Status Epilepticus -2 ( dosing /contraindications)

IV Antiepileptic Drugs – Status Epilepticus (ICU Reference)

Lorazepam

• Bolus: 0.1 mg/kg IV (max 4 mg/dose); may repeat once in 10–15 min
• Maintenance: Not used for continuous infusion in SE
• Contraindications: Severe respiratory depression, hypotension, caution elderly
• Notes: Preferred benzodiazepine for SE

Diazepam

• Bolus: 0.15–0.2 mg/kg IV (max 10 mg/dose); may repeat once
• Maintenance: Not ideal; bridge to longer AED
• Contraindications: Respiratory depression, hepatic impairment

Midazolam (⚠ sedation differs)

• Bolus (SE): 0.2 mg/kg IV over 2 min (max 10 mg)
• Maintenance (SE): 0.05–2 mg/kg/hr continuous infusion
• Sedation (ICU): 0.02–0.2 mg/kg/hr (much lower)
• Contraindications: Hypotension, respiratory depression

Propofol (⚠ sedation differs)

• Bolus (SE): 1–2 mg/kg IV
• Maintenance (SE): 2–10 mg/kg/hr continuous infusion
• Sedation (ICU): 0.3–5 mg/kg/hr (5–80 mcg/kg/min)
• Contraindications: Hemodynamic instability, egg/soy allergy, PRIS risk >4 mg/kg/hr >48h

Ketamine (⚠ sedation differs)

• Bolus (SE/RSE): 0.5–2 mg/kg IV (may repeat to a total of ~3 mg/kg as needed)
• Maintenance (SE/RSE): 1–5 mg/kg/hr continuous infusion; titrate to seizure control/EEG goals
• Sedation/Analgesia (ICU ⚠): 0.05–0.4 mg/kg/hr (≈0.8–6.7 mcg/kg/min); optional small bolus 0.1–0.5 mg/kg for breakthrough discomfort
• Contraindications/Cautions: Uncontrolled hypertension; tachyarrhythmias; decompensated CAD or aortic disease; severe hepatic dysfunction; history of psychosis; elevated intracranial/intraocular pressure (relative/controversial); pregnancy (relative). Can ↑ BP/HR (in catecholamine-depleted shock may cause hypotension).
• Notes: NMDA antagonist useful in refractory SE; bronchodilatory; tends to preserve respiratory drive.

Pentobarbital

• Bolus: 5–15 mg/kg IV over 1 hr
• Maintenance: 0.5–5 mg/kg/hr (EEG guided)
• Contraindications: Hypotension, respiratory depression, porphyria

Thiopental

• Bolus: 3–5 mg/kg IV
• Maintenance: 3–5 mg/kg/hr
• Contraindications: Same as pentobarbital

Valproic Acid

• Bolus: 20–40 mg/kg IV over 5–10 min (max 3 g)
• Maintenance: 1–6 mg/kg/hr infusion or 15–60 mg/kg/day divided
• Contraindications: Hepatic failure, POLG mutation, pregnancy (relative)

Levetiracetam

• Bolus: 60 mg/kg IV over 15 min (max 4.5 g)
• Maintenance: 20–30 mg/kg IV q12h (max 1.5 g q12h)
• Contraindications: Renal failure (dose adjust)

Lacosamide

• Bolus: 200–400 mg IV over 15 min
• Maintenance: 200–400 mg/day divided q12h
• Contraindications: AV block, PR prolongation

Phenytoin / Fosphenytoin

• Bolus: 15–20 mg PE/kg IV (max rate phenytoin ≤50 mg/min, fosphenytoin ≤150 mg PE/min)
• Supplemental: 5–10 mg/kg if needed
• Maintenance: 4–6 mg/kg/day divided q12h
• Contraindications: Bradycardia, AV block, hypotension, arrhythmias

Phenobarbital

• Bolus: 15–20 mg/kg IV at ≤100 mg/min
• Maintenance: 1–3 mg/kg/day divided BID
• Contraindications: Respiratory depression, porphyria, hepatic failure