In refractory generalized tonic-clonic status epilepticus

General guidelines for pentobarbital infusion

  • Loading dose: 5-20 mg/kg IV at infusion rate of 25 mg per min (5 mg/kg is effective for induction anesthesia for most patients)
  • Initial maintenance: 2.5 mg/kg per hr
  • For breakthrough seizures: 50-mg bolus and increase maintenance by 0.5-1.0 mg/kg per hr
  • Begin tapering 24 hrs after last seizure
  • Tapering rate (every 4-6 hrs): 1.0 mg/kg per hr if pentobarbital level is >50 mg/liter or 0.5 mg/kg per hr if pentobarbital level is
  • For seizures during tapering: 50-mg pentobarbital bolus, then increase maintenance to closest preseizure dose

General guidelines for patient management:

  • Endotracheal intubation; assisted ventilation
  • Continuous blood pressure monitoring (arterial line)
  • Hemodynamic monitoring (Swan-Ganz) optional
  • Hypotension*: fluids and dopamine up to 12 µg/kg per min (Decrease or discontinue pentobarbital temporarily if dopamine requirements exceed this amount.)
  • Prophylaxis of decubiti and venous thrombosis
  • Obtain serum at least once daily:Daily complete blood countMaintenance of high therapeutic serum concentrations of antiepileptic drugs
  • EEG monitoring BaselineContinuous monitoring for the first 2-6 hrs of anesthesiaTen-minute strips every 30-60 mins for duration of treatment

* Defined as a decrease in systolic blood pressure by 10 mm Hg as compared with preanesthetic blood pressure.

Table adapted from Osorio I, Reed RC. Treatment of refractory generalized tonic-clonic status epilepticus with pentobarbital anesthesia after high-dose phenytoin. Epilepsia 1989;30:464-471. From Kolb SJ and Litt B. Management of epilepsy and comorbid disorders in the emergency room and intensive care unit. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;515-535. With permission from Elsevier (

Authored By: 
I Osorio
RC Reed
Reviewed By: 
Steven C. Schachter MD
Saturday, May 1, 2004