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(Abst. 1.232), 2018

Transition From Benzodiazepines to Non-Benzodiazepine Antiseizure Medication in Pediatric Refractory Convulsive Status Epilepticus (the pSERG Cohort)
Authors: Theodore Sheehan, Boston Children’s Hospital, Harvard Medical School; Iván Sánchez Fernández, Boston Children’s Hospital, Harvard Medical School; Hospital Sant Joan de Déu, Universidad de Barcelona; Justice Clark, Boston Children’s Hospital, Harvard Medical School; Nicholas S. Abend, The Children’s Hospital of Philadelphia; Marta Amengual Gual, Boston Children’s Hospital, Harvard Medical School; Anne Anderson, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA; Ravindra Arya, Cincinnati Children's Hospital Medical Center, University of Cincinnati; J. Nicholas Brenton, University of Virginia Health System; Jessica L. Carpenter, Children’s National Medical Center, George Washington University School of Medicine and Health Sciences; Kevin E. Chapman, Children’s Hospital Colorado, University of Colorado School of Medicine; William D. Gaillard, Children’s National Medical Center; Marina Gaínza-Lein, Boston Children’s Hospital, Harvard Medical School; Tracy A. Glauser, Cincinnati Children's Hospital Medical Center, University of Cincinnati; Joshua L. Goldstein, Northwestern University Feinberg School of Medicine, Chicago, IL; Howard P. Goodkin, University of Virginia Health System; Michele Jackson, Boston Children’s Hospital, Harvard Medical School; Kush Kapur, Boston Children's Hospital, Harvard Medical School. Boston, MA, United States.; Yi-Chen Lai, Baylor College of Medicine; Tiffani L. McDonough, Columbia University Medical Center; Mohamad A. Mikati, Duke University; Lindsey Morgan, Seattle Children's Hospital; Edward J. Novotny, Seattle Children's Hospital; Adam P. Ostendorf, Nationwide Children's Hospital; Eric T. Payne, Mayo Clinic; Katrina Peariso, Cincinnati Children's Hospital Medical Center, University of Cincinnati; James J. Riviello, Jr, Baylor College of Medicine; Robert C. Tasker, Boston Children’s Hospital, Harvard Medical School; Dmitry Tchapyjnikov, Duke University Medical Center; Alexis Topjian, The Children’s Hospital of Philadelphia; Alejandra Vasquez, Boston Children’s Hospital, Harvard Medical School; Mark S. Wainwright, Seattle Children's Hospital; Angus Wilfong, University of Arizona College of Medicine; Korwyn Williams, University of Arizona College of Medicine; and Tobias Loddenkemper, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
Content: 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.
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