Initial dose | Re-loading dose | Maintenance dose | |
Parenteral benzodiazepine choices (initial regimen) | |||
Lorazepam | 2 to 4 mg IV bolus up to up to 2 mg/min | 2 to 4 mg IV | N/A |
Diazepam | 5 to 10 mg IV bolus up to 5 mg/min | 5 to 10 mg IV | N/A |
Midazolam | 5 to 10 mg IV or IM | 5 to 10 mg IV or IM | N/A |
Nonsedating antiseizure choices (initial regimen) | |||
Phenytoin | 15 mg/kg IV (up to 50 mg/min) | 10 to 15 mg/kg up to a maximum cumulative dose of 30 mg/kg* | 5 to 7 mg/kg/day orally/IV, divided every 8 hours |
Fosphenytoin | 15 mg PE/kg IV (up to 150 mg PE/min) | 10 mg PE/kg up to a maximum cumulative dose of 25 to 30 mg/kg* | 5 to 7 mg PE/kg/day IV, divided every 8 hours |
Valproate | 30 mg/kg IV (up to 5 mg/kg/min) | 20 mg/kg up to a maximum cumulative dose of 4000 mg | 30 to 60 mg/kg/day, orally/IV divided every 6 to 12 hours¶ |
Levetiracetam | 40 mg/kg IV (up to 5 mg/kg/min, typically given over 15 min, maximum 4500 mg) | 1000 to 2000 mg up to a maximum cumulative dose of 4500 mg | 2 to 4 g/day orally/IV, divided every 6 to 12 hours¶Δ |
Lacosamide | 200 mg IV (over 15 min) | 200 mg IV | 200 to 600 mg/day orally/IV, divided every 12 hours¶ |
Potential oral or nasogastric add-on nonanesthetic options | |||
Topiramate | 100 mg orally every 12 hours | N/A | 300 to 800 mg/day orally, divided every 8 to 12 hours |
Gabapentin | 300 mg orally every 8 hours | N/A | 1800 to 3600 mg/day orally, divided every 6 to 8 hours |
Pregabalin | 75 mg orally every 12 hours | N/A | 150 to 600 mg/day orally, divided every 8 to 12 hours |
Clobazam | 10 to 20 mg orally every 12 hours | N/A | Up to 60 mg/day orally, divided every 12 hours |
Perampanel | 6 to 12 mg orally every 24 hours | N/A | Up to 12 mg orally every 24 hours |
Oxcarbazepine | 300 to 600 mg orally every 12 hours | N/A | Up to 2400 mg/day orally, divided every 12 hours |
Carbamazepine | 300 to 800 mg orally in two to four divided doses (product dependent) | N/A | Up to 1600 mg/day orally, divided every 12 hours (tablets) or every 6 hours (liquid) |
Vigabatrin | 500 to 750 mg orally every 12 hours | N/A | Up to 3000 mg/day orally, divided every 12 hours◊ |
Continuous infusion anesthetic options in critically ill mechanically ventilated patients§ | |||
Midazolam | 0.2 mg/kg IV (up to 2 mg/min) every 5 min until seizures controlled or maximum dose of 2 mg/kg; followed by continuous infusion | N/A | 0.05 to 2.9 mg/kg/hour continuous IV infusion |
Propofol | 1 to 2 mg/kg IV every 5 min until seizures controlled or maximum dose 10 mg/kg; followed by continuous infusion | N/A | 1.8 to 12 mg/kg/hour continuous IV infusion (limit to 5 mg/kg/hour for treatment >48 hours) |
Pentobarbital | 5 mg/kg IV (up to 50 mg/min) every 5 min until seizures controlled up to a maximum of 25 mg/kg; followed by continuous infusion | N/A | 0.5 to 10 mg/kg/hour continuous IV infusion |
Ketamine | 1.5 mg/kg IV every 5 min until seizures controlled or up to a maximum dose of 4.5 mg/kg; followed by continuous infusion | N/A | 1.2 to 7.5 mg/kg/hour continuous IV infusion |
Other potential treatments | |||
Ketogenic diet | |||
Methylprednisolone | 1 g/day for 3 days | N/A | 1 mg/kg/day then taper |
IVIG | 0.4 g/kg/day for 5 days | N/A | N/A |
Plasma exchange | |||
Hypothermia | |||
Electroconvulsive therapy |
D: day; EEG: electroencephalography; g: gram; h: hour; IM: intramuscular; IV: intravenous; IVIG: intravenous immunoglobulin; kg: kilogram; min: minutes; mg: milligram; N/A: not applicable; NCSE: nonconvulsive status epilepticus; PE: phenytoin equivalent.
* In patients receiving phenytoin chronically the maximum reloading dose is determined by assessment of serum concentration.
¶ Oral/enteral bioavailability may be limited in critically ill patients due to ileus, intestinal wall edema, and visceral hypoperfusion; IV formulations are preferred when available.
Δ Higher doses and more frequent dosing may be necessary in some critically ill patients.
◊ Vigabatrin has been associated with vision loss and availability in the United States is restricted. The US Food and Drug administration recommends baseline and serial monitoring of visual fields every three months in patients treated with vigabatrin.
§ Anesthetic agents are titrated to seizure termination by an experienced intensivist in a critical care unit.Courtesy of the authors.
Additional data from:Do you want to add Medilib to your home screen?