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Hypotension: case report A 60-year-old man developed hypotension while receiving midazolam and propofol for the treatment of refractory nonconvulsive status epilepticus. The man, who had epilepsy treated with phenytoin and clobazam, developed a generalised seizure on day 10 of his hospitalisation for community-acquired pneumonia. After the seizure, he did not immediately regain consciousness and required admission to an ICU and endotracheal intubation. He received a further loading dose of phenytoin. He also received escalating doses of midazolam (repeated boluses of 5mg) [dosage information incomplete, route not stated] and an infusion of midazolam, which was progressively increased to 30 mg/hour. His seizures persisted. He subsequently received propofol, repeated boluses of 30mg [dosage information incomplete, route not stated], and an infusion of propofol increased to 50 µg/kg/min. In addition, he was given levetiracetam, but his seizure activity continued. He developed worsening hypotension with escalating doses of midazolam and propofol [duration of treatment to reaction onset not clearly stated]. The man received IV fluids and norepinephrine [noradrenaline] to maintain a mean arterial BP above 70mm Hg. He received ketamine, and his seizures were completely abolished approximately 12 hours later. There was no further need to adjust norepinephrine doses to support his BP. After he was seizure-free for approximately 48 hours, midazolam was discontinued. Propofol and ketamine were gradually withdrawn later, and he had no seizure recurrence. He regained consciousness 24 hours later and was then extubated. He was discharged from the ICU 24 hours later and discharged home 3 weeks later. Author comment: "In this patient, it would have been reasonable to further escalate doses of midazolam or propofol before resorting to ketamine. However, this approach would have undoubtedly resulted in more hypotension and the need for a higher vasopressor dose, which in turn would have increased the risk of other complications, such as arrhythmias or tissue hypoperfusion." Kramer AH. Early ketamine to treat refractory status epilepticus. Neurocritical Care 16: 299-305, No. 2, Apr 2012. Available from: URL: http:// 803074690 dx.doi.org/10.1007/s12028-011-9668-7 - Canada

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Reactions 11 Aug 2012 No. 1414