Propofol and midazolam in the treatment of refractory status epilepticus

Purpose: To explore outcome differences between propofol and midazolam (MDL) therapy for refractory status epilepticus (RSE). Methods: Retrospective chart review of consecutive patients treated for RSE between 1995 and 1999. Results: We found 14 patients treated primarily with propofol and six with MDL. Propofol and MDL therapy achieved 64 and 67% complete clinical seizure suppression, and 78 and 67% electrographic seizure suppression, respectively. Overall mortality, although not statistically significant, was higher with propofol (57%) than with MDL (17%) (p = 0.16). Subgroup mortality data in propofol and MDL patients based on APACHE II (Acute Physiology and Chronic Health Evaluation) score did not show statistically significant differences except for propofol-treated patients with APACHE II score greater than or equal to 20, who had a higher mortality (p = 0.05). Reclassifying the one patient treated with both agents to the MDL group eliminated this statistically significant difference (p = 0.22). Conclusions: In our small sample of RSE patients, propofol and MDL did not differ in clinical and electrographic seizure control. Seizure control and overall survival rates, with the goal of electrographic seizure elimination or burst suppression rather than latter alone. were similar to previous reports. In RSE patients with APACHE II score greater than or equal to 20, survival with MDL may be better than with propofol. A large multicenter, prospective, randomized comparison is needed to clarify these data. If comparable efficacy of these agents in seizure control is borne out. tolerance with regard to hemodynamic compromise, complications, and mortality may dictate the choice of RSE agents.