Abstracts

Rationale: Guidelines for the treatment of status epilepticus (SE) suggest timely stepwise transition between different antiseizure medication (ASM) classes; however, delays in treatment administration are common. We describe the utilization of benzodiazepines (BZDs) prior to escalation to non-benzodiazepine antiseizure medications (non-BZD ASMs) in the treatment of refractory status epilepticus (rSE). Methods: We performed a multicenter, prospective descriptive study evaluating children 1 month to 21 years of age with rSE from June 2011 to January 2018. rSE was defined as the failure of at least one BZD and at least one non-BZD ASM; or the use of a continuous infusion for seizure cessation. The primary descriptive outcomes were factors associated with transition from benzodiazepines to non-BZD AEDs, including the number of benzodiazepines used before escalating to non-BZD AEDs, and the proportion of those benzodiazepines given more than 30 minutes after seizure onset. We arbitrarily chose 30 minutes as it is a threshold frequently recommended in the SE treatment guidelines. Results: We included 227 patients (55% males) with a median (p₂₅-p₇₅) age of 3.9 (1.2 – 9.5) years. One hundred and thirty-two (58%) patients received at least one BZD after 30 minutes of seizure-onset and before the first non-BZD ASM. Compared with in-hospital rSE onset, patients with out-of-hospital rSE onset received the first BZD later than patients with in-hospital onset [20 (5 – 55) versus 7 (4 – 16.5) minutes, p < 0.0001]. A greater proportion of out-of-hospital rSE onset patients received at least one BZD later than 30 minutes after seizure-onset and before the first non-BZD ASM [107 of 152 (70%) versus 25 of 75 (33%), p < 0.0001] (Table 1, Figure 1). The median (p₂₅-p₇₅) time to first non-BZD ASM administration was longer in patients with out-of-hospital rSE onset as compared to patients with in-hospital rSE onset [80 (49.3 – 153.5) versus 34 (24 – 67.5) minutes, respectively, p < 0.0001]. Sixty of 152 (40%) patients with out-of-hospital onset did not receive any ASM until hospital arrival. Twenty-two of 93 (24%) patients who received at least two BZD out-of-hospital did not transition to non-BZD ASM as suggested, and received at least one additional BZD dose upon hospital arrival. Conclusions: Delays to BZD and non-BZD ASM treatment occur more frequently during out-of-hospital treatment as compared to in-hospital status epilepticus care. Lack of timely treatment prior to hospital arrival and repetitive use of BZDs beyond the recommended 2 doses prior to transitioning to non-BZD ASM are common. Funding: Funded by the Pediatric Epilepsy Research Foundation and the Epilepsy Research Fund.