Abstracts

Rationale: Refractory SE is a significant neurological emergency in children. Current agents are inadequate to control all cases.Levetiracetam (LVT) is approved as an anticonvulsant. Recently an IV formulation was approved as substitute for oral. Limited information is available for acute seizure care in pediatrics.Methods: 3 cases of refractory SE were identified through hospital records who received IV LVT during treatment for continuous seizures following adequate treatment with standard agents. Refractory SE was defined as ongoing seizures despite treatment with a typical first line agent and 2-3 second line agents. Charts were reviewed for age, gender, etiology of SE, prior seizure history, anticonvulsant levels, other labs, dosing of medications,tolerance during infusion, response to treatment. All were on continuous EEG during treatment.Results: 2/3 responded to IV LVT. Patient #1 - a 7 y.o. with hitory of intractable seizures from cortical dysplasia was withdrawn from medications for presurgical assessment. Ptient developed SE which failed to respond to lorazepam 0.1 mg/kg x4, fosphenytoin 23 PE/kg by rapid IV infusion, followed by 36.7 mg/kg of IV valproate, and finally 18.4 mg/kg IV LVT by push over 3 minutes. Cessation of EEG and clinical seizures was complete by 4.5 minutes post infusion of IV LVT. Patient #2 a 32 month old with no prior history of seizures was admitted for medulloblastoma. 2 days post resection developed seizures with a serum sodium of 119 mmol/l. Patient received 0.1 mg/kg lorazepam x3, followed by 18.5 PE/kg fosphenytoin load with free phenytoin of 1.8μg/ml.Also 37 mg/kg valproate was loaded IV by rapid infusion at over ~ 10 minutes, and 9.3 mg/kg phenobarbital x2 IV load with seizures persisting. IV LVT at 18.5 mg/kg was infused over 5 minutes. At end of infusion, clinical seizures ended and EEG seizures ceased by 5 minutes post infusion. Patient #3 a 23 month old was transferred for continuous SE, presumtively secondary to anoxia in a previously healthy child with no history of prior seizures. Patient previously received lorazepam, loaded with fosphenytoin with total serum concentration of 14.7 μg/ml, loaded with valproate with level of 66 μg/ml and phenobarbital of 10 μg/ml. Patient received 20 mg/kg IV LVT over 15 minutes x2 with no effect. Patient required pentobarbital coma for seizure cessation. Patient could not maintain control without pentobarbital and had evidence of multiorgan failure and succumbed 2 days later. 2/3 returned to baseline over the next 2 days. They tolerated infusion well with no site reactions, no difficulties during infusion, and rapid response clinically and by EEG. In the third case, no adverse reactions were noted during infusion and no worsening of patients medical condition.Conclusions: IV LVT was well tolerated in all 3 cases of refractory SE in pediatric patients. In 2/3 this treatment was efficacious despite following adequate treatment with accepted agents. While encouraing, larger, controlled studies are needed to determine the role of IV LVT for acute seizure treatment.