Benzodiazepine administration patterns before escalation to second-line medications in pediatric refractory convulsive status epilepticus.

2021

2766-2777

2021 11

1528-1167

<p><strong>OBJECTIVE: </strong>This study was undertaken to evaluate benzodiazepine (BZD) administration patterns before transitioning to non-BZD antiseizure medication (ASM) in pediatric patients with refractory convulsive status epilepticus (rSE).</p>

<p><strong>METHODS: </strong>This retrospective multicenter study in the United States and Canada used prospectively collected observational data from children admitted with rSE between 2011 and 2020. Outcome variables were the number of BZDs given before the first non-BZD ASM, and the number of BZDs administered after 30 and 45&nbsp;min from seizure onset and before escalating to non-BZD ASM.</p>

<p><strong>RESULTS: </strong>We included 293 patients with a median (interquartile range) age of 3.8 (1.3-9.3) years. Thirty-six percent received more than two BZDs before escalating, and the later the treatment initiation was after seizure onset, the less likely patients were to receive multiple BZD doses before transitioning (incidence rate ratio [IRR]&nbsp;=&nbsp;.998, 95% confidence interval [CI] = .997-.999 per minute, p&nbsp;=&nbsp;.01). Patients received BZDs beyond 30 and 45&nbsp;min in 57.3% and 44.0% of cases, respectively. Patients with out-of-hospital seizure onset were more likely to receive more doses of BZDs beyond 30&nbsp;min (IRR&nbsp;=&nbsp;2.43, 95% CI = 1.73-3.46, p&nbsp;&lt;&nbsp;.0001) and beyond 45&nbsp;min (IRR&nbsp;=&nbsp;3.75, 95% CI&nbsp;=&nbsp;2.40-6.03, p&nbsp;&lt;&nbsp;.0001) compared to patients with in-hospital seizure onset. Intermittent SE was a risk factor for more BZDs administered beyond 45&nbsp;min compared to continuous SE (IRR&nbsp;=&nbsp;1.44, 95% CI = 1.01-2.06, p&nbsp;=&nbsp;.04). Forty-seven percent of patients (n&nbsp;=&nbsp;94) with out-of-hospital onset did not receive treatment before hospital arrival. Among patients with out-of-hospital onset who received at least two BZDs before hospital arrival (n&nbsp;=&nbsp;54), 48.1% received additional BZDs at hospital arrival.</p>

<p><strong>SIGNIFICANCE: </strong>Failure to escalate from BZDs to non-BZD ASMs occurs mainly in out-of-hospital rSE onset. Delays in the implementation of medical guidelines may be reduced by initiating treatment before hospital arrival and facilitating a transition to non-BZD ASMs after two BZD doses during handoffs between prehospital and in-hospital settings.</p>

10.1111/epi.17043

Epilepsia

34418087

Super-Refractory Status Epilepticus in Children: A Retrospective Cohort Study.

2021

e613-e625

2021 12 01

1529-7535

<p><strong>OBJECTIVES: </strong>To characterize the pediatric super-refractory status epilepticus population by describing treatment variability in super-refractory status epilepticus patients and comparing relevant clinical characteristics, including outcomes, between super-refractory status epilepticus, and nonsuper-refractory status epilepticus patients.</p>

<p><strong>DESIGN: </strong>Retrospective cohort study with prospectively collected data between June 2011 and January 2019.</p>

<p><strong>SETTING: </strong>Seventeen academic hospitals in the United States.</p>

<p><strong>PATIENTS: </strong>We included patients 1 month to 21 years old presenting with convulsive refractory status epilepticus. We defined super-refractory status epilepticus as continuous or intermittent seizures lasting greater than or equal to 24 hours following initiation of continuous infusion and divided the cohort into super-refractory status epilepticus and nonsuper-refractory status epilepticus groups.</p>

<p><strong>INTERVENTIONS: </strong>None.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>We identified 281 patients (157 males) with a median age of 4.1 years (1.3-9.5 yr), including 31 super-refractory status epilepticus patients. Compared with nonsuper-refractory status epilepticus group, super-refractory status epilepticus patients had delayed initiation of first nonbenzodiazepine-antiseizure medication (149 min [55-491.5 min] vs 62 min [33.3-120.8 min]; p = 0.030) and of continuous infusion (495 min [177.5-1,255 min] vs 150 min [90-318.5 min]; p = 0.003); prolonged seizure duration (120 hr [58-368 hr] vs 3 hr [1.4-5.9 hr]; p &lt; 0.001) and length of ICU stay (17 d [9.5-40 d] vs [1.8-8.8 d]; p &lt; 0.001); more medical complications (18/31 [58.1%] vs 55/250 [22.2%] patients; p &lt; 0.001); lower return to baseline function (7/31 [22.6%] vs 182/250 [73.4%] patients; p &lt; 0.001); and higher mortality (4/31 [12.9%] vs 5/250 [2%]; p = 0.010). Within the super-refractory status epilepticus group, status epilepticus resolution was attained with a single continuous infusion in 15 of 31 patients (48.4%), two in 10 of 31 (32.3%), and three or more in six of 31 (19.4%). Most super-refractory status epilepticus patients (30/31, 96.8%) received midazolam as first choice. About 17 of 31 patients (54.8%) received additional treatments.</p>

<p><strong>CONCLUSIONS: </strong>Super-refractory status epilepticus patients had delayed initiation of nonbenzodiazepine antiseizure medication treatment, higher number of medical complications and mortality, and lower return to neurologic baseline than nonsuper-refractory status epilepticus patients, although these associations were not adjusted for potential confounders. Treatment approaches following the first continuous infusion were heterogeneous, reflecting limited information to guide clinical decision-making in super-refractory status epilepticus.</p>

10.1097/PCC.0000000000002786

Pediatr Crit Care Med

34120133