In refractory generalized tonic-clonic status epilepticus
Support information on page: Tables > Protocol for Treatment of SE
General guidelines for pentobarbital infusion
- Loading dose: 5-20 mg/kg IV at infusion rate of 25 mg per min (5 mg/kg is effective for induction anesthesia for most patients)
- Initial maintenance: 2.5 mg/kg per hr
- For breakthrough seizures: 50-mg bolus and increase maintenance by 0.5-1.0 mg/kg per hr
- Begin tapering 24 hrs after last seizure
- Tapering rate (every 4-6 hrs): 1.0 mg/kg per hr if pentobarbital level is >50 mg/liter or 0.5 mg/kg per hr if pentobarbital level is <50 mg/liter
- For seizures during tapering: 50-mg pentobarbital bolus, then increase maintenance to closest preseizure dose
General guidelines for patient management:
- Endotracheal intubation; assisted ventilation
- Continuous blood pressure monitoring (arterial line)
- Hemodynamic monitoring (Swan-Ganz) optional
- Hypotension*: fluids and dopamine up to 12 µg/kg per min (Decrease or discontinue pentobarbital temporarily if dopamine requirements exceed this amount.)
- Prophylaxis of decubiti and venous thrombosis
- Obtain serum at least once daily:Daily complete blood countMaintenance of high therapeutic serum concentrations of antiepileptic drugs
- EEG monitoring BaselineContinuous monitoring for the first 2-6 hrs of anesthesiaTen-minute strips every 30-60 mins for duration of treatment
* Defined as a decrease in systolic blood pressure by 10 mm Hg as compared with preanesthetic blood pressure.
Table adapted from Osorio I, Reed RC. Treatment of refractory generalized tonic-clonic status epilepticus with pentobarbital anesthesia after high-dose phenytoin. Epilepsia 1989;30:464-471. From Kolb SJ and Litt B. Management of epilepsy and comorbid disorders in the emergency room and intensive care unit. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;515-535.
With permission from Elsevier (www.elsevier.com).
Reviewed and revised May 2004 by Steven C. Schachter, MD, epilepsy.com Editorial Board.