Nonconvulsive seizure control in the intensive care unit.

OPINION STATEMENT: Nonconvulsive seizures (NCS) occur in as many as 20 % of comatose critically ill patients. These seizures need to be treated; however, the urgency with which this must be done and the medications that should be used are unclear. Often, data from treatment of convulsive status epilepticus (SE) is used to determine the best therapy for NCS. This may lead to "overtreatment" with sedating medications that prolongs hospitalization and worsens outcome. Nonsedating antiepileptic drug (AED) use is favored by many neurologists as the side effect profile is superior to sedating medications. Though limited, the available data suggests that valproic acid and lacosamide may be preferable to phenytoin/fosphenytoin and levetiracetam based on efficacy and side effect profiles. Other AEDs such as topiramate and pregabalin have also been used, but their data is even more limited, and they do not have an intravenous formulation. Clinical trials that have recently been completed and those that are ongoing will further inform our decisions about which drugs to use in the future.