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(Abst. B.06), 2014

CONTINUOUS INFUSIONS IN REFRACTORY CONVULSIVE STATUS EPILEPTICUS. RESULTS FROM THE PEDIATRIC STATUS EPILEPTICUS RESEARCH GROUP (PSERG).
Authors: Tobias Loddenkemper, Iván Sánchez Fernández, Nicholas Abend, Ravindra Arya, Rajit Basu, Nicholas Brenton, Jessica Carpenter, Kevin Chapman, John Condie, Nathan Dean, William Gaillard, Tracy Glauser, Joshua Goldstein, Howard Goodkin, Abeer Hani, Michele Jackson, Kush Kapur, Tewodros Kebede, Jacquelyn Klehm, Mohamad Mikati, Katrina Peariso, Melissa Sacco, Kristi Schmidt, Alexis Topjian, David Turner, Angus Wilfong, Korwyn Williams, Mark Wainwright and Robert Tasker
Content: Rationale: We describe treatment strategies with continuous infusions of antiepileptic drugs (AEDs) in children with refractory convulsive status epilepticus (RCSE). Methods: The Pediatric Status Epilepticus Research Group (pSERG) is a multicenter network that collects information from children with RCSE. We include consecutive children with: 1) age 1 month to 21 years, 2) convulsive seizures at onset, 3) failure of two or more AEDs or requirement of continuous administration of AEDs to control seizures. Results: Out of the entire cohort of 111 patients with RCSE, 55 (49.1%) went on to receive a continuous infusion (Table 1). At the time of starting continuous therapy, patients had received a median (IQR) of 4(4-6) doses of AEDs [2 (2-3) BZDs and 2(1-3) non-BZD]. The median duration from seizure onset to start of continuous infusion was 180 minutes (118-645). Timing to continuous infusion out-of-hospital and in-hospital onset is demonstrated in Figure 1. Midazolam. 45 patients received continuous infusion of midazolam (43 as first-choice and 2 as second choice). The treatment strategy in the 27/43 patients who had clinical resolution of seizures [versus no clinical resolution] with midazolam as the only continuous infusion included: bolus 0.13(0.1- 0.2)mg/Kg(n=15) [no resolution 0.1(0.1-0.2) (n=10)], initial infusion rate 0.1(0.1-0.3)mg/Kg/h (n=26) [versus:0.1(0.1-0.2)(n=15)], and effective infusion rate 0.3(0.2-1)mg/Kg/h (n=27) [versus:0.4 (0.1-0.9)]. The time from seizure onset to first continuous infusion of midazolam was 195(111-660) minutes. In patients with clinical seizure control, the time was 195(120-520) minutes and in those who did not achieve clinical seizure control the time was 189(59-825) minutes (p=0.9837). Propofol. 6 patients received propofol (4 as first-choice, 1 as second/third-choice, and 1 as fourth choice). Of the four patients who received propofol as the first continuous infusion all four achieved clinical control with this strategy (bolus 5(0-10) mg/Kg, initial infusion rate 0.6(0.003-6)mg/Kg/h and effective rate 0.6(0.003-6)mg/Kg/h). Pentobarbital. 15 patients received pentobarbital (2 first-choice, 10 as second/third-choice, and 3 as third choice). Of the 2 patients who used pentobarbital as the first continuous infusion 1 achieved clinical control with this strategy (bolus 0.9mg/Kg, initial infusion rate 2mg/Kg/h and effective rate 9mg/Kg/h). The other patient did not achieve clinical seizure control (bolus dose not available, initial infusion rate 0.5mg/Kg/h and effective rate 2mg/Kg/h). Conclusions: We describe the most frequent treatment strategies used for AEDs by continuous infusions in the treatment of RCSE in children across 11 centers in the United States. Of note, less than 50% of patients received continuous infusions as a third line treatment of refractory status epilepticus. We are collecting follow up data to determine whether this variability in care affects longitudinal outcome (Funded by American Epilepsy Society/Epilepsy Foundation of America Infrastructure Award).
Figure 1