• 
• 

Three Part Question

In [paediatric patients with Convulsive Status Epilepticus] is [Lignocaine, in addition to established anti-epileptic protocols] effective [at controlling seizure activity]?

Clinical Scenario

A 2 year old boy with known epilepsy presents to your Emergency Department. He is actively fitting and has continued to do so despite treatment with benzodiazepines, paraldehyde and phenytoin for 30 minutes. You are aware that this patient is going to require rapid sequence induction with thiopentone and transfer to PICU but have been made aware of Lignocaine as an alternative anticonvulsant in these patients and wonder whether it is an effective treatment.

Search Strategy

Medline (1950-2008), Embase (1980-2008) and CINHAL (1981-2008).
(*lignocaine/ or *lidocaine/ or *xylocaine/) and (exp status epilepticus/)
[LIMIT to Humans and (Age Group All Child 0-18, Age Group Child unspecified) and English language]

Search Outcome

A total of 17 papers were found, of which 14 were irrelevant or of insufficient quality for inclusion. For the purposes of this report, case reports and case series were not included.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hattori H et al, 2008, Japan	261 CSE episodes aged 1 month – 15 years, 28 hospitals sent questionnaires concerning patients admitted for CSE that were managed with lignocaine.	Retrospective multi-institutional questionnaire	Usefulness, Seizure outcome, Efficiacy of initial loading dose (LD) and maintenance infusion	148 (56.7%) lignocaine rated useful or extremely useful, Epilepsy 79% effective OR 1, CNS infection 12% effective OR 0.41 (0.78-3.44) p<0.033, Other acute disease effective 57% OR 9.99 (3.65-27.4) p<0.000, adverse events 13.5%.	Retrospective study, selection bias, no indication of questionnaire validity or piloting, responder related bias, confounding effect of SE severity not excluded, statistically wide CI, patient cohort comparison may be limited, no indication time period
Yildiz et al, 2008, Turkey	49 patients, mean age 5.5+/-3 yr, the effects of lignocaine on patients with CSE due to infectious or non-infectious reasons were compared. Given to those patients that failed to respond to first line therapy (Feb 1996-Nov 2001)	Retrospective Cohort Study (case record review)	Cessation of CSE with loading dose and continuous infusion.	Mean duration lignocaine infusion 14.6+/- 7.8hr, 44.4% effectivity, 55.3% failed to respond, infection related CSE responded better than seizures due to epilepsy (39.9% vs 6.8%; p<0.05), adverse reaction 10.3%, 4 patients died	Retrospective data collection, small study, no specified criteria for efficacy.
Hamano et al, 2006, Japan	37 children ( mean age 3yr 7 mo +/- 3yr 5 mo) admitted to Saitama Children’s Medical Centre between Oct 1997-Dec 2003 with CSE treated with lignocaine.	Retrospective Cohort Study, (medical record review)	Lignocaine effective when bolus injection resulted in no recurrence of seizures at 24 hours or no recurrence during infusion at 48 hours.	19/53 convulsive episodes controlled (35.8%). Seizures ceased within 5 mins of lignocaine administration in all 19 that were responsive to the drug. There was no statistical difference in effectiveness regarding aetiology of SE.	Retrospective Study, selection bias, small numbers/ low power

Comment(s)

Available evidence for lignocaine as an effective anticonvulsant in children with CSE is limited to small retrospective cohort studies. Although there is some evidence for the use of lignocaine as an anticonvulsive agent in the literature, this mostly relates to the adult population and is in low powered case reports. The Status Epilepticus Working Party guideline(2), NICE guideline and APLS guideline(1) therefore make no reference to the use of lignocaine for status epilepticus.

Clinical Bottom Line

The clinical bottom line is that the role of Lignocaine in standard therapy for CSE has yet to be established. There are no large, double-blind, placebo controlled trials of lignocaine efficacy in CSE and it is therefore not recommended in current guidelines.

References

1. Hattori H et al. Effectiveness of Lidocaine infusion for status epilepticus in childhood: A retrospective multi-institutional study in Japan. Brain & Development 2008; 30(8);504-512.
2. Bilal Yildiz et al. Lidocaine treatment in pediatric convulsive status epilepticus. Pediatrics international 2008; 50 (1); 35-39.
3. Shin-ichiro Hamano et al. Intravenous lidocaine for status epilepticus during childhood. developmental Medicine & child Neurology 2006:48(3); 220-222.
4. The convulsing child. In: Advanced Life Support Group (eds). Advanced Paediatric Life Support: The Practical Approach, 4th Edn. BMJ Publishing Group, London 2005; Ch.12, 139-148.
5. Appleton R, Choonara I, Martand T, Phillips B, Scott R, Whitehouse W, The Status Epilepticus Working Party. The treatment of convulsive status epilepticus in children. Arch Dis Child 2000;83;415-419.