Association of guideline publication and delays to treatment in pediatric status epilepticus

Abstract

<jats:sec><jats:title>Objective:</jats:title><jats:p>To determine whether publication of evidence on delays in time to treatment shortens time to treatment in pediatric refractory convulsive status epilepticus (rSE), we compared time to treatment before (2011-2014) and after (2015-2019) publication of evidence of delays in treatment of rSE in the pediatric status epilepticus research group (pSERG) as assessed by patient interviews and record review.</jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p>We performed a retrospective analysis of a prospectively collected dataset from June 2011 to September 2019 on pediatric patients (1 month to 21 years of age) with rSE.</jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p>We studied 328 patients (56% males) with median (p<jats:sub>25</jats:sub>-p<jats:sub>75</jats:sub>) age of 3.8 (1.3-9.4) years. There were no differences in the median (p<jats:sub>25</jats:sub>-p<jats:sub>75</jats:sub>) time to first benzodiazepine (BZD) [20 (5-52.5) minutes versus 15 (5-38) minutes, <jats:italic>p</jats:italic>=0.3919], time to first non-BZD anti-seizure medication [68 (34.5-163.5) minutes versus 65 (33-142) minutes, <jats:italic>p</jats:italic>=0.7328], and time to first continuous infusion [186 (124.2-571) minutes versus 160 (89.5-495) minutes, <jats:italic>p</jats:italic>=0.2236]. Among 157 patients with out-of-hospital onset whose time to hospital arrival was available, the proportion who received at least one BZD before hospital arrival increased after publication of evidence of delays [41/81 (50.6%) versus 57/76 (75%), <jats:italic>p</jats:italic>=0.0018], and the odds ratio (OR) was also increased in multivariable logistic regression [OR=4.35 (95% confidence interval: 1.96-10.3), <jats:italic>p</jats:italic>=0.0005].</jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p>Publication of evidence on delays in time to treatment was not associated with improvements in time to treatment of rSE, although it was associated with an increase in the proportion of patients who received at least one BZD before hospital arrival.</jats:p></jats:sec>

Status Epilepticus Australasian Registry for Children: A pilot prospective, observational, cohort study of paediatric status epilepticus

“…Guidelines advocate a stepwise approach with benzodiazepines (usually two doses), then a second‐line agent, followed by rapid sequence induction of anaesthesia to allow further medications to be given without compromising respiratory drive and oxygenation 4 . Existing data demonstrate delays to hospital presentation, anticonvulsant medication administration and treatment escalation are common 5–7 . Recent randomised controlled trial (RCT) data for SE in children have become available 8–10 with guidelines now suggesting the use of a rapid third line agent in order to improve treatment escalation 11 .…”

Benzodiazepine administration patterns before escalation to second‐line medications in pediatric refractory convulsive status epilepticus

“…Out‐of‐hospital SE onset showed a trend toward a higher total number of BZD doses compared to in‐hospital onset, and this difference was more prominent with a longer time from seizure onset. Potential explanations of this factor based on our data and prior literature 18 may be related to different series of events. First, a considerable proportion of patients with out‐of‐hospital SE onset are not receiving any BZD before hospital arrival, or some patients receive multiple doses of BZD because most EMS personnel are not authorized to give a second‐line ASM and may not have other options available 40–42 …”

“…Current SE guidelines recommend administration of the first BZD within 5–10 min from seizure onset and a transition to non‐BZD ASMs at 10–20 min from seizure onset 15,16 . However, in clinical practice, treatment often occurs more slowly than recommended by guidelines 17,18 . Slower treatment is independently associated with longer seizure duration, increased need for continuous infusions, more frequent hypotension, and increased mortality 11,19 …”

“… 15 , 16 However, in clinical practice, treatment often occurs more slowly than recommended by guidelines. 17 , 18 Slower treatment is independently associated with longer seizure duration, increased need for continuous infusions, more frequent hypotension, and increased mortality. 11 , 19 No studies have focused on BZD administration patterns before escalating to non‐BZD ASMs in rSE.…”

Benzodiazepines for Out-of-Hospital Status Epilepticus: Do or Do Not! There Is No Try!

“…Evidence and guidelines themselves will not be sufficient unless efforts are made to improve local adhesion. 10 Let’s not lose hope, however, as examples of successful and impactful standardized protocols exist. 11 , 12 Trusting the Force served Luke and the Rebellion quite well in their victory over the Empire.…”