Neonatal Seizure/Status Epilepticus — Anti-Seizure Medications (ASM) — Clinical Pathway: N/IICU

Neonatal Seizure/Status Epilepticus Clinical Pathway — N/IICU

Anti-Seizure Medications (ASM)

  • Phenobarbital indicated for
    • Definite seizures on cEEG
    • Highly probable clinical seizures: focal tonic or focal tonic-clonic events that are recurrent or prolonged
    • Highly probable aEEG seizures which are recurrent or prolonged
  • Benzodiazepines indicated for
    • Possible clinical seizures: not focal tonic or focal tonic-clonic
    • Possible aEEG seizures
Medication Dose Therapeutic Levels Comments
1st Line
Phenobarbital
  • Initial Loading
    • 20 mg/kg IV
    • Allow 30 mins for efficacy
  • 2nd Loading
    • 10-20 mg/kg IV
    • Allow 30 mins for efficacy
  • Max Cumulative Dose
    • 40 mg/kg
  • Consider lower doses based on cardiovascular stability
  • Check peak level 1-2 hrs after 2nd dose
  • Target level: 15-40 mcg/mL
  • > 50 mcg/mL accepted in certain scenarios in absence of adverse effects
  • Can cause cardiovascular effects
  • If target level > 50 mcg/mL,
    then neonatology and
    neurology discussion
  • Administration
    • Undiluted or diluted with NS to final concentration of 10 mg/mL
  • Max infusion rate:
    1 mg/kg/min up to 30 mg/min
2nd Line
Fosphenytoin
  • Initial Loading
    • 20 mg PE/kg IV
    • Allow 30 mins for efficacy
  • 2nd Loading
    • 10-20 mg PE/kg IV
    • Allow 30 mins for efficacy
    • Consider lower doses based on cardiovascular stability
    • Phenytoin sodium equivalents (PE)
  • Check total phenytoin peak level 1-2 hrs after each load dose
  • Target level: 10-20 mcg/mL
  • Obtain albumin level since fosphenytoin level can be higher than reported if hypoalbuminemia present
  • Use phenytoin if fosphenytoin is
    not available
  • Consider alternatives if there are concerns regarding poor IV access or cardiac arrhythmias
  • Administration
    • Dilute with D5W or NS to final concentration of 1.5-25 mg PE/mL
    • Max infusion rate: 2 mg PE/kg/min
3rd Line
Levetiracetam
  • Initial Loading
    • 60 mg/kg IV
    • Allow 15 mins for efficacy
  • 2nd Loading
    • 20-40 mg/kg
    • Allow 15 mins for efficacy
    • Consider if response to initial loading dose
 Blood levels of levetiracetam are not useful for acute management
  • Administration
    • Dilute with NS or D5W to final concentration of 10-15mg/mL
    • Infuse over 10-15 mins
4th Line Midazolam
  • Refractory Status Epilepticus
    • Use loading dose(s)
      and infusions
      • Loading Dose
        • 0.1 mg/kg IV
        • Bolus every 30 min for continued seizures
      • Infusion
        • IV 0.05-0.1 mg/kg/hr
        • Increase by 0.05 mg/kg/hr every 30-60 mins up to
          1 mg/kg/hr for continued seizures
      • Consider lower doses based on cardiovascular stability
  • Monitor for hypotension
  • Administration of Loading Doses
    • Infuse over 2-5 mins
Benzodiazepines indicated for possible clinical seizures (not focal tonic or focal tonic-clonic) or possible aEEG seizures
Midazolam
  • 0.1 mg/kg/dose IV
  • Repeat in 5 mins as indicated
  • Consider lower dose if concern for respiratory depression
  • 0.05 mg/kg/dose IV
  • Confirm seizure activity with cEEG
  • Initiate phenobarbital if confirmed
  • Monitor for hypotension
  • Administration
    • Infuse over 2-5 mins
Lorazepam
  • 0.1 mg/kg/dose IV
  • Repeat in 5 mins as indicated
  • Consider lower dose if concern for respiratory depression
  • 0.05 mg/kg/dose IV
  • Confirm seizure activity with cEEG
  • Initiate phenobarbital if confirmed
  • Monitor for hypotension
  • Administration
    • Dilute with NS, D5W or SWFI due
      to viscosity
    • Max infusion rate:
      0.05 mg/kg over 2-5 mins