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(Abst. 1.192), 2017

Factors associated with treatment delays in pediatric convulsive status epilepticus (the pSERG cohort)
Authors: on behalf of Pediatric Status Epilepticus Research Group (pSERG), Boston Children’s Hospital, Harvard University Medical School, Boston, MA, United States; Iván Sánchez Fernández, Boston Children’s Hospital, Harvard University Medical School, Boston, MA, United States;Hospital Sant Joan de Déu, Universidad de Barcelona, Barcelona, Spain; Marina Gaínza-Lein, Boston Children’s Hospital, Harvard University Medical School, Boston, MA, United States; Universidad Austral de Chile, Valdivia, Chile; Nicholas S. Abend, The Children’s Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania. Philadelphia, PA, United States; Anne Anderson, Baylor College of Medicine, Texas Children's Hospital; Ravindra Arya, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States; J. Nicholas Brenton, University of Virginia Health System, Charlottesville, VA, United States.; Jessica L. Carpenter, Children’s National Medical Center, George Washington University School of Medicine and Health Sciences. Washington, DC, United States; Kevin Chapman, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States; William D. Gaillard, Children’s National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, United States.; Tracy A. Glauser, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States; Joshua L. Goldstein, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Howard P. Goodkin, University of Virginia Health System, Charlottesville, VA, United States; Ashley Reynolds (Helseth), Duke University Medical Center, Duke University, Durham, NC, United States; Michele Jackson, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States; Kush Kapur, Boston Children’s Hospital, Harvard University Medical School, Boston, MA, United States; Yi-Chen Lai, Baylor College of Medicine. Houston, TX, United States.; Tiffani L. McDonough, Columbia University Medical Center, Columbia University. New York, NY, United States.; Mohamad A. Mikati, Duke University Medical Center, Duke University, Durham, NC, United States; Anuranjita Nayak, Baylor College of Medicine. Houston, TX, United States.; Katrina Peariso, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States; James Riviello, Columbia University Medical Center, Columbia University, New York City, NY, United States.; Robert C. Tasker, Boston Children’s Hospital, Harvard University Medical School, Boston, MA, United States; Dmitry Tchapyjnikov, Duke University Medical Center, Duke University. Durham, NC, United States; Alexis Topjian, The Children’s Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Mark S. Wainwright, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Angus Wilfong, Barrow Neurological Institute, Phoenix Children’s Hospital; Korwyn Williams, Barrow Neurological Institute, Phoenix Children’s Hospital, University of Arizona School of Medicine, Phoenix, AZ, United States; and Tobias Loddenkemper, Boston Children’s Hospital, Harvard University Medical School, Boston, MA, USA
Content: Rationale: Time to administration of antiepileptic drugs (AEDs) in SE is often longer than recommended. The objective of this study is to identify factors associated with treatment delays in refractory pediatric convulsive status epilepticus (rSE). Methods: This prospective observational study was performed from June 2011 to March 2017 on pediatric patients (1 month to 21 years of age) with rSE. rSE was defined as status epilepticus that continued after the administration of at least two AEDs including at least one non-benzodiazepine AED (non-BZD AED) or the use of continuous infusion. The main outcome was time from seizure onset to administration of AEDs expressed as median (p25-p75): first benzodiazepine (BZD), first non-BZD AED, and first continuous infusion. We evaluated continuous (single prolonged seizure) versus intermittent (several seizures without return to baseline function) rSE, in-hospital versus out-of-hospital rSE onset, the period 2011-2014 versus the period 2015-2017, day versus night, first half versus last half of the academic year, and race as factors potentially associated with treatment delays in a Cox proportional hazards model controlling for etiology, prior diagnosis of epilepsy, prior episode of SE, and age. Results: We studied 219 patients (53% males) with a median (p25-p75) age of 3.9 (1.2-9.5) years. SE episodes started out-of-hospital in 141 (64.4%) and in-hospital in 78 (35.6%) patients. The median (p25-p75) time from seizure onset to first BZD was 16 (5 – 45) minutes and to first non-BZD AED was 63 (33 – 146) minutes. Among 107 patients who received at least one continuous infusion, time to first continuous infusion was 170 (107 – 539) minutes. Factors associated with more delays to administration of the first BZD were intermittent SE HR: 1.54 (95% CI: 1.14 – 2.09), p = 0.0467 and out-of-hospital onset HR: 1.5 (95% CI: 1.11 – 2.04), p = 0.0467. Factors associated with more delays to administration of the first non-BZD-AED were intermittent SE HR: 1.78 (95% CI: 1.32 – 2.4), p = 0.001and out-of-hospital onset HR: 2.25 (95% CI: 1.67 – 3.02), p < 0.0001. None of the studied factors were associated with a delayed administration of continuous infusion (Figure 1). Among the 141 patients with out of hospital onset, the median (p25-p75) time to first BZD administration was 20 (8 – 55) minutes and to first non-BZD AED administration was 80 (45 – 165) minutes. Among 71 patients who received at least one continuous infusion, the median (p25-p75) time to first continuous infusion was 164 (97.5 – 641) minutes. In the population with out-of-hospital SE onset the factor associated with more delay to the first BZD was no prior SE [HR: 2.32 (95% CI: 1.58 - 3.42), p = 0.0053]. The factor associated with more delay to the first non-BZD AED was intermittent SE [HR: 2.33 (95% CI: 1.58 - 3.42), p = 0.0002. None of the studied factors were associated with a delayed administration of continuous infusions (Figure 2). Conclusions: Intermittent rSE and out-of-hospital rSE onset are independently associated with longer delays to treatment in pediatric rSE. (Supported by the Pediatric Epilepsy Research Foundation and the Epilepsy Research Fund) Funding: This study  was supported by the Pediatric Epilepsy Research Foundation and the Epilespy Research Fund.
Figure 1
Figure 2