Dados do Trabalho

Título

Management of Neonatal Status with Proporfol

Resumo

During the neonatal period there are variable mechanisms that ensure the maintenance of seizures, delineated by a pro excitatory brain and an underdeveloped mechanism of seizure abortion. In general, regular medications like phenobarbital and phenytoin can control up to 57% of those seizures. When first and second-line medications are used and they fail to control seizures is considered as refractory status epilepticus and the third line therapy is not clearly established, it depends on whether convulsions are still present and seizure burden. Propofol is an intravenous anesthetic/ hypnotic drug and exerts its effects through potentiation of the inhibitory neurotransmitter γ-aminobutyric acid (GABA) at the GABAA receptor. Described as one of the possible medications in the management of status in adults, its use in pediatric is not so common. There is no consensus on how to treat a refectory status in the neonatal period and several unconventional treatments have been used off label. Methodology: Here we describe five newborns with super refractory status treated with propofol intravenous infusion achieving seizure control. Demography information is described in the table below. Refractory seizures due to hypoxic ischemic encephalopathy were controlled at lower rates of propofol, whereas seizures due to brain hemorrhage required higher doses. All newborns received phenobarbital as the first drug of choice (maximum loading dose of 40 mg/kg), second line medications were either continuous midazolam, phenytoin, or lidocaine. Clinical seizures improved in all patients however, on aEEG monitoring seizures did not stop and propofol was used. The option for this medication at the unit was based on the lack of other available IV drugs. Loading dose of 1 mg/kg, (IV infusion pump), followed by continuous infusion of 1mg/kg/h titrating, according to seizure control on the aEEG to a maximum of 10 mg/kg/h for about 48h when the drug was weaned off. Result: Complete seizure control was achieved on three cases, even after weaning off the medication. In two of them (seizures due to brain hemorrhage), seizures resurged when reducing the medication. Two of those newborns died, one after a couple of months due to pulmonary problems, and the other one because of multiple organs malformation. Three others survived and were discharged home on phenobarbital maintenance dose only. No side effects were witnessed during the treatment, and they were all in mechanical ventilation. Conclusion: As there is no consensus on how to treat refractory status in newborns and not even a proper medication focused on treating seizures in this population, propofol could be considered as an available option to control refractory status in neonates as the consequences of it on neurodevelopment and higher rates of death seems to overcome the risks.