[S1-1A-3] Treatment of refractory convulsive status epilepticus in children
When seizures persist despite adequate second-line treatment including IV diazepam, midazolam (MDL), fosphenytoin, or phenobarbital, barbiturates (BAR) coma or MDL coma therapy should be started. Two BAR, pentobarbital and thiopental, are usually used in the world. The treatment goal is clinical seizure cessation, and electrical seizure cessation (ESC) for 24-48 h with MDL and burst-suppression pattern (BSP) on EEG for 24-48 h with BAR. Practical procedures of MDL and BAR coma therapy will be discussed: initial bolus dose, following continuous intravenous infusion (CIV) details (starting dose, escalation rate, maximum dose, and duration), withdrawal, management of breakthrough seizures, adverse events and caution. Since status epilepticus (SE) is life-threatening event, treatment of SE requires higher doses of these medicines than those of officially approved. BSP on EEG is obtained well with PTB, less with THP, and hardly with MDL. Adverse events include respiratory and circulatory depression, red or blue thrombophlebitis, increased CRP, and decreased gastrointestinal function. Mechanical ventilation and inotropic support are mandatory during BAR or MDL coma therapy. Management of difficult withdrawal of MDL or BAR coma therapy will be discussed including non-intravenous high dose phenobarbital therapy which we have developed.