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Three Part Question

In [patients in resistant status epilepticus] is [propofol] effective at [reducing seizure activity]?

Clinical Scenario

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.

Search Strategy

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

Search Outcome

24 papers of which 6 included data on patients relevant to the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Mackenzie SJ et al, 1990, Scotland	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, 1991, Italy	4 patients on ICU with RSE	Case series	Observation of seizure activity	Propofol infusion stopped apparent seizure activity	Case series
Borgeat A et al, 1994, Switzerland	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 1995 Finland	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, 1998, USA	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, 1998, USA	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)

Comment(s)

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.

References

1. Mackenzie SJ, Kapadia F, Grant IS. Propofol infusion for control of status epilepticus. Anaesthesia 1990;45:1043-5.
2. 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.
3. Borgeat A, Wilder-Smith OH, Jallon P, et al. Propofol in the management of refractory status epilepticus. Intensive Care Med 1994;20:148-9.
4. Kuisma M, Roine RO. Propofol in prehospital treatment of convulsive status epilepticus Epilepsia 1995;36:1241-3.
5. Harrison AM, Lugo RA, Schunk JE. Treatment of convulsive status epilepticus with propofol: case report. Pediatr Emerg Care 1997;13:420-2.
6. Stecker MM, Kramer TH, Raps EC, et al. Treatment of refractory status epilepticus with propofol: clinical and pharmacokinetic findings. Epilepsia 1998;39:18-26.