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A review of admissions to the intensive care unit (ICU) of the Great Ormond Street Hospital for Children in London (
) has led to the conclusion that only one in six children admitted to the ICU with status epilepticus (SE) was treated appropriately before arrival in the emergency department.
During a 3-year period, 1 April 1998 to 31 March 2001, there were 2285 admissions to the ICU, 98 (4.3%) with SE. The 98 episodes occurred in 91 children aged between 1 month and 12 years (median 2.2 years) and there was an equal number of girls and boys. Seventy-eight children (86%) were under 5 years old and 70 (77%) had had no previous episode of SE. All of the children were intubated and ventilated, in 55 episodes because of respiratory insufficiency after seizures had stopped and in the remaining 43 in order to give treatment (thiopentone) to stop the SE.
The main diagnoses were prolonged febrile convulsion (31%), acute symptomatic SE (24%), and SE in idiopathic epilepsy (21%). The main cause of acute symptomatic SE was CNS infection (18 of 24 cases). Pre-ICU treatment was with diazepam or lorazepam in almost all episodes. The dose was unknown in 12 episodes and was considered to have been too high in three and too low in 29. It was considered appropriate (within the range of 80-120% of the ideal dose defined as 0.1 mg/kg for lorazepam and 0.45 mg/kg for diazepam) in 54 episodes (55%). Respiratory insufficiency was more frequent among the 53 children who had more than two doses of benzodiazepine (64% vs 45%). Rectal paraldehyde and intravenous phenytoin were used almost equally as second line drugs. The dose of phenytoin was usually appropriate (92% of cases) but the dose of paraldehyde was often considered high (30%) or low (16%). The median duration of ventilatory support was 15 hours and median stay on ICU one day (range 1-13 days). Five children died of acute bacterial meningitis (2), acute liver failure (1), brain tumour (1), and neurodegenerative disease (1).
The main messages of this paper appear to be: 1) get the dose right (consult guidelines) and 2) don’t give too many doses of benzodiazepine before moving to a second line drug and then, if necessary, to thiopentone anaesthesia with intubation and ventilation on ICU. (Two doses of benzodiazepine is probably enough (be aware of doses already given by someone else) and thiopentone anaesthesia is recommended when the seizure has lasted for 40 minutes or more after the start of treatment.) The authors state that appropriate audit and modifications of standard guidelines are required.
Please note that the reference in paragraph one is incomplete. The full reference is shown here:
Journal of Neurology Neurosurgery and Psychiatry 2004;75:1584-8
The error is much regretted.