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Treatment of electrical seizures in HIE


hehady

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The current (national) recommendations is to treat subclinical seizures if they are recurrent (as registr by CFM or EEG).

We usually have infants with suspected seizures or post-asphyxia monitored with CFM, but check regular EEG's - daily until the infant is stable neurologically, and then less frequent until the EEG is normalized or has become stationary.

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  • 10 years later...
On 11/6/2006 at 6:40 PM, Stefan Johansson said:

The current (national) recommendations is to treat subclinical seizures if they are recurrent (as registr by CFM or EEG).

We usually have infants with suspected seizures or post-asphyxia monitored with CFM, but check regular EEG's - daily until the infant is stable neurologically, and then less frequent until the EEG is normalized or has become stationary.

Hi Stefan, 

I am not sure if I understand your answer. Do you mean that you check the aEEG on daily basis i.e. every 12 or 24 hrs and see if seizures are increasing or decreasing to consider treating?

According to my practice, once the aEEG shows a seizure or the baby shows a clinical seizure we start phenobarbital (PB). Later on during cooling, if the aEEG shows seizures in spite that the PB level in the blood is within the therapeutic range we add another (2nd) antiepileptic drug (AD) for example Midazolam. We continue to increase the 2nd AD if the seizure activity is still present until it stops or we reach the maximum dose of Midazolam. I mean by "seizure activity" here if even there is an aEEG seizure activity every six or 12 hrs. We actually don't wait to count them. Once there is a seizure we proceed further. In addition, when the baby receives PB we depend mainly on the aEEG because it causes uncoupling.

Could you please make it clearer for me?

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7 hours ago, Hamed said:

Hi Stefan, 

I am not sure if I understand your answer. Do you mean that you check the aEEG on daily basis i.e. every 12 or 24 hrs and see if seizures are increasing or decreasing to consider treating?

We monitor aEEG (CFM) continuosly, so if we see recurrent subclinical seizures (i.e. ≥2 episodes) we most often treat.

If we consider the aEEG to be abnormal or if we have poor seizure control, we commonly also follow regular EEG, for example 1-2 during cooling (of 72h) and then maybe every 7-14 days until we see normalization. But I feel that EEG has become less frequently done, as we mostly rely on aEEG. 

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We do not have set national guidelines in the US due to the way our health services are organized, but in the NICUs I cover (one in-born one out-born, both with cooling) we do treat electrographic seizures though our tolerance for isolated seizures will increase as time goes on if it becomes established that seizures are persisting and there is the need to balance the benefits of extinguishing seizure against the side effects of AEDs.

Regarding aEEG/CFM vs. EEG, because there is an active neurocritical care service available, we tend to reserve aEEG for urgent/emergent neurodevelopment-monitoring as it can be done by NICU nursing staff and interpreted by neonatologists as opposed to EEG which requires staff from neurology to set up and interpret.  Once a patient is clearly on a pathway where we may plan and anticipate their monitoring needs, we use EEG and/or vEEG per the preference/recommendation of our neurocritical care service.

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I agree with treating recurrent electrical seizures, however, what frequency of seizures and how long is each seizure until we would tolerate until starting AED or adding a 2nd one that is a concern which needs to be clarified. So long that it is not yet clearly outlined, I would go with what Stefan mentioned using a trigger for AEDs use, increase or addition of another line if  > 2 seizure episodes. However, yet it is not clear is the > 2 episodes time-related? i.e. > 2 episodes in 3~6 hrs or in 12 ~ 24 hrs.

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I know it is not the question you asked, Hamed, but I just re-read one of your posts and was intrigued to see you identify a benzodiazepine as your second line agent.  Is that common in your institutional or national practice?  We reserve Midazolam infusion for seizure refractory to multiple AEDs and up-titrate to effect (usually patient needs to be intubated for airway protection if we are starting Midazolam infusion).  I have used fosphenytoin and Keppra after phenobarbital (in discussion with colleagues in neurology) before starting benzodiazepines.  I am now curious about other's experience/practice.

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Hi Bimlac and thanks for asking, Midazolam infusion is one of the 2nd line AEDs in Japan, and the most commonly used one when the infant is intubated. I myself prefer Keppra over both Midazolam and fosphenytoin. Especially, during cooling. Midazolam causes hypotension and fosphenytoin has several side effects as well as, it's hard to reach and maintain a therapeutic level using fosphenytoin. In Japan Keppra is not yet accepted for use in children under 4 years of age unless the treating doctor submits a special request to use it. According to my practice, Keppra showed almost no side effects during using as a 2nd AED in infants with and without cooling. If the infant is not intubated, fosphenytoin takes place as the most commonly used 2nd AED.

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