Seizure · 2026
Early ketamine plus midazolam therapy and clinical outcomes in pediatric refractory convulsive status epilepticus: A retrospective cohort study.
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Yavuz Merve, Bingöl İbrahim
Аннотация
BACKGROUND: Refractory convulsive status epilepticus (RCSE) in children is associated with substantial morbidity and mortality. Ketamine has emerged as a potential adjunctive therapy because of its NMDA receptor antagonism and complementary mechanism to GABAergic agents. This study aimed to evaluate the association of concomitant ketamine plus midazolam therapy with clinical outcomes, compared with midazolam alone, as the initial anesthetic strategy in pediatric RCSE.
METHODS: In this retrospective single-center cohort study, pediatric patients with RCSE received either continuous midazolam infusion alone or concomitant ketamine plus midazolam infusion as the initial anesthetic strategy. The primary outcome was sustained seizure cessation within 24 h without the need for an additional continuous anesthetic agent. Propensity score overlap weighting was used to adjust for baseline differences between treatment groups.
RESULTS: Seventy-seven patients were included (midazolam, n = 40; ketamine plus midazolam, n = 37). In unadjusted analyses, the combination therapy group demonstrated higher rates of primary treatment success (73.0%vs 40.0%, p = 0.006), lower requirement for a second anesthetic agent (24.3%vs 60.0%, p = 0.003), and shorter time to seizure control (p = 0.010). After overlap weighting, ketamine plus midazolam remained associated with higher odds of treatment success, although the association did not reach statistical significance (adjusted OR, 4.16; 95% CI, 0.99-17.44; p = 0.052). No serious treatment-limiting adverse events were observed.
CONCLUSIONS: Early ketamine plus midazolam therapy was associated with favorable unadjusted clinical outcomes and faster seizure control in pediatric RCSE; however, adjusted analyses were inconclusive. Prospective multicenter studies are needed to further clarify the role of ketamine as part of the initial anesthetic strategy in pediatric RCSE.
METHODS: In this retrospective single-center cohort study, pediatric patients with RCSE received either continuous midazolam infusion alone or concomitant ketamine plus midazolam infusion as the initial anesthetic strategy. The primary outcome was sustained seizure cessation within 24 h without the need for an additional continuous anesthetic agent. Propensity score overlap weighting was used to adjust for baseline differences between treatment groups.
RESULTS: Seventy-seven patients were included (midazolam, n = 40; ketamine plus midazolam, n = 37). In unadjusted analyses, the combination therapy group demonstrated higher rates of primary treatment success (73.0%vs 40.0%, p = 0.006), lower requirement for a second anesthetic agent (24.3%vs 60.0%, p = 0.003), and shorter time to seizure control (p = 0.010). After overlap weighting, ketamine plus midazolam remained associated with higher odds of treatment success, although the association did not reach statistical significance (adjusted OR, 4.16; 95% CI, 0.99-17.44; p = 0.052). No serious treatment-limiting adverse events were observed.
CONCLUSIONS: Early ketamine plus midazolam therapy was associated with favorable unadjusted clinical outcomes and faster seizure control in pediatric RCSE; however, adjusted analyses were inconclusive. Prospective multicenter studies are needed to further clarify the role of ketamine as part of the initial anesthetic strategy in pediatric RCSE.