Characteristics of Patient with Status Epilepticus at the Emergency Department of Sanglah General Hospital

Introduction: Status epilepticus is a neurological condition caused by a failure of body mechanism to terminate the seizures or the onset of abnormal seizure activity resulting in prolonged seizure’s duration for more than five minutes. The available research data on status epilepticus in Indonesia is still limited. The purpose of this study was to determine the profile of patients with status epilepticus at Sanglah General Hospital from 2020 to 2021. Methods: This was a descriptive study with a retrospective approach. The study populations were patients with status epilepticus who were treated at Sanglah General Hospital in 2019-2020 who had no missing data in the medical records. Results: There were 117 patients with status epilepticus, 63 males (53.8%) and 54 females (46.2%). There are 41 patients>60 years (35%), general onset in 63 patients (53.8%), and focal onset in 54 patients (46.2%). Etiology from cerebral was 68 patients (58.1%), followed by metabolic in 28 patients (23.9%). The most common OAE therapy was phenytoin (86.3%) and the longest length of stay status epilepticus patients was 8 days (55.6%). Patients with status epilepticus had leukocytosis (73.5%), increased NLR (66.7%), and decreased mean platelet volume (53.8%). Conclusion: The highest incidence of status epilepticus is in women, above 60 years, general onset type of seizure, and etiology from cerebral. Initial therapy in 117 patients was intravenous diazepam followed by phenytoin for maintenance. NLR increased in most of the patients showing signs of inflammation which further worsened the patient's outcome with a mortality rate of 47%. Keywords: Status epilepticus, seizure duration, anticonvulsant, neutrophil-lymphocyte ratio.

Ifosfamide-related encephalopathy with severe clinical presentations in children with cancer

Introduction Ifosfamide is an alkylating agent, mostly used against variety of solid tumors in pediatric oncology practice. Although hemorrhagic cystitis is known as a common adverse effect, encephalopathy is the another one that should be kept in mind. It may occur in 2–5% of the children, and manifested by different clinical spectrums such as somnolence, lethargy, irritability, excitement, disorientation, confusion, weakness, hallucinations, seizures, movement disorders, and coma. Case report Herein, we present two patients who developed generalized seizure activity and one who developed coma during ifosfamide infusion. Management and outcome: In the first two patients, ifosfamide infusion was discontinued and intravenous diazepam was given. Their seizure stopped in a few minutes and neurological examination was back to normal, and no focal deficits were observed. In the third patient, ifosfamide infusion was discontinued, methylene blue and thiamine were given. After the tenth dose of methylene blue, she became neurologically normal, without any mental and motor deficit. Nevertheless, later she developed febrile neutropenia, septic shock and she died. Discussion These cases highlight that pediatric oncologists and hematologists should be aware of possibility of severe neurological toxicity after administration of ifosfamide in adolescent patients. Apart from seizure, clinicians should also be prepared to notice drowsiness during ifosfamide infusions in children. Most of the time cessation of ifosfamide and hydration is enough. However, in severe toxicities there is a risk of irreversible neurological damage, and for these patients methylene blue (MB) and thiamine treatment should be kept in mind.

Outcomes for 298 breastfed neonates whose mothers received ketamine and diazepam for postpartum tubal ligation in a resource-limited setting

Background Anesthesia in lactating women is frequently indicated for time-sensitive procedures such as postpartum tubal ligation. Ketamine and diazepam are two of the most commonly used anesthetic agents in low resource settings, but their safety profile in lactating women has not been established. Methods Medical records of post-partum tubal ligations between 2013 and 2018 at clinics of the Shoklo Malaria Research Unit were reviewed for completeness of key outcome variables. Logistic regression identified presence or absence of associations between drug doses and adverse neonatal outcomes: clinically significant weight loss (≥95th percentile) and neonatal hyperbilirubinemia requiring phototherapy. Results Of 358 records reviewed, 298 were lactating women with singleton, term neonates. There were no severe outcomes in mothers or neonates. On the first postoperative day 98.0% (290/296) of neonates were reported to be breastfeeding well and 6.4% (19/298) had clinically significant weight loss. Phototherapy was required for 13.8% (41/298) of neonates. There was no association between either of the outcomes and increasing ketamine doses (up to 3.8 mg/kg), preoperative oral diazepam (5 mg), or increasing lidocaine doses (up to 200 mg). Preoperative oral diazepam resulted in lower doses of intraoperative anesthetics. Doses of intravenous diazepam above 0.1 mg/kg were associated with increased risk (adjusted odds ratio per 0.1 mg/kg increase, 95%CI) of weight loss (1.95, 95%CI 1.13–3.35, p = 0.016) and jaundice requiring phototherapy (1.87, 95%CI 1.11–3.13, p = 0.017). Conclusions In resource-limited settings ketamine use appears safe in lactating women and uninterrupted breastfeeding should be encouraged and supported. Preoperative oral diazepam may help reduce intraoperative anesthetic doses, but intravenous diazepam should be used with caution and avoided in high doses in lactating women.

Clonazepam versus Lorazepam in the Treatment of Methamphetamine-Poisoned Children: A Pilot Clinical Trial

Objectives: To evaluate the efficacy of oral clonazepam versus oral lorazepam following initial parenteral benzodiazepine administration to control methamphetamine-induced agitation in children. Methods: In a single-center clinical trial, intravenous diazepam (0.2 mg/Kg) was initially administered to all methamphetamine-poisoned pediatric patients to control their agitation, followed by a single dose of oral clonazepam (0.05 mg/Kg; n=15) or oral lorazepam (0.05 mg/Kg; n=15) to prevent relapse of toxicity. Results: The median age [IQR] (range) was 15 [ 10, 36] (6-144) months. The source of poisoning was methamphetamine exposure from oral ingestion in 23 (76.7%) and passive inhalation in 7 (23.3%) patients. The most common symptoms/signs were agitation (29; 96.7%), mydriatic pupils (26; 86.7%), and tachycardia (20; 66.6%). Two in each group (13.3%) needed re-administration of intravenous diazepam due to persistent agitation. There was no report of benzodiazepine complications in either group. Conclusions: Clonazepam and lorazepam treatment was equally effective at similar doses. However, considering the higher potency of clonazepam, it seems that lorazepam is the safer benzodiazepine for oral maintenance treatment of methamphetamine-induced agitation in children and can be used with minimal complications. Trial registration: IRCT20180610040036N2, April 18 th , 2020. Retrospectively registered

Oral clonazepam versus lorazepam in the treatment of methamphetamine-poisoned children: a pilot clinical trial

Objectives To evaluate the efficacy of oral clonazepam versus oral lorazepam following initial parenteral benzodiazepine administration to control methamphetamine-induced agitation in children. Methods In a single-center clinical trial, intravenous diazepam (0.2 mg/Kg) was initially administered to all methamphetamine-poisoned pediatric patients to control their agitation, followed by a single dose of oral clonazepam (0.05 mg/Kg; n = 15) or oral lorazepam (0.05 mg/Kg; n = 15) to prevent relapse of toxicity. Results The median age [IQR] (range) was 15 [10, 36] (6-144) months. The source of poisoning was methamphetamine exposure from oral ingestion in 23 (76.7%) and passive inhalation in 7 (23.3%) patients. The most common symptoms/signs were agitation (29; 96.7%), mydriatic pupils (26; 86.7%), and tachycardia (20; 66.6%). Two in each group (13.3%) needed re-administration of intravenous diazepam due to persistent agitation. There was no report of benzodiazepine complications in either group. Conclusions Clonazepam and lorazepam treatment was equally effective at similar doses. However, considering the higher potency of clonazepam, it seems that lorazepam is the safer benzodiazepine for oral maintenance treatment of methamphetamine-induced agitation in children and can be used with minimal complications. Trial registration IRCT20180610040036N2, April 18th, 2020. Retrospectively registered.

A comparison of intravenous midazolam and diazepam in management of status epilepticus in children

Objective: To compare the efficacy of intravenous midazolam and diazepam in the management of status epilepticus seizures in children. Method: The comparative study was conducted in the paediatric neurological emergency unit of The Children’s Hospital and the Institute Of Child Health, Multan, Pakistan, from December 15, 2018, to May 14, 2019, and comprised paediatric patients of status epilepticus seizures whi were divided into Diazepam and Midazolam groups. Data was analysed using Graph-Pad Prism 5. Results: Of the 164 patients, 82(50%) were in each of the two groups. There was no significant difference between the groups in terms of weight, age, residence area of patients and mean duration of seizures (p>0.05). Status epilepticus seizures subsided after intravenous midazolam administration in 77(93.90%) cases, while success in the diazepam group 64(78.05%) (p<0.05). Mean time taken by midazolam to halt seizures was significantly shorter than diazepam (p<0.05) and less cases of treatment failure were observed with intravenous midazolam (p<0.05). Somnolence was observed after diazepam administration in 47(57.3%) cases (p=0.0001). Conclusion: Intravenous midazolam was found to be superior in efficacy than intravenous diazepam in controlling status epilepticus seizures. Key Words: Diazepam, Midazolam, Status epilepticus, Seizures

Neuroleptic Malignant Syndrome or Catatonia? A Case Report

IntroductionA review of the literature has shown that there are many similarities in the presentation of neuroleptic malignant syndrome (NMS) and catatonia. Attempts to reconcile the differences have been made by suggesting that NMS and catatonia may represent different presentations of the same illness or that they lie within the same spectrum of a poorly understood clinical syndrome. The described case is of a patient who presented with NMS and catatonia which was difficult to diagnose, but which responded to treatment with intravenous diazepam.Case presentationThe case concerns a 22-year-old male admitted for pulmonary hypertension to an intensive care unit (ICU). Three days following admission, he developed a high fever that did not respond to antibiotics. The patient then developed rigidity, nocturnal agitation, decreased responsiveness, and somnolence. Without the use of bromocriptine (Novartis, Basel, Switzerland) or dantrolene (Par Pharmaceuticals, Chestnut Ridge, USA) discontinuation of neuroleptics combined with intravenous diazepam (Pfizer, NY, USA) led to a very rapid response and marked improvement in the case.ConclusionsEarly recognition and management of NMS and MC in a complex, gravely ill patient, may be accomplished in the ICU despite obfuscation of traditional signs and symptoms of the NMS and MC syndrome. Such interventions can have life-saving effects on patients in danger of fatal autonomic instability.

Oral Clonazepam versus Lorazepam in the Treatment of Methamphetamine-Poisoned Children: A Pilot Clinical Trial

Background: To evaluate the efficacy of oral clonazepam versus oral lorazepam following initial parenteral benzodiazepine administration to control methamphetamine-induced agitation in children. Methods: In a single-center clinical trial, intravenous diazepam (0.2 mg/Kg) was initially administered to all methamphetamine-poisoned pediatric patients to control their agitation, followed by a single dose of oral clonazepam (0.05 mg/Kg; n=15) or oral lorazepam (0.05 mg/Kg; n=15) to prevent relapse of toxicity. Results: The median age [IQR] (range) was 15 [10, 36] (6-144) months. The source of poisoning was methamphetamine exposure from oral ingestion in 23 (76.7%) and passive inhalation in 7 (23.3%) patients. The most common symptoms/signs were agitation (29; 96.7%), mydriatic pupils (26; 86.7%), and tachycardia (20; 66.6%). Two in each group (13.3%) needed re-administration of intravenous diazepam due to persistent agitation. There was no report of benzodiazepine complications in either group.Conclusions: Although both benzodiazepines were effective, considering the similar administered doses of oral clonazepam and lorazepam as well as the higher potency of clonazepam, it seems that lorazepam is a better suited oral benzodiazepine for the maintenance treatment of methamphetamine-induced agitation in children and can be used with minimal complications.Trial registration: IRCT20180610040036N2, April 18th, 2020. Retrospectively registered

Clonazepam Versus Lorazepam in the Treatment of Methamphetamine-Poisoned Children: A Pilot Clinical Trial

Background: To evaluate the efficacy of oral clonazepam versus oral lorazepam following initial parenteral benzodiazepine administration to control methamphetamine-induced agitation in children.Methods: In a single-center clinical trial, intravenous diazepam (0.2 mg/Kg) was initially administered to all methamphetamine-poisoned pediatric patients to control their agitation, followed by a single dose of oral clonazepam (0.05 mg/Kg; n = 15) or oral lorazepam (0.05 mg/Kg; n = 15) to prevent relapse of toxicity.Results: The median age [IQR] (range) was 15 [10, 36] (6-144) months. The source of poisoning was methamphetamine exposure from oral ingestion in 23 (76.7%) and passive inhalation in 7 (23.3%) patients. The most common symptoms/signs were agitation (23; 96.7%), mydriatic pupils (26; 86.7%), and tachycardia (20; 66.6%). Four patients (13.3%) needed re-administration of IV diazepam due to persistent agitation. There was no report of benzodiazepine complications in either group.Conclusions: Although both benzodiazepines were effective, considering the similar administered doses of oral clonazepam and lorazepam as well as the higher potency of clonazepam, it seems that lorazepam is a better suited oral benzodiazepine for the maintenance treatment of methamphetamine-induced agitation in children and can be used with minimal complications.Trial registration: IRCT20180610040036N2, April 18th 2020. Retrospectively registered

Clonazepam versus Lorazepam in the Treatment of Methamphetamine-Poisoned Children: A Pilot Clinical Trial

Background: To evaluate the efficacy of oral clonazepam versus oral lorazepam following initial parenteral benzodiazepine administration to control methamphetamine-induced agitation in children. Methods: In a single-center clinical trial, intravenous diazepam (0.2 mg/Kg) was initially administered to all methamphetamine-poisoned pediatric patients to control their agitation, followed by a single dose of oral clonazepam (0.05 mg/Kg; n=15) or oral lorazepam (0.05 mg/Kg; n=15) to prevent relapse of toxicity. Results: The median age [IQR] (range) was 15 [10, 36] (6-144) months. The source of poisoning was methamphetamine exposure from oral ingestion in 23 (76.7%) and passive inhalation in 7 (23.3%) patients. The most common symptoms/signs were agitation (23; 96.7%), mydriatic pupils (26; 86.7%), and tachycardia (20; 66.6%). Four patients (13.3%) needed re-administration of IV diazepam due to persistent agitation. There was no report of benzodiazepine complications in either group.Conclusions: Although both benzodiazepines were effective, considering the similar administered doses of oral clonazepam and lorazepam as well as the higher potency of clonazepam, it seems that lorazepam is a better suited oral benzodiazepine for the maintenance treatment of methamphetamine-induced agitation in children and can be used with minimal complications.Trial registration: IRCT20180610040036N2, April 18th 2020. Retrospectively registered