepileptic drugs including a high dose midazolam infusion. Complications included hypotension requiring inotropic support in 23 (79%) patients, ventilator-acquired pneumonia in 17 (59%) patients, and sepsis in 5 (17%) patients. Short-term electrographic seizure cessation was achieved in 21 (72%) patients. Seizures recurred within 24 hours of treatment cessation in 7 of these patients (33%), while 14 (67%) remained seizure free at the time of hospital discharge or had returned to their baseline epilepsy frequency. There was no clear correlation between the efficacy and choice or dose of barbiturate used. Outcome at hospital discharge was variable, ranging from return to baseline function to death following withdrawal of life sustaining therapy. Conclusions: Barbiturate coma is an effective method to achieve at least short term seizure suppression in children with SRSE. However, many patients experience treatable sequelae including hypotension and infections. These findings support the cautious use of barbiturate coma in pediatric SRSE.