MANAGEMENT OF PEDIATRIC REFRACTORY CONVULSIVE STATUS EPILEPTICUS IN CLINICAL PRACTICE. PEDIATRIC STATUS EPILEPTICUS RESEARCH GROUP (PSERG)
Authors: T. Loddenkemper, N. Abend, S. Agadi, S. An, R. Arya, J. Carpenter, K. Chapman, W. Gaillard, T. Glauser, H. Goodkin, M. Mikati, K. Peariso, M. Ream, I. Sánchez Fernández, R. Tasker, .. pSERG
There are limited clinical practice data on management of refractory convulsive status epilepticus (RCSE) in children. The aim of this study was to describe the care of children with RCSE, with particular attention to the type of medications given, their order and the timing of administration.
The Pediatric Status Epilepticus Research Group (pSERG) is a multicenter network of reference hospitals that collects information from children with RCSE and records de-identified data into a common database. We included consecutive children with: 1) age 1 month to 21 years, 2) convulsive seizures at onset, 3) failure of two or more antiepileptic drugs (AEDs) or requirement of any continuous administration of AEDs to abort seizures. We excluded patients with: 1) non-convulsive SE detected on EEG (without convulsive seizures at onset), or 2) non-convulsive status epilepticus and infrequent myoclonic jerks. We collected information on medication types, their sequence, and timing of administration.
We analyzed 74 episodes in 72 patients (37 males and 35 females). The median (p25-p75) age at the episode was 2.5 (1-7) years. The most frequently used first benzodiazepines (BZD) were lorazepam (57% of cases) and diazepam (36% of cases). The most frequently used first non-BZD-AED (nBZD-AED) were fosphenytoin (46% of cases), phenytoin (25% of cases), and levetiracetam (17% of cases). The most frequently used second nBZD-AED were phenobarbital (41% of cases), levetiracetam (30% of cases), and fosphenytoin (16% of cases). The preferred drug as initial continuous infusion was midazolam (85% of the cases) (Table 1). Most RCSE episodes [56 (77%)] started out of the hospital and of those 56 episodes, 33 ocurred in children without prior seizures. Administration of the first BZD at home occurred in 8/56 (14%) episodes and by the EMS in 13/48 (27%) episodes. The first nBZD-AED was administered before arriving to the hospital in 1/56 (2%) episodes. Only 33/74 (45%) episodes were treated with a continuous AED infusion. The median timing since seizure onset until administration of the first BZD was 23 minutes, until the administration of the second BZD was 35 minutes, until the administration of the first nBZD-AED was 61 minutes, until the administration of the second nBZD-AED 117 minutes, and until the start of the first continuous infusion 270 minutes (Table 2).
We described variability in current AED choices in a network of reference hospitals in the United States. The escalation from one type of AED to the next and, especially, the timing of AED administration left room for improvement and shows opportunities to be more aggressive in timely administration of AEDs and in the progression from one AED to the next. This study has been funded by the American Epilepsy Society Infrastructure Award and the Epilepsy Foundation of America.
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