Abstracts

Rationale: Rapid initiation and escalation of pediatric status epilepticus (SE) treatment has been associated with shortened seizure duration and more favorable outcomes, including decreased mortality.¹ Evidence-based guidelines propose medication algorithms and timelines for each management step. However, time to antiseizure medication (ASM) administration remains delayed in both the pre- and in-hospital settings.² We aim to highlight treatment and delays in the management of benzodiazepine (BZD)-resistant convulsive SE (CSE) in a cohort of pediatric patients presenting to a tertiary care center.   Methods: Children aged 1 month to 21 years with CSE (defined as a single seizure lasting 5 minutes or longer) admitted to a tertiary pediatric hospital requiring an ASM(s) were included. We excluded patients with infantile spasms, episodes of non-convulsive status epilepticus, seizures resolving without ASM use, and episodes without clear time-to-treatment data. Results: Considering only the first episode in the 2-year enrollment period, 49 patients met inclusion criteria (median age (p25-p75) of 3.5 (1.2-7.0) years; 49% females, n=24) from February 2016-February 2018. 61% (n=30) had a prior history of epilepsy, and 80% of those patients (n=24) had at least one prior episode of CSE. 43% (n=21) had seizure onset in-hospital. In patients requiring second-line ASMs, median time (p25-p75) to the first non-BZD was 58 (32-86) minutes (n=22). The first non-BZD was given as the 4th medication (median (p25-p75) of 4 (3-5)) in management of CSE. Comparing patients with BZD-responsive versus resistant CSE, median time (p25-p75) to first, second, and third ASMs was 7.5 (5-15), 10 (8-22), and 36 (n=1) minutes, respectively, in the responsive group; comparatively, median time (p25-p75) to first, second, and third ASMs was 15 (6-30) (p=0.078), 31 (17-55) (p=0.001), and 39 (26-80) (p=0.80) minutes, respectively, in the resistant group (Figure 1).  In children with BZD-resistant CSE, the hospital-approved algorithm, AES algorithm or a personal algorithm was followed in 0/22, 1/22, and 4/22 cases, respectively, and medications were given at doses, times, or sequences other than those recommended in all other cases. Conversely, in patients who responded to BZDs, the hospital-approved algorithm, AES algorithm or a personal algorithm was followed in 9/27 (p=0.003), 16/27 (p<0.001), and 7/27 (p=0.518) cases, respectively. When a personalized CSE medication algorithm was present (n=30), this was followed in 37% (n=11) of cases. In these patients, the median seizure duration (p25-p75) was 8 (5-13) minutes compared to 25 (11-65) minutes with algorithm compliance versus noncompliance, respectively (p<0.001). Median time (p25-p75) from seizure onset to the first, second and third ASMs when the algorithm was followed versus when not followed was 5 (4-5) versus 15 (7.5-25.5) (p<0.001), 10 (8-18.5) versus 30 (17-54) (p=0. 0255), and 23.5 (15.5-29) versus 46 (35.5-80.5) (p<0.001) minutes (Figure 2). Conclusions: Time to second-line therapy in BZD-resistant cases is delayed beyond the recommended time points set by evidence-based guidelines. Patients with BZD-resistant CSE were less likely to receive medication protocols and time to the second ASM was significantly delayed when compared to BZD-responsive patients. In patients treated with a personalized ASM protocol, seizure duration was significantly shorter and time to first, second, and third ASMs was significantly faster. Funding: Fred Lovejoy Grant and Epilepsy Research FundReferences1. Gainza-Lein et al. JAMA Neurol. 2018;75(4):410-418.2. Sanchez Fernandez et al. Neurology. 2015;84(23):2304-2311.