Refractory status epilepticus: Propofol could be fatal

Patients treated for their prolonged seizures with the sedative Propofol ( Diprivan ) may be at high risk for complications and even death.

New research showed that the use of Propofol as an antiepileptic agent in patients with refractory status epilepticus ( RSE ), prolonged seizures that do not respond to initial treatment, was associated with significant mortality and morbidity.

Refractory status epilepticus is a difficult clinical problem seen in patients with primary epilepsy and in those with other conditions such as trauma, tumors, and infections affecting the brain. Although Propofol is used to treat patients with RSE, it is more commonly used for sedation during surgeries or other patient procedures but at a much lower dose and shorter duration than that used for the control of seizures.

Iyer and his colleagues from Mayo Clinic, Rochester, reviewed 39 consecutive patients ( median age of 54 years ) from 1997 to 2007, who were admitted to the ICU with refractory status epilepticus, in order to examine the link between Propofol use and related side effects, including Propofol infusion syndrome ( PRIS ).

PRIS is a usually fatal complication of Propofol use that has been reported especially at high infusion rates for prolonged periods. For this study, PRIS was defined by the unexplained presence of at least one or more of the following: metabolic acidosis, rhabdomyolysis, bradycardia, and/or cardiac arrest.

Propofol was used in 32 ( 82 percent ) of the patients ( group A ) for a median of 63 hours and a median peak infusion rate of 67 mcg/kg/min. Other agents, such as Midazolam and Pentobarbital, were used in the other seven ( 18 percent ) patients ( group B ). Within group A, three patients had sudden unexplained cardiac arrest while on Propofol infusions, resulting in two deaths, while no deaths occurred in group B. Median hospital stay ( 12 days ) and ICU length of stay ( 9 days ) did not differ between the two groups. The overall occurrence of PRIS was 30 percent of patients in group A ( seven patients with bradycardia, three patients with sudden unexplained cardiac arrest ) compared with less than 3 percent ( one patient with bradycardia ) in group B.

In light of the new data, Iyer advises that caution should be taken with the use of Propofol to treat patients with refractory status epilepticus. " There are several other medications we can turn to in the case of uncontrolled seizures," he said. "Alternative agents should first be tried for patients with refractory status epilepticus, and Propofol should only be used after exhausting all other options."

Source: American College of Chest Physicians, 2008


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