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poster
two
ACUPUNCTURE
FOR STATUS EPILEPTICUS
IN A 5-YEAR-OLD PATIENT
Rex Lee Cheng, MD Dora T Hsu, MD
REPORT OF A CASE
A 5-year-old Korean
boy with no significant past medical history
was initially brought to the emergency department
by his parents for a 5-day history of fever
and 1 day of increased somnolence. In the
emergency department, the patient was combative
and displayed altered mental status, and then
developed apnea, requiring intubation. He
was transferred to the pediatric intensive
care unit for further treatment.
The pain service
was consulted on the 30th hospital day for
acupuncture treatment. Work-up at that point
included 2 computed tomography scans of the
head, a single-photon emission computed tomography
scan, 3 lumbar punctures, blood chemistry,
and urine and sputum cultures. All test results
were negative. In addition, the patient required
tracheotomy for long-term ventilator dependence.
The working diagnosis was intractable seizures
of unclear etiology, possibly due to postinfectious
encephalitis. He had mild fevers of up to
10 I'F Q 8'C) throughout his stay. The patient
underwent continuous electroencephalographic
monitoring during the hospitalization, allowing
real-time observation of his seizure activity.
The approach to this
patient was to give acupuncture treatments
simultaneous with his medical management.
All anticonvulsant medications were continued.
A steroid regimen was also completed during
the acupuncture series (Table
1).
A total of 15 treatments
were given (Table 2).
During the first 9 treatments, there was a
gradual decrease in the number and duration
of the seizures, and the pentobarbital drip
was tapered by 0.5-mg/kg per hour increments,
from 5.5 to a low of 1.5 mg/kg per hour. After
the ninth treatment, the child's seizures
became more frequent and of longer duration,
requiring progressive titration of the pentobarbital
up to 4 mg/kg per hour; then, after an extremely
long seizure of 70 minutes, up to 5.5 mg/kg
per hour. The pentobarbital was subsequently
decreased to 4 mg/kg per hour as the frequency
and duration of seizures decreased.
The patient was transferred
after 15 treatments to another facility for
further care.
DISCUSSION
This patient was
given treatments with points known for their
calming qualities or dispersive properties
for excess agitation and fever. It was thought
in the patient's best interest not to interfere
with any planned medical treatments even if
they could theoretically interfere with the
acupuncture treatment (eg, steroids). Consultation
was also made with Joseph Helms, MD, in the
management of this patient. 1,1 Although there
initially seemed to be some response to the
acupuncture, the patient appeared to worsen
after 9 treatments, requiring titration of
the pentobarbital infusion. The discharge
pentobarbital dosage (4 mg/kg per hour) was
less than the dosage at initiation of acupuncture
treatment (5.5 mg/kg per hour); however, the
patient's overall clinical condition was essentially
unchanged. The use of electroencephalographic
monitoring allowed for continuous observation
of seizure activity.
There are limited
data on the use of acupuncture in patients
having seizures. However, because of its favorable
risk-benefit ratio, acupuncture would seem
to be a reasonable treatment in these cases.
Further studies are warranted.
CONCLUSIONS
Although there appeared
to be an initial transient response to acupuncture
treatment, there was no sustained benefit
for this patient.
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Table 1.
Medications in Patient's Regimen
|
| Dopamine |
5 pg/kg per hour |
| Pentobarbital |
4 mg/kg per hour (at
discharge) |
| Valproic acid |
300 mg every 8 h |
| Topiramate |
100 mg twice daily |
| Clonazeparn |
1 mg every 6 h |
| Phenytoin sodium |
60 mg every 6 h |
| Camitine |
850 mg/d |
| Phenobarbital |
40 mg every 12 h |
| Intramuscular |
|
| adrenocorticotropic |
|
| hormone gel |
60 U every 12 h |
| Cisapride |
|
| Ranitidine |
|
Table 2.
Acupuncture Treatments
for Status Epilepticus*
|
HT 3, LV 3, GV 20 for 20 min
Pentobarbital,
5.5 mg/kg per hour
HT 3, LV 3, GV 20 for 20 min
HT 3, LV 3, GV 20 for 20 min
Pentobarbital,
5.0 mg/kg per hour
KI 1, HT 3, LV 3, GV 20 for 25 min
Pentobarbital,
4.5 mg/kg per hour
KI 1, HT 3, LV 3, GV 20 for 25 min
Pentobarbital,
4.0 mg/kg per hour
KI 1, SI 3, GV 20, BL 10, Master of
Heart (MH) 1,
LV 3 for 25 min
Pentobarbital,
3.0 mg/kg per hour
GV 20, KI 1, SI 3, MH 1, LV 3 for
25 min
Pentobarbital,
2.5 mg/kg per hour
GV 20, GV 24.5, Yintang, LI 4, HT
3, LV 3, KI I for 25 min
Pentobarbital,
2.5 mg/kg per hour
GV 20, GV 24.5, Yintang, MH 1 and
6, KI 1, LV 3 for 25 min
Pentobarbital,
tapering to 1.5 mg/kg per hour
GV 20, GV 24.5, MH 1, LV 3, HT 3,
KI 1 for 25 min
Pentobarbital
increased, 2.5 mg/kg per hour
GV 20, Yintang, KI 1, LV 3, HT 3,
MH 6 for 25 min
Pentobarbital
increased, 3.0 mg/kg per hour; 3 more
boluses
for
recurrent seizures
KI 1 and 3, BL 60, HT 3, LI 4, GV
26, Yintang for 25
min; more
frequent seizures up to every 10 min
GV 20, BL 10, SI 16, HT 3, LV 3, MH
6, KI 3 for 25 min
Pentobarbital,
3.5 then 4.0 mg/kg per hour; boluses
needed for recurrent breakthrough
seizures
GV 20, Yintang, HT 3, LV 3, KI 1,
LI 4 for 30 min
GV 20, LV 3, HT 3, MH 6, LI 4, KI
I for 25 min
Pentobarbital,
5.5 then 4.0 mg/kg per hour |
| * Treatments are
presented inconsecutive order as performed
in this case. Treatments were done
daily to every-other-day. All points
were procured bilaterally when possible
in dispersion. |
REFERENCES
1. Helms JM. Consultation and
review course. Los Angeles: University of
California Los Angeles Medical School; October
1997.
2. Helms JM. Acupuncture Energetics: A Clinical
Approach for Physicians. Berkeley, Calif:
Medical Acupuncture Publishers; 1995.
AUTHORS
INFORMATION
Dr Rex Cheng is an Assistant Professor at
Harbor[UCLA Medical Center in Torrance, California,
specializing in Anesthesiology and Pain Management.
Rex
Cheng, MD
Harbor/UCLA Medical Center, Dept. of Anesthesiology,
Box #10
Torrance, CA 90509
Phone: 310-222-3477 - E-mail: rexerl@earthlink.net
Dr
Dora T. Hsu is an attending Anesthesiologist
and Director of Pain Service, Department of
Anesthesiology, Harbor-UCLA Medical Center.
She is an Associate Professor of Anesthesiology
at UCLA School of Medicine.
Dora
T. Hsu, MD
Harbor[UCLA Medical Center, Dept. of Anesthesiology
1000 W. Carson St, Torrance, CA 90509
Phone: 310-222-3477 - E-mail: dthsu@telis.org
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