Very-high-dose phenobarbital was used for refractory status epilepticus in 50 children treated in the Neurology Division, Children's Hospital, University of Southern California School of Medicine, Los Angeles, CA. Intravenous boluses of 5-20 mg/kg, in increments of 10 mg/kg at 30-60 min intervals, produced a linear increase in drug level of 9.7 mcg/ml over a 24- to 48-hour time span. All patients were intubated prior to treatment. Side-effects, principally depression of respiratory drive and cardiac suppression with hypotension, were influenced more by the severity of the underlying disease and the seizures than by the use of the drug. Phenobarbital controlled seizures in all cases where limits were not imposed on the maximum dose by uncontrollable hypotension. Seven patients died, none during a period of rising drug level. Maximum serum levels ranged from 70-344 mcg/ml. [1]

COMMENT. Phenobarbital in adequate amounts given intravenously is a relatively safe and effective treatment for status epilepticus, but in those cases not responding to initial doses of 10-20 mg/kg, further amounts should be used only after the patient has been intubated. Pressor agents may be required to treat hypotension and assisted ventilation for respiratory depression. When the intravenous administration of drugs is not possible or practical, rectal therapy with paraldehyde, diazepam, or valproic acid has been recommended (see Ped Neur Briefs, Jan 1988;2:7) for termination of prolonged or serial seizures. The treatment of status epilepticus in children with rectal sodium valproate was reported from the Children's Hospital, Birmingham, Alabama [2]. A loading dose of 20 mg/kg was effective but a marked rise in serum glumatic oxaloacetic transaminase activityoccurred in 3 of 7 patients treated, requiring cessation of valproate therapy.