Authors :
Presenting Author: Megan Fredwall, MD – Nationwide Children's Hospital
Melissa Asmar, MD, MSc – Emory University; Laura Lamberta, DO – Nationwide Children's Hospital; Stephanie Ahrens, DO – Nationwide Children's Hospital; Shasha Bai, PhD – Emory University; Mariah Eisner, MS – Ohio State University; Fred Lado, MD, PhD – Hofstra Northwell Comprehensive Epilepsy Center; Stephan Schuele, MD, MPH – Northwestern University; Dave Clarke, MD – University of Texas at Austin; Ahmed Abdelmoity, MD – Children's Mercy Hospital- Kansas City; Kathryn Davis, MD – Hospital of the University of Pennsylvania; Jennifer Hopp, MD – University of Maryland; Mohamad Koubeissi, MD – George Washington University; Meriem Bensalem-Owen, MD – University of Kentucky; Susan Herman, MD – Barrow Neurological Institute; Adam Ostendorf, MD – Nationwide Children's Hospital
Rationale: Status epilepticus (SE), prolonged or repeated seizures without return to consciousness, may result in irreversible brain injury or death.
1 The American Epilepsy Society (AES) published treatment guidelines incorporating high-level evidence and expert opinion.
2 The National Association of Epilepsy Centers (NAEC) requires centers to submit their institutional protocols as part of its annual accreditation process.
3 This study compares SE protocols across 256 United States epilepsy centers to assess congruence to the AES SE treatment.
Methods: We analyzed SE protocols for recommended steps and its order (e.g., oxygen monitoring, adjunctive dextrose therapy, etc.), timing, medication routes, and dosing, and presented the results with descriptive statistics. The distribution of SE treatment times and AES goals across each phase were visualized with violin plots, as were minimum and maximum dosing for phases I and III medications.
Results: In total, 256 protocols were included. Goal treatment times were detailed in 66% (
Figure 1). The initial therapy phase benzodiazepine (BZD) and continuous infusion dosing ranges are shown in
Figure 2. Doses below AES recommendations occurred an average of 4% for initial BZD [intramuscular (IM) midazolam 4%; intravenous (IV) lorazepam 7%; IV diazepam 4%; rectal diazepam 2%] and an average of 14% for first non-BZD medications [IV fosphenytoin 1%; IV valproic acid 28%; IV levetiracetam 27%; IV phenobarbital 0%]. Infusion therapy was outlined in 61% of submitted protocols, with recommended dosing for midazolam (52%), pentobarbital (41%), propofol (45%), and ketamine (18%) (
Figure 2).
Conclusions: Successful SE treatment results in seizure cessation and requires rapid administration of an escalating therapeutic regimen, with prolonged seizures requiring IV anesthetics.
2 Despite the importance of expeditiousness in SE management, 1/3 of institutional protocols did not specify treatment times. Initial BZD dosing was often adequate, but second-line therapy dosing of valproic acid or levetiracetam was low in nearly one quarter, which likely reduces efficacy. This analysis of institutional SE protocols is the most comprehensive to date, provides expert opinion regarding infusion therapy management, and highlights targets for improvement in SE treatment across the US healthcare system.
Funding: This study is supported by Award 45141-0001-0321 from Nationwide Children's Hospital Foundation.