Neurocritical Care

Antiepileptic

Drug

Dosing

Common

Adverse Effects

Considerations

Pentobarbital

10 mg/kg (typically over

15–30 min, depending on

blood pressure); typically need

additional 5 to 10 mg/kg boluses

to full loading dose of 25–30

mg/kg; 1 to 3 mg/kg/hr infusion

Sedation,

hypotension,

respiratory

depression,

constipation,

cardiac depression,

immunosuppression

IV formulation contains propylene

glycol; target is burst suppression;

several drug-drug interactions

Midazolam

high-dose

infusion

0.05–2 mg/kg/hr

Sedation,

hypotension,

respiratory depression

Potential tachyphylaxis, target is

burst suppression

Propofol

20–200 mcg/kg/min, titrate by

5 mcg/kg/min; use caution

when administering doses >

80 mcg/kg/min for extended

periods

Sedation,

hypotension,

respiratory

depression,

pancreatitis, propofol-

related infusion

syndrome

Target is burst suppression; provides

1.1 kcal/mL; hypertriglyceridemia at

higher doses

Ketamine

0.5–10 mg/kg/hr

Excitation,

hypertension, possible

neurotoxicity,

hallucinations

May be more effective in prolonged

refractory status epilepticus. May

cause hypotension in patients with

decreased shock index; consider

IV fluid volume with high-dose

infusions

AES = American Epilepsy Society; BID = twice daily; IM = intramuscular(ly); NCS = Neurocritical Care Society; PE = phenytoin equivalents; QID = four times daily.

Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012;17:3-23; Glauser T, Shinnar S, Gloss D,

et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the Guideline Committee of the American Epilepsy Society.

Epilepsy Curr 2016;16:48-61.

Patient Case

A 37-year-old man (weight 75 kg) is admitted to the emergency department with meningitis. On admis-

sion, his GCS score decreases from E3-M6-V1T to E1-M5-V1T over 10 minutes, and his nurse notices

facial twitching. An EEG is ordered. Current medications include famotidine 20 mg intravenously every 12

hours, heparin 5000 units subcutaneously every 8 hours, docusate 100 mg nasogastrically twice daily, and

a supplemental vitamin infusion for potential alcohol withdrawal. Which is the best acute therapy for this

patient’s suspected seizure activity?