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Status epilepticus is a life threatening condition associated with long term morbidity that occurs mainly in childhood and becomes more refractory with duration.1 Until recently standard treatment of children with a history of prolonged (>10 minutes) seizures has been to provide families with rectal diazepam to terminate the seizure as soon as possible.
Rectal diazepam has many problems when used outside the hospital setting: it is difficult to administer to wheelchair users; tonic seizures make administration difficult; constipation and bowel movements can interfere with absorption; it becomes more socially unacceptable with increasing age; and is detrimental to the self esteem of children and teenagers. In our experience schools are uncomfortable with rectal administration. Midazolam has been used nasally since 1988 as a preanaesthetic agent2 and an anxiolytic in accident and emergency departments.3 Following a study in 1996 showing its effectiveness in abolishing epileptiform abnormalities in children with subclinical status epilepticus,4 we began to offer families the choice of midazolam or rectal diazepam for home and school use. The aims of this survey were to assess the effectiveness of buccal and nasal midazolam in terminating prolonged seizures in the community, evaluate how easy parents found it to use, and in the families who had previously used rectal diazepam, establish which was the preferred treatment.
As nasal/buccal midazolam is unlicensed for use as an anticonvulsant, prescriptions were issued from the hospital. Copies of these prescriptions over a 16 month period were obtained and 53 children were identified (table 1). Their parents were then contacted by telephone (table 2).
We use the intravenous preparation of 10 mg/2 ml at a dose of 0.2 mg/kg. The different methods of administration are discussed with the parents and a decision made on the most appropriate route, taking into account previous seizure patterns, practical issues, and parental preference. The buccal surface area is greater and parents prefer this route as they turn the child onto one side during a seizure, which is the preferred position for buccal administration. We suggest nasal administration in the following situations, however: if copious saliva has been produced in previous seizures; if the child is resisting administration; and for focal seizures with altered awareness (the midazolam is usually swallowed in this situation).
After demonstration, parents and carers have supervised practice in breaking the ampoule, drawing up, and administering a solution on a doll. Written guidelines on administration are provided. Filter straws are used to draw up the medication and protective ampoule breakers are provided.
Midazolam had been used for 40 of the 53 children (74%) and 33 (83%) of those found it effective. Twenty four of the 40 families had also used rectal diazepam, and 20/24 (83%) of those expressed a preference for midazolam. The most commonly stated reasons for this preference were: personal dignity (all of the respondents); more socially appropriate; ease of administration in wheelchair users; and quicker response than rectal diazepam.
Analysis of the seven families who found it ineffective was as follows: two of the children were also unresponsive to rectal diazepam; one parent had only used it once as a “preventative” and not as recommended; and one mother thought it had been lost in saliva. In all but one case the midazolam had been given buccally.
Four families had expressed a preference for rectal diazepam. The reasons given by two were familiarity and ease of administration at night (although one of them carries midazolam for day use); one child was said to be euphoric after midazolam administration, and the fourth parent gave it buccally and felt some was expelled in saliva.
Midazolam given buccally and nasally is an effective treatment for prolonged seizures in the community and is preferred to rectal diazepam by most families in this cohort. Scott and colleagues5 showed that buccal midazolam was at least as effective as rectal diazepam in the termination of prolonged seizures in a residential school for young people with difficult epilepsy, and our study supports these findings when used by parents at home. Drawing up and measuring the contents of midazolam is a more complicated procedure than using a tube of rectal diazepam, but only one parent experienced difficulty with administration without help because of her daughter’s resistance. For the majority the social benefits exceeded the disadvantages. Filter straws and ampoule breakers have made the process easier.
Midazolam allows families a choice in rescue medication and how they manage prolonged seizures in the community. Some families use either rectal diazepam or buccal/nasal midazolam depending on the social situation. There is no difference between the cost of rectal diazepam and midazolam.
The current preparation remains unlicensed for use in epilepsy, which can cause problems with prescribing. There is now a preparation of midazolam syrup for buccal use, which the manufacturers state can also be administered nasally. This preparation is more expensive but we intend to explore its use in the termination of prolonged seizures. It dispenses with the use of glass ampoules, filter straws, and ampoule breakers, simplifying administration.
We would like to thank the pharmacy staff and the families who helped us with this survey.
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