Comparison of midazolam and ketamine efficacies as first-line continuous infusions (CIs) for the treatment of status epilepticus (SE) in children with (CHD).  

Children with CHD are at high risk of SE.  Unfortunately, the treatment of SE has a high failure rate. Once loading doses of anti-seizure medications (ASMs) have failed to control seizures, patients are started on a CI, most commonly midazolam.  This is often accompanied by side effects, including hypotension, which can be especially problematic in patients with CHD.  Ketamine, a noncompetitive NMDA receptor antagonist, has emerged as an alternative for the treatment of SE, and it has a relatively favorable side effect profile.  However, it is unclear how ketamine compares to other CIs for the treatment of SE in children with CHD.

Retrospective review of the electronic medical record of patients with CHD and SE treated with CI of ketamine and/or midazolam between 2017 and 2023 at a single tertiary pediatric hospital.  The primary outcome was seizure cessation with a single CI. Descriptive statistics were used.

Of 34 CHD patients with SE, 20 patients received midazolam as the first-line CI and 14 received ketamine.  The ketamine-first group was younger (Median 1.5 days, IQR 0-23.75) than the midazolam-first group (Median 87.5, IQR 10.75-121.75; p = 0.007). Most patients experienced multifocal (83% ketamine, 80% midazolam) and electrographic-only seizures (85% ketamine, 79% midazolam). The number of bolus ASMs given prior to CI was comparable, and there was no difference between groups in the rate of seizure cessation.