Institutional Use of Seizure Prophylaxis in TBI Patients

Introduction: Levetiracetam is a common therapy for seizure prophylaxis in patients presenting with a severe traumatic brain injury (TBI). National guidelines recommend seizure prophylaxis (PPX) for 7 days for severe TBIs. Institutional protocol is to give 20 mg/kg of a loading dose (LD) followed by scheduled dose pending renal function for 7 days. Due to variability in practice, the purpose of this study was to assess institutional use of levetiracetam for seizure prophylaxis in patients with suspected TBI and to assess institutional guideline adherence.


Methods: This was a retrospective analysis of patients treated with levetiracetam for seizure prophylaxis at a level 1, academic health system. Patients were identified via the electronic medical record and an institutional TBI database. Patients were included if they received a levetiracetam LD and/or PPX dosing for seizure prophylaxis in TBI. Patients were excluded if the levetiracetam was for active seizing or if the PPX dose was given for an aneurysmal subarachnoid hemorrhage. The admission reason, head bleed location (if applicable), and incidence of seizure within one week of admit were collected as well.


Results: A total of 69 patients were included. There were 11 (16%) patients with severe TBI correctly given a LD. There were 15 (22%) patients with severe TBI correctly treated with 7 days of PPX. However, only 5 (7%) of those patients correctly received both the LD and PPX dose per institutional protocol for severe TBI. Of the patients who got a LD, there were 5 (7%) that received status epilepticus dosing (60 mg/kg, max 4500mg) instead of TBI LD. There were 7 (10%) other patients with a severe TBI that had the LD inappropriately withheld. A fixed dose strategy of 1 or 2 grams for a loading dose was used in 4 (6%) patients. A total of 31 (45%) patients with mild/moderate TBIs had levetiracetam correctly withheld. There were 9 (13%) patients with a mild/moderate TBI that inappropriately received a LD. There were 20 (29%) patients with mild/moderate TBIs that inappropriately received 7 days of PPX dosing.


Conclusions: Levetiracetam dosing varied widely and there was low protocol adherence. Given these results institution guidelines were updated to only recommend 7 days of levetiracetam prophylaxis and remove the loading dose recommendation.