Three Part Question
In [patients in resistant status epilepticus] is [propofol] effective at [reducing seizure activity]?
A 20 year old man presents to the emergency department in status epilepticus. Initial therapy with benzodiazepines and phenytoin is unsuccessful. He is intubated and ventilated using thiopentone and suxamethonium. 10 minutes later he starts to fit again. The anaesthetist suggests that propofol may help but you have heard that propofol can increase EEG activity. You wonder whether this is an appropriate drug to use.
Medline 1966-12/01 using the OVID interface.
[exp propofol OR propofol.mp OR diprivan.mp] AND [exp status epilepticus OR status epilepticus.mp] LIMIT to human, English, abstracts
24 papers of which 6 included data on patients relevant to the clinical question.
|Author, date and country
||Study type (level of evidence)
|Mackenzie SJ et al,|
|2 patients with RSE. Standard treatment unsuccesful.||Case series||Observation of seizure activity ||Propofol stopped seizure activity clinically and on EEG||Case series
|Campostrini R et al,|
|4 patients on ICU with RSE||Case series||Observation of seizure activity ||Propofol infusion stopped apparent seizure activity||Case series|
|Borgeat A et al,|
|Adult OD patient. Propofol was given to suppress EEG activity||Case report||Observation of EEG activity||Propofol appeared to suppress EEG seizure activity||Case report|
|Kuisma M and Roine RO|
|8 adult patients in prehospital care with RSE. All received propofol boluses of 100-200mg. All patients were intubated and ventilated.||Case series||Success at terminating seizures||All patients stopped RSE with propofol||Case series. Not clear if patients intubated before or after propofol usage. This could be a result of the use of propofol.|
|Harrison AM et al,|
|9/12 child with hereditary fructose intolerance in RSE||Case report||Observation||RSE stopped on infusion of 3mg/Kg propofol||Case report
Rare underlying disorder|
|Stecker MM et al,|
|16 Adult patients with RSE. All patients intubated.
Thiopentone (8) vs propofol (8) 1mg/kg over 5 mins, repeated if needed.||Open trial||Time to seizure termination (elimination of EEG and clinical seizures)||Thiopentone 123 min vs propofol 2.6 min (p=0.002)||Open trial. Some of the propofol patients part of another trial, others identified retrospectively.
Very small trial|
|Success at terminating seizures||Thiopentone 82% vs propofol 63% (NS)|
The evidence for propofol in RSE is weak. It is based on case series and small open label trials. However there is some theoretical basis for the use of propofol in RSE and the observations made in the studies presented are encouraging. Further work is clearly needed but in refractory status epilepticus resistant to conventional therapy it would not be unreasonable to try propofol.
Clinical Bottom Line
Propofol may be considered as a therapy for status epilepticus if conventional therapies have failed.
- Mackenzie SJ, Kapadia F, Grant IS. Propofol infusion for control of status epilepticus. Anaesthesia 1990;45:1043-5.
- Campostrini R, Bati MB, Giorgi C, et al. Propofol in the treatment of convulsive status epilepticus: a report of 4 cases. Rivista di Neurologia 1991;61:176-9.
- Borgeat A, Wilder-Smith OH, Jallon P, et al. Propofol in the management of refractory status epilepticus. Intensive Care Med 1994;20:148-9.
- Kuisma M, Roine RO. Propofol in prehospital treatment of convulsive status epilepticus Epilepsia 1995;36:1241-3.
- Harrison AM, Lugo RA, Schunk JE. Treatment of convulsive status epilepticus with propofol: case report. Pediatr Emerg Care 1997;13:420-2.
- Stecker MM, Kramer TH, Raps EC, et al. Treatment of refractory status epilepticus with propofol: clinical and pharmacokinetic findings. Epilepsia 1998;39:18-26.