Updated July 2026 · 8 min read

Levetiracetam (Keppra): The ICU Nurse's Guide

Part of the ICU Emergencies Hub — browse every related guide in one place.

Levetiracetam has become the workhorse anticonvulsant of the ICU — easy to load, few drug interactions, no need for level monitoring, and a clean IV form. It is the drug that follows the benzodiazepine in status epilepticus and the one you'll hang for seizure prophylaxis after a bleed or a craniotomy.

What levetiracetam does

Levetiracetam binds a synaptic vesicle protein (SV2A) and modulates neurotransmitter release, dampening the abnormal, synchronized firing of a seizure. Its exact mechanism is different from older anticonvulsants, and that difference is part of its appeal: it doesn't rely on the liver's enzyme systems the way phenytoin does, so it has far fewer drug interactions and doesn't require the careful serum-level titration those older drugs demand.

Status epilepticus — where it fits

The management of status epilepticus follows a ladder. First-line is a benzodiazepine — lorazepam or midazolam — to break the seizure. If seizing continues, a second-line agent is loaded, and levetiracetam is one of the three standard choices (alongside fosphenytoin and valproate), shown in trials to be roughly equivalent. It is often favored for its ease and safety profile. If seizures persist beyond second-line therapy, the patient is moving toward refractory status and continuous infusions of anesthetic agents.

Dosing at a glance

Renal clearance

Levetiracetam is eliminated largely unchanged by the kidneys, so dosing tracks renal function. In significant renal impairment the dose and/or frequency drop, and patients on hemodialysis need a supplemental dose after a session because dialysis removes a meaningful fraction. This is one of the few things to actively watch — it doesn't need drug levels, but it does need attention to the creatinine clearance.

The behavioral side effects

The most talked-about downside is neuropsychiatric: irritability, agitation, anxiety, mood swings, and occasionally aggression or depressed mood. Nurses and families sometimes call it "Kepprage." It's usually manageable and reversible, and in some patients supplemental vitamin B6 is used, but it matters for the agitated ICU patient — a new behavioral change on levetiracetam is worth flagging rather than automatically attributing to delirium. Somnolence and dizziness also occur.

Why the ICU likes it

Compared with phenytoin/fosphenytoin, levetiracetam skips the cardiac monitoring for infusion-related hypotension and arrhythmia, avoids the tangle of drug interactions, and doesn't require serial serum levels. That simplicity is why it has largely become the default for prophylaxis and a co-first-line option in status. The trade-off is the behavioral profile and the need to respect renal dosing.

Bottom line

Levetiracetam earned its place as the ICU's default anticonvulsant by being easy: quick IV load, no levels, few interactions. Remember it is a second-line agent that follows adequate benzodiazepine dosing in status epilepticus, adjust it for the kidneys, and keep an eye on the behavioral side effects that can masquerade as delirium. Used that way, it's one of the most nurse-friendly drugs in the seizure toolkit.

This article is general educational information for licensed clinicians and students, not medical advice or a substitute for your institution's protocols, pharmacy guidance, or a provider's orders. Always follow facility policy and verify doses independently.