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DOI: 10.1055/s-0044-1779495
Standardizing the Treatment for Pediatric Status Epilepticus: A Quality Improvement Study
Funding We would like to acknowledge the Memorial Medical Foundation whose funding helped with the statistical analysis of the manuscript and expenses associated with Dr. Babbitt presenting an abstract at the Society of Critical Care Medicine Conference 2023. Virtual Pediatric Systems data were provided by VPS, LLC. No endorsement or editorial restriction of the interpretation of these data or opinions of the authors has been implied or stated.
Abstract
Approximately 30 to 40% of children with generalized convulsive status epilepticus remain refractory to benzodiazepines. Due to inconsistences in our approach for these patients in the emergency department, we initiated a quality improvement project to standardize the treatment process.
A plan, do, study, act (PDSA) format was used for the project that involved creating a treatment algorithm based on the American Epilepsy Society (AES) guidelines, educating the staff on the treatment recommendations, and then collecting clinical data. We selected time to second-line anticonvulsant therapy as our primary outcome measure. Following the implementation of the treatment algorithm and order set, we performed comparative analyses of the pre- and post-implementation cohorts.
A total of 21 pre- and 36 post-implementation patients were identified. Baseline data demonstrated no difference in age or gender. Post-implementation patients received second-line therapy sooner (24 vs. 39 minutes, p = 0.001) and more post patients received second-line therapy within the AES guideline's time frame (83 vs. 52%, p = 0.012) compared with the pre-implementation patients. In a multivariable analysis, post-implementation patients had a higher likelihood of receiving second-line therapy within the AES-recommended time frame (odds ratio [OR] = 5.78; 95% confidence interval [CI]: 1.49–22.48; p = 0.011). Age, gender, intubation status, anticonvulsants given prior to emergency department (ED), and treatment by a pediatric ED specialist were not associated with increased odds of provider adherence to AES guidelines.
In conclusion, a standardized approach utilizing a treatment algorithm for patients with pediatric benzodiazepine refractory status epilepticus was associated with reduced time to administration of second-line anticonvulsant therapy and better compliance with AES guidelines in a mixed pediatric and adult ED setting.
Publication History
Received: 09 June 2023
Accepted: 29 December 2023
Article published online:
28 March 2024
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References
- 1 Glauser TA. Designing practical evidence-based treatment plans for children with prolonged seizures and status epilepticus. J Child Neurol 2007; 22 (05) 38S-46S
- 2 Novorol CL, Chin RF, Scott RC. Outcome of convulsive status epilepticus: a review. Arch Dis Child 2007; 92 (11) 948-951
- 3 Gilbert DL, Gartside PS, Glauser TA. Efficacy and mortality in treatment of refractory generalized convulsive status epilepticus in children: a meta-analysis. J Child Neurol 1999; 14 (09) 602-609
- 4 McTague A, Martland T, Appleton R. Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Cochrane Database Syst Rev 2018; 1 (01) CD001905
- 5 Lewena S, Pennington V, Acworth J. et al. Emergency management of pediatric convulsive status epilepticus: a multicenter study of 542 patients. Pediatr Emerg Care 2009; 25 (02) 83-87
- 6 Dalziel SR, Borland ML, Furyk J. et al; PREDICT research network. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. Lancet 2019; 393 (10186): 2135-2145
- 7 Lyttle MD, Rainford NEA, Gamble C. et al; Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI) collaborative. Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE): a multicentre, open-label, randomised trial. Lancet 2019; 393 (10186): 2125-2134
- 8 Chamberlain JM, Kapur J, Shinnar S. et al; Neurological Emergencies Treatment Trials, Pediatric Emergency Care Applied Research Network investigators. Efficacy of levetiracetam, fosphenytoin, and valproate for established status epilepticus by age group (ESETT): a double-blind, responsive-adaptive, randomised controlled trial. Lancet 2020; 395 (10231): 1217-1224
- 9 Klowak JA, Hewitt M, Catenacci V. et al. Levetiracetam versus phenytoin or fosphenytoin for second-line treatment of pediatric status epilepticus: a meta-analysis. Pediatr Crit Care Med 2021; 22 (09) e480-e491
- 10 Cassel-Choudhury G, Beal J, Longani N, Leone B, Rivera R, Katyal C. Protocol-driven management of convulsive status epilepticus at a tertiary children's hospital: a quality improvement initiative. Pediatr Crit Care Med 2019; 20 (01) 47-53
- 11 Glauser T, Shinnar S, Gloss D. et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults—report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr 2016; 16 (01) 48-61
- 12 Wetzel RC, Sachedeva R, Rice TB. Are all ICUs the same?. Paediatr Anaesth 2011; 21 (07) 787-793
- 13 Sathe AG, Underwood E, Coles LD. et al. Patterns of benzodiazepine underdosing in the Established Status Epilepticus Treatment Trial. Epilepsia 2021; 62 (03) 795-806
- 14 Knudsen FU. Rectal administration of diazepam in solution in the acute treatment of convulsions in infants and children. Arch Dis Child 1979; 54 (11) 855-857
- 15 Vasquez A, Farias-Moeller R, Sánchez-Fernández I. et al; Pediatric Status Epilepticus Research Group (pSERG). Super-refractory status epilepticus in children: a retrospective cohort study. Pediatr Crit Care Med 2021; 22 (12) e613-e625