Abstracts

Rationale: Current clinical practice shows variability in the treatment of status epilepticus (SE). We aimed to assess SE protocols used by the pediatric SE research group (pSERG) hospitals and compare them to the most recent AES-SE guideline (Glauser2016), published after the protocols were created. Methods: Cross-sectional evaluation of SE treatment protocols in 9 pediatric tertiary US hospitals compared with the AES-SE treatment guideline. Criteria for initial benzodiazepines (BZDs), 2nd-line non-BZD anti-seizure drugs, and 3rd-line therapy (repeated 2nd-line boluses or continuous infusion) phases were summarized. We assessed the recommended timing, dosing and medication choices. Results: Six protocols had well-described intervals for each therapy phase (Fig 1). None of the protocols perfectly matched the timeline in the AES-SE guideline; and they were often stricter regarding timing, and recommended higher doses for certain medications. Early pretreatment stabilization was 0-5 minutes in all protocols; 4 protocols also suggested that 1st-line BZD be administered within this period. In all protocols, the timing of the 2nd-line therapy phase was earlier than the AES-SE guideline (20 min): 1 starting by 5 min, 5 by 10 min, and 3 by 15 min. The suggested timing of the 3rd-line therapy was the same as the AES-SE guideline (40 min) in 1 protocol; the rest suggested an earlier time for intervention (median 20 [range 20-30] min).The initial 1st-line BZD recommended in all hospitals was intravenous lorazepam (Fig 2). Intramuscular midazolam could be used as an alternative in 5 protocols; rectal diazepam was also an option in 3 of these, and in 2 more protocols. If SE persisted after this initial phase, 3 protocols recommended that clinicians consider whether a BZD had been administered pre-hospital – if so, they should proceed to 2nd-line non-BZD therapy rather than repeating a BZD. In the 2nd-line therapy phase, 8 protocols recommended fosphenytoin. Levetiracetam was an alternative in 3 protocols, phenytoin in 2, and valproate/phenobarbital in another 2. For the 3rd-line therapy phase, 8 protocols recommended additional boluses of a different 2nd-line medication prior to continuous infusion –phenobarbital was the most common recommendation (7 protocols). Midazolam was the recommendation for continuous infusion in all 9 protocols.For drug dosing, we found the following variance: 1st-line therapy phase, dosing of midazolam varied in 7 protocols (dosing range 0.2-0.5mg/kg, irrespective of route of administration); 2nd-line therapy included variations in the loading dose of fosphenytoin (range 20-30mgPE/kg) and levetiracetam (range 50-60mg/kg); and, in 3rd-line phase, the loading dose of medication chosen after fosphenytoin. Conclusions: In the pSERG hospital SE protocols, centers followed the recommendations regarding medication choice but aimed for a more rapid medication escalation and higher dosing than recommended by the AES-SE guideline. This variability in protocols offers an opportunity for comparative effectiveness studies. (Funded by the Pediatric Epilepsy Research Foundation, Epilepsy Research Fund) Funding: Funded by the Pediatric Epilepsy Research Foundation, Epilepsy Research Fund