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Yi ZM, Zhong XL, Wang ML, Zhang Y, Zhai SD. Efficacy, Safety, and Economics of Intravenous Levetiracetam for Status Epilepticus: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:751. [PMID: 32670054 PMCID: PMC7326124 DOI: 10.3389/fphar.2020.00751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/06/2020] [Indexed: 12/11/2022] Open
Abstract
Objective To evaluate efficacy, safety, and economics profiles of intravenous levetiracetam (LEV) for status epilepticus (SE). Methods We searched PubMed, Embase, the Cochrane Library, Clinicaltrials.gov, and OpenGrey.eu for eligible studies published from inception to June 12th 2019. Meta-analyses were conducted using random-effect model to calculate odds ratio (OR) of included randomized controlled trials (RCTs) with RevMan 5.3 software. Results A total of 478 studies were obtained. Five systematic reviews (SRs)/meta-analyses, 9 RCTs, 1 non-randomized trial, and 27 case series/reports and 1 economic study met the inclusion criteria. Five SRs indicated no statistically significant difference in rates of seizure cessation when LEV was compared with lorazepam (LOR), phenytoin (PHT), or valproate (VPA). Pooled results of included RCTs indicated no statistically significant difference in seizure cessation when LEV was compared with LOR [OR = 1.04, 95% confidence interval (CI) 0.37 to 2.92], PHT (OR = 0.90, 95% CI 0.64 to 1.27), and VPA (OR = 1.47, 95% CI 0.81 to 2.67); and no statistically significant difference in seizure freedom within 24 h compared with LOR [OR = 1.83, 95% CI 0.57 to 5.90] and PHT (OR = 1.08, 95% CI 0.63 to 1.87). Meanwhile, LEV did not increase the risk of mortality during hospitalization compared with LOR (OR = 1.03, 95% CI 0.31 to 3.39), PHT (OR = 0.89, 95% CI 0.37 to 2.10), VPA (OR = 1.28, 95% CI 0.32 to 5.07), and placebo (plus clonazepam, OR = 0.73, 95% CI 0.16 to 3.38). LEV had lower need for artificial ventilation (OR = 0.23, 95% CI 0.06 to 0.92) and a lower risk of hypotension (OR = 0.15, 95% CI 0.03 to 0.84) compared to LOR. A trend of lower risk of hypotension and higher risk of agitation was found when LEV was compared with PHT. Case series and case report studies indicated psychiatric and behavioral adverse events of LEV. Cost-effectiveness evaluations indicated LEV as the most cost-effective non-benzodiazepines anti-epileptic drug (AED). Conclusions LEV has a similar efficacy as LOR, PHT, and VPA for SE, but a lower need for ventilator assistance and risk of hypotension, thus can be used as a second-line treatment for SE. However, more well-conducted studies to confirm the role of intravenous LEV for SE are still needed.
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Affiliation(s)
- Zhan-Miao Yi
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University Health Science Center, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Xu-Li Zhong
- Department of Pharmacy, Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Ming-Lu Wang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yuan Zhang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Suo-Di Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
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Noureen N, Khan S, Khursheed A, Iqbal I, Maryam M, Sharib SM, Maheshwary N. Clinical Efficacy and Safety of Injectable Levetiracetam Versus Phenytoin as Second-Line Therapy in the Management of Generalized Convulsive Status Epilepticus in Children: An Open-Label Randomized Controlled Trial. J Clin Neurol 2019; 15:468-472. [PMID: 31591834 PMCID: PMC6785465 DOI: 10.3988/jcn.2019.15.4.468] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/11/2019] [Accepted: 04/11/2019] [Indexed: 11/25/2022] Open
Abstract
Background and Purpose There is sparsity of quality evidence for the use of drugs after first-line benzodiazepines in convulsive status epilepticus in children. The aim of the study was to compare the clinical efficacy and safety of intravenous levetiracetam versus intravenous phenytoin as second-line drugs in the management of generalized convulsive status epilepticus in children. Methods This open-label randomized controlled trial was conducted in the Emergency Department of The Children's Hospital and The Institute of Child Health, Multan, Pakistan over a period of 4 years and 6 months from January 2014 to June 2018. This study included 600 children with generalized convulsive status epilepticus: 300 in the 40 mg/kg levetiracetam group, and 300 in the 20 mg/kg phenytoin group. Cessation of a clinical seizure (seizure cessation rate) within 30 minutes after the end of drug administration was the primary outcome in this study, and the presence or absence of adverse effects was noted as the secondary outcome. Data were analyzed using SPSS (version 20.0). Results The children in the levetiracetam and phenytoin were aged 3.5±0.2 and 3.4±0.2 years (mean±SD), respectively, their seizure durations before the start of treatment were 25.1±0.6 and 23.8±0.4 minutes, and their treatment efficacies were 278/300 (92.7%) and 259/300 (83.3%). Levetiracetam was significantly more effective than phenytoin (p=0.012), with no significant difference in safety. Adverse events were observed in eight children in the phenytoin group. Conclusions Levetiracetam is significantly more effective than phenytoin for the treatment of convulsive status epilepticus in children who have failed to respond to benzodiazepines.
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Affiliation(s)
- Nuzhat Noureen
- Department of Paediatric Neurology, The Children Hospital and Institute of Child Health Multan, Multan, Pakistan.
| | - Saadia Khan
- Department of Paediatrics, The Children Hospital and Institute of Child Health Multan, Multan, Pakistan
| | - Asim Khursheed
- Paediatric Intensive Care Unit, The Children Hospital and Institute of Child Health Multan, Multan, Pakistan
| | - Imran Iqbal
- Department of Paediatrics, The Children Hospital and Institute of Child Health Multan, Multan, Pakistan
| | - Moallah Maryam
- Department of Paediatrics, The Children Hospital and Institute of Child Health Multan, Multan, Pakistan
| | | | - Neeta Maheshwary
- Medical Affairs Department, Hilton Pharma Pvt Ltd, Karachi, Pakistan
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Kim MJ, Yum MS, Yeh HR, Ko TS, Lim HS. Pharmacokinetic and Pharmacodynamic Evaluation of Intravenous Levetiracetam in Children With Epilepsy. J Clin Pharmacol 2018; 58:1586-1596. [PMID: 30052270 DOI: 10.1002/jcph.1282] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/18/2018] [Indexed: 11/08/2022]
Abstract
This study aimed to evaluate the safety and tolerability of intravenous (IV) levetiracetam (LEV) as a monotherapy in children aged 1 month-16 years and to explore the pharmacokinetics (PK) of IV LEV and the time to seizure after IV then oral administration of LEV in pediatric children with epilepsy. Children diagnosed with acute unprovoked seizures requiring in-hospital IV LEV administration were included. After administration, the clinical seizure outcomes, side effects, and the Korean-Child Behavior Checklist were monitored and the PK and repeated time to seizure were analyzed via modeling using NONMEM software. Overall, 37 children with epilepsy were enrolled and underwent a PK analysis (median age, 4.6 years; median weight, 18.0 kg). Nine children (24.3%) had seizure recurrence during the follow-up period (median, 3.8 months) and 5 children (13.5%) experienced LEV-associated adverse events such as irritability (n = 2; 5.4%) and somnolence (n = 3; 8.1%). The plasma LEV concentrations after IV LEV were best described by a one-compartment linear PK model. Only body weight was associated with both the clearance and volume of distribution of LEV. The Weibull distribution model described the time to seizure recurrence well; no statistically significant predictor for the time to seizure was identified. Therefore, IV LEV was a well-tolerated and effective alternative in children with acute unprovoked seizures, and models for the PK and time to repeated seizure recurrence after LEV were successfully developed. In particular, the current use of a weight-based IV LEV dosing regimen in pediatric children is practical.
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Affiliation(s)
- Min-Jee Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Ryun Yeh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeong-Seok Lim
- Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Singh K, Aggarwal A, Faridi MMA, Sharma S. IV Levetiracetam versus IV Phenytoin in Childhood Seizures: A Randomized Controlled Trial. J Pediatr Neurosci 2018. [PMID: 30090128 DOI: 10.4103/jpn.jpn-126-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To compare the efficacy of IV phenytoin and IV levetiracetam in acute seizures. DESIGN Randomized controlled trial. SETTING Tertiary care hospital, November 2012 to April 2014. PATIENTS 100 children aged 3-12 yrs of age presenting with acute seizures. INTERVENTION Participants randomly received either IV phenytoin 20 mg/kg (n = 50) or IV levetiracetam 30 mg/kg (n = 50). Patients who were had seizures at presentation received IV diazepam prior to these drugs. OUTCOME MEASURES Primary: Absence of seizure activity within next 24 hrs.Secondary: Stopping of clinical seizure activity within 20 mins of first intervention, change in cardiorespiratory parameters, and achievement of therapeutic drug levels. RESULTS Two groups were comparable in patient characteristics and seizure type (P > 0.05). Of the 100 children, 3 in levetiracetam and 2 in phenytoin group had a repeat seizure in 24 hrs, efficacy was comparable (94% vs 96%, P > 0.05). Of these, 18 (36%) in phenytoin and 12 (24%) in levetiracetam group received diazepam. Sedation time was 178.80 ±97.534 mins in phenytoin and 145.50 ±105.208 mins in levetiracetam group (P = 0.346). Changes in cardiorespiratory parameters were similar in both groups except a lower diastolic blood pressure with phenytoin (P = 0.023). Therapeutic drug levels were achieved in 38 (76%) children both at 4 and 24 hrs with phenytoin, compared to 50 (100%) and 48 (98%) at 1 and 24 hrs with levetiracetam (P < 0.05). CONCLUSION Intravenous levetiracetam and phenytoin have similar efficacy in preventing seizure recurrences for 24 hrs in children 3-12 years presenting with acute seizures.
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Affiliation(s)
- Kanika Singh
- Department of Paediatrics, University College of Medical Sciences and GTB Hospital, Delhi - 110095 India
| | - Anju Aggarwal
- Department of Paediatrics, University College of Medical Sciences and GTB Hospital, Delhi - 110095 India
| | - M M A Faridi
- Department of Paediatrics, University College of Medical Sciences and GTB Hospital, Delhi - 110095 India
| | - Sangeeta Sharma
- Department of Neuropsychopharmacology, Institute of Human Behaviour and Allied Sciences Delhi - 110095 India
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Singh K, Aggarwal A, Faridi MMA, Sharma S. IV Levetiracetam versus IV Phenytoin in Childhood Seizures: A Randomized Controlled Trial. J Pediatr Neurosci 2018; 13:158-164. [PMID: 30090128 PMCID: PMC6057176 DOI: 10.4103/jpn.jpn_126_17] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objectives: To compare the efficacy of IV phenytoin and IV levetiracetam in acute seizures. Design: Randomized controlled trial. Setting: Tertiary care hospital, November 2012 to April 2014. Patients: 100 children aged 3–12 yrs of age presenting with acute seizures. Intervention: Participants randomly received either IV phenytoin 20 mg/kg (n = 50) or IV levetiracetam 30 mg/kg (n = 50). Patients who were had seizures at presentation received IV diazepam prior to these drugs. Outcome Measures: Primary: Absence of seizure activity within next 24 hrs. Secondary: Stopping of clinical seizure activity within 20 mins of first intervention, change in cardiorespiratory parameters, and achievement of therapeutic drug levels. Results: Two groups were comparable in patient characteristics and seizure type (P > 0.05). Of the 100 children, 3 in levetiracetam and 2 in phenytoin group had a repeat seizure in 24 hrs, efficacy was comparable (94% vs 96%, P > 0.05). Of these, 18 (36%) in phenytoin and 12 (24%) in levetiracetam group received diazepam. Sedation time was 178.80 ±97.534 mins in phenytoin and 145.50 ±105.208 mins in levetiracetam group (P = 0.346). Changes in cardiorespiratory parameters were similar in both groups except a lower diastolic blood pressure with phenytoin (P = 0.023). Therapeutic drug levels were achieved in 38 (76%) children both at 4 and 24 hrs with phenytoin, compared to 50 (100%) and 48 (98%) at 1 and 24 hrs with levetiracetam (P < 0.05). Conclusion: Intravenous levetiracetam and phenytoin have similar efficacy in preventing seizure recurrences for 24 hrs in children 3–12 years presenting with acute seizures.
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Affiliation(s)
- Kanika Singh
- Department of Paediatrics, University College of Medical Sciences and GTB Hospital, Delhi - 110095 India
| | - Anju Aggarwal
- Department of Paediatrics, University College of Medical Sciences and GTB Hospital, Delhi - 110095 India
| | - M M A Faridi
- Department of Paediatrics, University College of Medical Sciences and GTB Hospital, Delhi - 110095 India
| | - Sangeeta Sharma
- Department of Neuropsychopharmacology, Institute of Human Behaviour and Allied Sciences Delhi - 110095 India
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Smith DM, McGinnis EL, Walleigh DJ, Abend NS. Management of Status Epilepticus in Children. J Clin Med 2016; 5:jcm5040047. [PMID: 27089373 PMCID: PMC4850470 DOI: 10.3390/jcm5040047] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 04/02/2016] [Accepted: 04/07/2016] [Indexed: 01/04/2023] Open
Abstract
Status epilepticus is a common pediatric neurological emergency. Management includes prompt administration of appropriately selected anti-seizure medications, identification and treatment of seizure precipitant(s), as well as identification and management of associated systemic complications. This review discusses the definitions, classification, epidemiology and management of status epilepticus and refractory status epilepticus in children.
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Affiliation(s)
- Douglas M Smith
- Departments of Neurology and Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Emily L McGinnis
- Departments of Neurology and Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Diana J Walleigh
- Departments of Neurology and Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Incecik F, Horoz OO, Herguner OM, Yıldızdas D, Besen S, Tolunay I, Altunbasak S. Intravenous levetiracetam in critically ill children. Ann Indian Acad Neurol 2016; 19:79-82. [PMID: 27011634 PMCID: PMC4782558 DOI: 10.4103/0972-2327.167702] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: To report the effectiveness and safety of intravenous (IV) levetiracetam (LEV) in the treatment of critically ill children with acute repetitive seizures and status epilepticus (SE) in a children's hospital. Materials and Methods: We retrospectively analyzed data from children treated with IV LEV. Results: The mean age of the 108 children was 69.39 ± 46.14 months (1-192 months). There were 58 (53.1%) males and 50 (46.8%) females. LEV load dose was 28.33 ± 4.60 mg/kg/dose (10-40 mg/kg). Out of these 108 patients, LEV terminated seizures in 79 (73.1%). No serious adverse effects were observed but agitation and aggression were developed in two patients, and mild erythematous rash and urticaria developed in one patient. Conclusion: Antiepileptic treatment of critically ill children with IV LEV seems to be effective and safe. Further study is needed to elucidate the role of IV LEV in critically ill children.
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Affiliation(s)
- Faruk Incecik
- Department of Pediatric Neurology, Cukurova University, Adana, Turkey
| | - Ozden O Horoz
- Department of Pediatric Intensive Care Unit, Cukurova University, Adana, Turkey
| | - Ozlem M Herguner
- Department of Pediatric Neurology, Cukurova University, Adana, Turkey
| | - Dincer Yıldızdas
- Department of Pediatric Intensive Care Unit, Cukurova University, Adana, Turkey
| | - Seyda Besen
- Department of Pediatric Neurology, Cukurova University, Adana, Turkey
| | - Ilknur Tolunay
- Department of Pediatric Intensive Care Unit, Cukurova University, Adana, Turkey
| | - Sakir Altunbasak
- Department of Pediatric Neurology, Cukurova University, Adana, Turkey
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Lee YJ, Yum MS, Kim EH, Ko TS. Intravenous levetiracetam versus phenobarbital in children with status epilepticus or acute repetitive seizures. KOREAN JOURNAL OF PEDIATRICS 2016; 59:35-9. [PMID: 26893602 PMCID: PMC4753198 DOI: 10.3345/kjp.2016.59.1.35] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 07/06/2015] [Accepted: 07/15/2015] [Indexed: 12/11/2022]
Abstract
Purpose This study compared the efficacy and tolerability of intravenous (i.v.) phenobarbital (PHB) and i.v. levetiracetam (LEV) in children with status epilepticus (SE) or acute repetitive seizure (ARS). Methods The medical records of children (age range, 1 month to 15 years) treated with i.v. PHB or LEV for SE or ARS at our single tertiary center were retrospectively reviewed. Seizure termination was defined as seizure cessation within 30 minutes of infusion completion and no recurrence within 24 hours. Information on the demographic variables, electroencephalography and magnetic resonance imaging findings, previous antiepileptic medications, and adverse events after drug infusion was obtained. Results The records of 88 patients with SE or ARS (median age, 18 months; 50 treated with PHB and 38 with LEV) were reviewed. The median initial dose of i.v. PHB was 20 mg/kg (range, 10–20 mg/kg) and that of i.v. LEV was 30 mg/kg (range, 20–30 mg/kg). Seizure termination occurred in 57.9% of patients treated with i.v. LEV (22 of 38) and 74.0% treated with i.v. PHB (37 of 50) (P=0.111). The factor associated with seizure termination was the type of event (SE vs. ARS) in each group. Adverse effects were reported in 13.2% of patients treated with i.v. LEV (5 of 38; n=4, aggressive behavior and n=1, vomiting), and 28.0% of patients treated with i.v. PHB (14 of 50). Conclusion Intravenous LEV was efficacious and safe in children with ARS or SE. Further evaluation is needed to determine the most effective and best-tolerated loading dose of i.v. LEV.
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Affiliation(s)
- Yun-Jeong Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Eun-Hee Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
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Intravenous levetiracetam in Thai children and adolescents with status epilepticus and acute repetitive seizures. Eur J Paediatr Neurol 2015; 19:429-34. [PMID: 25800343 DOI: 10.1016/j.ejpn.2015.02.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 01/08/2015] [Accepted: 02/21/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Intravenous levetiracetam is an option for treatment of status epilepticus (SE) and acute repetitive seizures (ARS). However, there have been relatively few studies with children and adolescents. Also, an appropriate dosage has yet to be determined. AIM This study investigated the safety and the efficacy of levetiracetam for intravenous treatment of convulsive status epilepticus and acute repetitive seizures in children and adolescents. METHOD Retrospectively, the study reviewed the medical records of 19 male and 31 female patients under 18 years of age who had received intravenous levetiracetam treatment either for acute repetitive seizures or for convulsive status epilepticus. The patients were admitted between April 1st, 2010 and December 31st, 2011 to the Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. Data were collected on underlying illnesses, etiology of seizures, indication for levetiracetam therapy, initial dosage, rate of infusion, untoward effects during infusion and emerged complications. Efficacy of treatment was defined as the termination of seizure within 30 min of completing levetiracetam infusion and no seizure recurrence within 6 h of initial treatment. RESULTS The age range of the 50 patients was from one day to 18 years (mean 79.6 months). The analysis included 52 episodes of 34 acute repetitive seizures (63.4%) and 18 convulsive status epilepticus (34.6%). Infusion rates ranged from 2 to 66 mg/kg/min (mean 29.6). Cessation of seizure was obtained in 59.6% of 52 episodes. Patients with underlying drug resistant epilepsy did not respond to levetiracetam therapy as well as patients with other etiology of seizures. There were no adverse drug reactions or untoward effects observed during the therapy. CONCLUSION Intravenous administration of levetiracetam is safe and effective for treatment of acute repetitive seizures and convulsive status epilepticus in children and adolescents. Failure of treatment may be related to underlying drug resistant epilepsy. Further study of appropriate initial dosage and pharmacokinetic variations in the patients is needed as possible explanation of the unresponsiveness.
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Kurz JE, Goldstein J. Status Epilepticus in the Pediatric Emergency Department. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2015. [DOI: 10.1016/j.cpem.2015.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
Status epilepticus (SE) describes persistent or recurring seizures without a return to baseline mental status and is a common neurologic emergency. SE can occur in the context of epilepsy or may be symptomatic of a wide range of underlying etiologies. The clinician's aim is to rapidly institute care that simultaneously stabilizes the patient medically, identifies and manages any precipitant conditions, and terminates seizures. Seizure management involves "emergent" treatment with benzodiazepines followed by "urgent" therapy with other antiseizure medications. If seizures persist, then refractory SE is diagnosed and management options include additional antiseizure medications or infusions of midazolam or pentobarbital. This article reviews the management of pediatric SE and refractory SE.
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Cheng L, Lei S, Chen SH, Hong Z, Yang TH, Li L, Chen F, Li HX, Zhou D, Li JM. Pretreatment with intravenous levetiracetam in the rhesus monkey Coriaria lactone-induced status epilepticus model. J Neurol Sci 2014; 348:111-20. [PMID: 25579413 DOI: 10.1016/j.jns.2014.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 11/08/2014] [Accepted: 11/11/2014] [Indexed: 02/05/2023]
Abstract
PURPOSE To investigate the antiepileptic and protective effects of intravenous levetiracetam (iv LEV) in the rhesus monkey model of acute status epilepticus (SE). METHODS Thirty minutes before intraperitoneal induction of SE by Coriaria lactone (CL), rhesus monkeys were treated with LEV (15 or 150 mg/kg) delivered intravenously as a single bolus. CL dose and epileptic behavior were recorded. Electroencephalography (EEG) was performed before and during the experiment. All rhesus monkeys were killed after 1-month video monitoring and processed for pathological investigation of neuronal injury, terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) staining, and glial fibrillary acidic protein (GFAP) staining. RESULTS No animal exhibited spontaneous seizures during 1-month video monitoring. Development of acute SE was significantly inhibited in the group given 150 mg/kg LEV, compared with controls and the 15 mg/kg LEV group. Delayed latency, reduction of SE duration, decreased cumulative time of tonic convulsions, slight severity of SE, and a high CL induction dose were observed in the high LEV dose group (p<0.05). The EEG showed less frequent epileptic discharges in the group administered with 150 mg/kg LEV. Hematoxylin and eosin (H&E) staining, ultrastructural examination, TUNEL and GFAP staining revealed serious damage, including neuron loss, swollen mitochondrion, and strong positivity for TUNEL in the hippocampus and thalamus of controls, whereas moderate damage in the group administered with 15 mg/kg LEV, and very mild damage in the 150 mg/kg LEV group. Gliosis was found in the hippocampus of controls, not in the LEV groups and normal rhesus monkey. CONCLUSION The study supports the antiepileptic and protective effect of pretreatment with intravenous LEV in rhesus monkey model with SE.
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Affiliation(s)
- Lan Cheng
- Department of Neurology, West China Hospital, Sichuan University, PR China
| | - Song Lei
- Department of Pathology, West China Hospital, Sichuan University, PR China
| | - Si-Han Chen
- Department of Neurology, West China Hospital, Sichuan University, PR China
| | - Zhen Hong
- Department of Neurology, West China Hospital, Sichuan University, PR China
| | - Tian-Hua Yang
- Department of Neurology, West China Hospital, Sichuan University, PR China
| | - Li Li
- Laboratory of Transplant, West China Hospital, Sichuan University, PR China
| | - Fei Chen
- Laboratory of Transplant, West China Hospital, Sichuan University, PR China
| | - Hong-Xia Li
- National Chengdu Center for Safety Evaluation of Traditional Chinese Medicine, West China Hospital, Sichuan University, PR China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, PR China.
| | - Jin-Mei Li
- Department of Neurology, West China Hospital, Sichuan University, PR China.
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Gertsch EA, Ullrich NJ. Seizures in children treated for a primary brain tumor: risk factors, evaluation and management. FUTURE NEUROLOGY 2014. [DOI: 10.2217/fnl.14.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Seizures may be a presenting symptom of a brain tumor in childhood or can occur as a complication of treatment or subsequent effect occurring years after completion of therapy. Seizures create a number of therapeutic challenges and represent a significant comorbidity that results in decreased quality of life. Treatment options may be limited by interactions with chemotherapy and/or increased susceptibility to side effects. Moreover, seizures in this patient population may be less responsive to the traditional therapies typically effective for nontumor related epilepsy. While the pathophysiology of tumor-related epilepsy remains unclear, advances are being made in our understanding of the possible mechanisms involved. Newer anticonvulsants and improved diagnostic tools with refined surgical techniques show promise for future treatment approaches.
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Affiliation(s)
- Emily A Gertsch
- Department of Neurology, Boston Children‘s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Nicole J Ullrich
- Department of Neurology, Boston Children‘s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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İşgüder R, Güzel O, Ağın H, Yılmaz Ü, Akarcan SE, Celik T, Ünalp A. Efficacy and safety of IV levetiracetam in children with acute repetitive seizures. Pediatr Neurol 2014; 51:688-95. [PMID: 25172096 DOI: 10.1016/j.pediatrneurol.2014.07.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 07/11/2014] [Accepted: 07/13/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Levetiracetam has been proven to be effective in both partial and generalized seizures in children. However, few studies have reported its efficacy in the treatment of acute repetitive seizures. We aimed to investigate the efficacy and safety of levetiracetam in children with acute repetitive seizures. METHODS The medical records of children from the age of 1 month-18 years who received levetiracetam because of acute repetitive seizures in the pediatric intensive care unit between 2010 and 2013 were reviewed retrospectively. RESULTS Of the 133 patients, levetiracetam terminated seizures in 104 (78.2%). Side effects such as agitation and aggression were observed in three patients (2.2%). The likelihood of treatment failure was increased by four times by younger age at seizure onset; by six times in the individuals with neurological abnormalities; and by 22 times in the patients with West syndrome. The patients who used levetiracetam as the first treatment option for acute repetitive seizures had a longer duration of epilepsy, a higher rate of neurological abnormality, and a higher proportion of medically resistant epilepsy compared with the individuals who used levetiracetam as an add-on treatment to the other intravenous antiepileptic drugs. However, no differences were detected between these two groups in terms of treatment response. CONCLUSIONS Intravenous levetiracetam appears to be effective and safe in the treatment of acute repetitive seizures. Randomized clinical trials are needed to determine whether intravenous levetiracetam may replace other antiepileptic drugs as the first-line therapy in the management of acute repetitive seizures.
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Affiliation(s)
- Rana İşgüder
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Children's Hospital, Izmir, Turkey.
| | - Orkide Güzel
- Department of Pediatric Neurology, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Hasan Ağın
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Ünsal Yılmaz
- Department of Pediatric Neurology, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Sanem Eren Akarcan
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Tanju Celik
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Aycan Ünalp
- Department of Pediatric Neurology, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
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15
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Effectiveness of intravenous levetiracetam as an adjunctive treatment in pediatric refractory status epilepticus. Pediatr Emerg Care 2014; 30:525-8. [PMID: 25062293 DOI: 10.1097/pec.0000000000000183] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Intravenous levetiracetam (LEV) has been shown to be effective and safe in treating adults with refractory status epilepticus (SE). We sought to investigate the efficacy and safety of intravenous LEV for pediatric patients with refractory SE. METHODS We performed a retrospective medical-record review of pediatric patients who were treated with intravenous LEV for refractory SE. Clinical information regarding age, sex, seizure type, and underlying neurological status was collected. We evaluated other anticonvulsants that were used prior to administration of intravenous LEV and assessed loading dose, response to treatment, and any adverse events from intravenous LEV administration. RESULTS Fourteen patients (8 boys and 6 girls) received intravenous LEV for the treatment of refractory SE. The mean age of the patients was 4.4 ± 5.5 years (range, 4 days to 14.6 years). Ten of the patients were neurologically healthy prior to the refractory SE, and the other 4 had been previously diagnosed with epilepsy. The mean loading dose of intravenous LEV was 26 ± 4.6 mg/kg (range, 20-30 mg/kg). Seizure termination occurred in 6 (43%) of the 14 patients. In particular, 4 (57%) of the 7 patients younger than 2 years showed seizure termination. No immediate adverse events occurred during or after infusions. CONCLUSIONS The current study demonstrated that the adjunctive use of intravenous LEV was effective and well tolerated in pediatric patients with refractory SE, even in patients younger than 2 years. Intravenous LEV should be considered as an effective and safe treatment option for refractory SE in pediatric patients.
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Abstract
OPINION STATEMENT Status epilepticus (SE) is a medical emergency consisting of persistent or recurring seizures without a return to baseline mental status. SE can be divided into subtypes based on seizure types and underlying etiologies. Management should be implemented rapidly and based on pre-determined care pathways. The aim is to terminate seizures while simultaneously identifying and managing precipitant conditions. Seizure management involves "emergent" treatment with benzodiazepines (lorazepam intravenously, midazolam intramuscularly, or diazepam rectally) followed by "urgent" therapy (phenytoin/fosphenytoin, phenobarbital, levetiracetam or valproate sodium). If seizures persist, "refractory" treatments include infusions of midazolam or pentobarbital. Prognosis is dependent on the underlying etiology and seizure persistence. This article reviews the current management strategies for pediatric convulsive SE.
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Dewolfe JL, Szaflarski JP. Levetiracetam use in the critical care setting. Front Neurol 2013; 4:121. [PMID: 23986742 PMCID: PMC3750522 DOI: 10.3389/fneur.2013.00121] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 08/08/2013] [Indexed: 11/22/2022] Open
Abstract
Intravenous (IV) levetiracetam (LEV) is currently approved as an alternative or replacement therapy for patients unable to take the oral form of this antiepileptic drug (AED). The oral form has Food and Drug Administration (FDA) indications for adjunctive therapy in the treatment of partial onset epilepsy ages 1 month or more, myoclonic seizures associated with juvenile myoclonic epilepsy starting with the age of 12 and primary generalized tonic-clonic seizures in people 6 years and older. Since the initial introduction, oral and IV LEV has been evaluated in various studies conducted in the critical care setting for the treatment of status epilepticus, stroke-related seizures, seizures following subarachnoid or intracerebral hemorrhage, post-traumatic seizures, tumor-related seizures, and seizures in critically ill patients. Additionally, studies evaluating rapid infusion of IV LEV and therapeutic monitoring of serum LEV levels in different patient populations have been performed. In this review we present the current state of knowledge on LEV use in the critical care setting focusing on the IV uses and discuss future research needs.
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Affiliation(s)
- Jennifer L Dewolfe
- Department of Neurology, UAB Epilepsy Center, University of Alabama at Birmingham (UAB) , Birmingham, AL , USA
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19
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García-Salido A, Iglesias-Bouzas MI, Nieto-Moro M, Lassaleta-Atienza A, Serrano-González A, Casado-Flores J. Management of unstable pediatric hemato-oncology patient: results of a Web-based survey to pediatric oncologists in Spain. Eur J Pediatr 2013; 172:51-8. [PMID: 23015044 DOI: 10.1007/s00431-012-1840-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 09/10/2012] [Indexed: 12/21/2022]
Abstract
UNLABELLED The current management and monitoring of unstable pediatric hemato-oncology patient (UPHOP) in the oncology ward is not well defined. To evaluate this concept, an anonymous Web-based survey was sent to the 150 Spanish pediatric oncologists registered in the Spanish Society of Pediatric Hemato-Oncology. The response rate was 57 %, with the following main results: Pediatric intensive consulting was available for 97 %, and it was made in case of UPHOP by 37 % of oncologists, up to 65 % if hemodynamic instability. In case of inotropic support initiation, 32 % of respondents never consulted the intensivist. Dopamine is first chosen inotropic; 28 % of surveyed considered there is no limit in its dosage or it is superior to 20 μg/kg/min before an intensivist consulting. Pediatric intensive care admission was considered necessary in case of fever with hemodynamic instability by 15 % of respondents. Respiratory monitoring was mainly done by clinical signs (67 %). In case of respiratory insufficiency, the noninvasive respiratory support by high-flow ventilation with nasal cannula was applied by 57 % in the oncology ward. In case of acute kidney injury, diuretics were generally the initial therapy. The anticonvulsive drugs most frequently applied were valproic acid (93 %), diazepam (88 %), and phenytoin (81 %). CONCLUSION A consensus should be achieved among oncologists and intensivists. The creation and training of rapid response teams could be useful to improve the UPHOP management.
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Affiliation(s)
- Alberto García-Salido
- Pediatric Critical Care Unit, Hospital Infantil Universitario Niño Jesús, Avenida Menéndez Pelayo 65, Madrid, Spain.
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21
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Intravenous levetiracetam in acute repetitive seizures and status epilepticus in children: Experience from a children's hospital. Seizure 2012; 21:529-34. [DOI: 10.1016/j.seizure.2012.05.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 05/16/2012] [Accepted: 05/18/2012] [Indexed: 11/22/2022] Open
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Abstract
Current standard treatment of established status epilepticus after failure of benzodiazepines is intravenous phenytoin/fosphenytoin, phenobarbital, or valproate. Since 2006 two new antiseizure drugs have become available as intravenous formulation: levetiracetam (2006) and lacosamide (2008). Both drugs have been taken up very rapidly by the clinicians to treat acute seizures and status epilepticus, despite lack of evidence from randomized controlled trials. The favorable pharmacokinetic profile and the good tolerability, especially the lack of sedating effects of both drugs make them promising potential alternatives to the standard antiseizure drugs. Future randomized controlled trials are needed to inform clinicians better about the best choice of treatment in established status epilepticus. The experimental evidence as well as the current clinical experience with levetiracetam and lacosamide are summarized in this review.
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Paracelsus Medical University, Ignaz Harrer Strasse 79, Salzburg, Austria.
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Abstract
OPINION STATEMENT Status epilepticus is characterized by a prolonged, self-sustaining seizure or repeated seizures without return to baseline. The clinical manifestations of status epilepticus in children and adults range from overt generalized convulsions to more subtle behavioral manifestations, including unresponsiveness in the setting of the intensive care unit. Status epilepticus is the most common neurologic emergency of childhood. A large proportion of these episodes are the result of a prolonged febrile seizure or an acute symptomatic etiology. Fortunately, status epilepticus occurs without consequence for many children, but for others, it is correlated with long-term neurologic dysfunction or death. Treatment of status epilepticus should commence promptly upon its recognition, using predefined treatment protocols. The goal of treatment is the rapid termination of the seizure, to minimize the acute and chronic effects of this emergency and to allow for the prompt assessment and management of the underlying precipitant. Currently, the drug class of first choice in the in-hospital and out-of-hospital treatment of status epilepticus is the benzodiazepines, which may need to be quickly followed by a next-line agent, as the efficacy of the benzodiazepines is negatively correlated with seizure duration. Traditionally, these next-line agents have included phenobarbital and phenytoin, but emerging evidence supports the use of intravenous formulations of other antiepileptic drugs. If the first two agents fail, high-dose intravenous midazolam or anesthetic therapy should be rapidly initiated. This paper reviews the current treatment options and strategies for pediatric patients with status epilepticus.
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Affiliation(s)
- Tobias Loddenkemper
- Harvard Medical School, Division of Epilepsy and Clinical Neurophysiology, Fegan 9, Children's Hospital Boston, 300 Longwood Ave., Boston, MA, 02115, USA,
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Hardesty DA, Sanborn MR, Parker WE, Storm PB. Perioperative seizure incidence and risk factors in 223 pediatric brain tumor patients without prior seizures. J Neurosurg Pediatr 2011; 7:609-15. [PMID: 21631197 DOI: 10.3171/2011.3.peds1120] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECT The incidence of, and risk factors for, perioperative seizures and the need for perioperative antiepileptic drugs (AEDs) in previously seizure-free children with brain tumors remains unclear. The authors have undertaken a review of previously seizure-free pediatric patients with brain tumors undergoing resection to identify the incidence of seizures in the perioperative period, and to characterize risk factors for perioperative seizures in this population. METHODS A retrospective review was conducted of all patients between 0 and 19 years of age without prior seizures who underwent intracranial tumor resection at the authors' institution between January 2005 and December 2009. RESULTS Of the 223 patients undergoing 229 operations, 7.4% experienced at least 1 clinical seizure during the surgical admission. Over half of all tumors were supratentorial. Only 4.4% of patients received prophylactic AEDs. Independent factors associated with perioperative seizures included supratentorial tumor, age < 2 years, and hyponatremia due to syndrome of inappropriate antidiuretic hormone or cerebral salt wasting. Tumor type, lobe affected, operative blood loss, and length of surgery were not independently associated with seizure incidence. CONCLUSIONS Perioperative seizures in previously seizure-free children undergoing resection of brain tumors are associated with supratentorial tumor location, age < 2 years, and postoperative hyponatremia. Perioperative seizures are not associated with tumor pathology, tumor size, or frontotemporal location. Due to the low incidence of seizures in this series in patients more than 2 years old with normal serum sodium, the authors recommend that pediatric patients with brain tumors not routinely receive perioperative prophylactic AEDs. However, the role for prophylaxis in patients younger than 2 years of age deserves further study.
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Affiliation(s)
- Douglas A Hardesty
- Department of Neurosurgery, University of Pennsylvania Medical Center, and Division of Neurosurgery, Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104-4399, USA.
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Wachtel EV, Hendricks-Muñoz KD. Current management of the infant who presents with neonatal encephalopathy. Curr Probl Pediatr Adolesc Health Care 2011; 41:132-53. [PMID: 21458747 DOI: 10.1016/j.cppeds.2010.12.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Neonatal encephalopathy after perinatal hypoxic-ischemic insult is a major contributor to global child mortality and morbidity. Brain injury in term infants in response to hypoxic-ischemic insult is a complex process evolving over hours to days, which provides a unique window of opportunity for neuroprotective treatment interventions. Advances in neuroimaging, brain monitoring techniques, and tissue biomarkers have improved the ability to diagnose, monitor, and care for newborn infants with neonatal encephalopathy as well as predict their outcome. However, challenges remain in early identification of infants at risk for neonatal encephalopathy, determination of timing and extent of hypoxic-ischemic brain injury, as well as optimal management and treatment duration. Therapeutic hypothermia is the most promising neuroprotective intervention to date for infants with moderate to severe neonatal encephalopathy after perinatal asphyxia and has currently been incorporated in many neonatal intensive care units in developed countries. However, only 1 in 6 babies with encephalopathy will benefit from hypothermia therapy; many infants still develop significant adverse outcomes. To enhance the outcome, specific diagnostic predictors are needed to identify patients likely to benefit from hypothermia treatment. Studies are needed to determine the efficacy of combined therapeutic strategies with hypothermia therapy to achieve maximal neuroprotective effect. This review focuses on important concepts in the pathophysiology, diagnosis, and management of infants with neonatal encephalopathy due to perinatal asphyxia, including an overview of recently introduced novel therapies.
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Affiliation(s)
- Elena V Wachtel
- Department of Pediatrics, Division of Neonatology, New York University School of Medicine, New York, NY, USA
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27
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Abstract
Status epilepticus is a common neurological emergency in childhood and associated with significant morbidity and mortality. Status epilepticus (SE) has been defined as continuous seizure activity lasting more than 30 min or 2 or more seizures in this duration without gaining consciousness between them. However, the operational definition has brought the time down to 5 min. Management can be broadly divided into initial stabilization, seizure termination, and evaluation and treatment of the underlying cause. Diagnostic evaluation and seizure control should be achieved simultaneously to improve outcome. Seizure termination is achieved by pharmacotherapy. Benzodiazepines are the first line drugs for SE. Commonly used drugs include lorazepam, diazepam, and midazolam. In children without an IV access, buccal or nasal midazolam or rectal diazepam can be used. Phenytoin as a second line agent is usually indicated when seizure is not controlled after one or more doses of benzodiazepines. If the seizures continue to persist, valproate, phenobarbitone or levetiracetam is indicated. Midazolam infusion is useful in refractory status epilepticus. Thiopentone, propofol or high dose phenobarbitone are considered for treatment of refractory status epilepticus. Prolonged SE is associated with higher morbidity and mortality. Long term neurological sequelae include epilepsy, behavioural problems, cognitive decline, and focal neurologic deficits.
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28
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Saz EU, Karapinar B, Ozcetin M, Polat M, Tosun A, Serdaroglu G, Gokben S, Tekgul H. Convulsive status epilepticus in children: etiology, treatment protocol and outcome. Seizure 2010; 20:115-8. [PMID: 21195636 DOI: 10.1016/j.seizure.2010.10.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Revised: 09/21/2010] [Accepted: 10/25/2010] [Indexed: 10/18/2022] Open
Abstract
This study aimed to determine the etiology, treatment protocol and outcome of convulsive status epilepticus (SE) in children. An institutional treatment protocol using benzodiazepines (diazepam and midazolam) was assessed in a retrospective case study. The treatment protocol (Ege Pediatric Status Epilepticus Protocol or EPSEP) was developed based on an operational definition of pediatric SE according to the duration of seizure activity. Pediatric SE is divided into three categories: initial SE (20-30 min), established SE (30-60 min) and refractory SE (>60 min). Eight (30%) of the studied episodes were initial SE, 10 (37%) were established SE, and 9 (33%) were refractory SE. With respect to the etiological spectrum of SE, 11 (40%) children had meningitis or encephalitis. Febrile SE was identified in 7 (26%) patients. Only 2 episodes of initial SE (7.5%) were controlled with first step of the protocol (two concomitant-doses of rectal diazepam). Midazolam bolus and infusions (up to 1.2 μg/kg/min) were used to treat 22 episodes of SE (9 refractory SE, 10 established SE and 3 initial SE). Complete arrest of convulsive SE was achieved in 21 of 22 (95%) episodes with midazolam infusion. We concluded that the combined use of benzodiazepines (diazepam+midazolam) was safe and effective in the treatment of convulsive SE in children.
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Affiliation(s)
- Eylem Ulas Saz
- Pediatric Emergency Department, Ege University School of Medicine, 35100 Bornova, Izmir, Turkey
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