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Management of status epilepticus in Malaysia: A national survey of current practice and treatment gap

Lim KS, Khoo CS, Fong SL, Tan HJ, Fong CY, Mohamed AR, et al.

J Clin Neurosci, 2023 Aug;114:25-31.
PMID: 37279626 DOI: 10.1016/j.jocn.2023.05.006

INTRODUCTION: Early and effective treatment is fundamental in status epilepticus (SE) management. At the initiative of the Epilepsy Council of Malaysia, this study aimed to determine the treatment gap in SE across different healthcare settings in Malaysia.
METHODS: A web-based survey was sent to clinicians involved in the management of SE, across all states and at all levels of healthcare services.
RESULTS: A total of 158 responses were received from 104 health facilities, including 23 tertiary government hospitals (95.8% of all government tertiary hospitals in Malaysia), 4 (80.0%) universities, 14 (6.7%) private, 15 (11.5%) district hospitals and 21 clinics. Intravenous (IV) diazepam was available in 14 (93.3%) district and 33 (80.5%) tertiary hospitals for prehospital management. Non-IV benzodiazepine (rectal diazepam and intramuscular midazolam) was not widely available in prehospital services (75.8% and 51.5%). Intramuscular midazolam was underutilised (60.0% in district and 65.9% in tertiary hospitals). IV sodium valproate and levetiracetam were only available in 66.7% and 53.3% of the district hospitals, respectively. Electroencephalogram (EEG) services were available in only 26.7% of the district hospitals. Non-pharmacological therapies such as ketogenic diet, electroconvulsive therapy, and therapeutic hypothermia were not available in most district and tertiary hospitals for refractory and super-refractory SE.
CONCLUSIONS: We identified several gaps in the current practice of SE management, including limited availability and underutilization of non-IV midazolam in prehospital services, underutilization of non-IV midazolam and other second-line ASMs, and lack of EEG monitoring in district hospitals and limited treatment options for refractory and super-refractory SE in tertiary hospitals.

Matched MeSH terms: Midazolam/therapeutic use
Case series of buprenorphine injectors in Kuala Lumpur, Malaysia

Bruce RD, Govindasamy S, Sylla L, Haddad MS, Kamarulzaman A, Altice FL

Am J Drug Alcohol Abuse, 2008;34(4):511-7.
PMID: 18584580 DOI: 10.1080/00952990802122259

Diversion of buprenorphine has been described in settings where it is legally prescribed and has become an increasing concern in Malaysia; it resulted in banning of buprenorphine in Singapore where unsubstantiated case reports suggested that buprenorphine injection was associated with particularly poor outcomes. We therefore conducted a case series of qualitative interviews with buprenorphine injectors in Kuala Lumpur, Malaysia to examine further the issues surrounding buprenorphine injection as well as the abuse of midazolam in combination with buprenorphine. Interviews with 19 men do not suggest significant adverse health consequences from buprenorphine injection alone and injectors have adapted diverted buprenorphine as a treatment modality. A subset of these injectors, however, combined buprenorphine and midazolam for euphoric effects with resultant symptoms of a possible pharmacological interaction. Prospective cohort studies, rather than hospital-derived samples, are needed to better understand the safety of buprenorphine injection.

Matched MeSH terms: Midazolam/therapeutic use*
Fulltext Intravenous ketamine is as effective as midazolam/fentanyl for procedural sedation and analgesia in the emergency department

Jamal SM, Fathil SM, Nidzwani MM, Ismail AK, Yatim FM

Med J Malaysia, 2011 Aug;66(3):231-3.
PMID: 22111446

The study compared the effectiveness of ketamine and midazolam/fentanyl as procedural sedation and analgesia agents for reduction of fractures and dislocated joints. Forty-one adult patients were enrolled by convenience sampling. They were randomized to receive ketamine or midazolam/fentanyl. Depth of sedation, pain score, procedural outcome and memory of the procedure were documented. The ketamine group had deeper sedation, but there was no statistical difference in other variables between the two groups. Three patients in the midazolam/fentanyl group had oxygen desaturation. More adverse effects were associated with ketamine. Intravenous ketamine is as effective as midazolam/fentanyl for procedural sedation.

Matched MeSH terms: Midazolam/therapeutic use*
The use of propofol for procedural sedation and analgesia in the emergency department: a comparison with midazolam

Rahman NH, Hashim A

Emerg Med J, 2011 Oct;28(10):861-5.
PMID: 21098799 DOI: 10.1136/emj.2009.085019

This study aimed to determine the effectiveness of propofol as an alternative agent for procedural sedation and analgesia (PSA) in the emergency department (ED) and to make a comparison between two different sedative (propofol vs midazolam) drugs used in combination with fentanyl.

Matched MeSH terms: Midazolam/therapeutic use*
Fulltext Arthroscopy under local anaesthesia

Ramanathan R

Med J Malaysia, 1998 Sep;53 Suppl A:99-101.
PMID: 10968190

We studied 95 patients who underwent knee Arthroscopy under local anaesthesia between JANUARY 1995 till 1997. Materials used were 1% Xylocaine and 0.25% Bupivacaine of 20 mls each combined with midazolam 2 mg and IV pethidine 30 mgm for sedation. The patients were attached to monitors (pulse Oxymeter, ECG and BP and pulse recorders) and blood less field was created using a tornquet. The procedures lasted about 45 minutes. 90 out of 95 patients completed the procedures successfully without any complications. 2 developed respiratory embarrassments and were intubated and ventilated. 3 procedures abandoned and converted to general anaesthesia. The range of procedures done include meniscectomy, meniscal repair, synovial biopsy, debridement for osteoarthrosis, shaving of osteophytes, drilling of cartilage and bones and removal of loose bodies. This study is to show that knee arthroscopy under LA is a safe alternative in hospitals where GA time is limited.

Matched MeSH terms: Midazolam/therapeutic use