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Outcomes in Children Treated with Pentobarbital Infusion for Refractory and Super-Refractory Status Epilepticus
Jennifer Erklauer1, Jeanine Graf2, Mona McPherson2
1Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1250, Houston, TX, 77030, USA. jclee@bcm.edu.
Insights
Pediatric refractory status epilepticus (SE) treatment with pentobarbital infusion led to high mortality. Many children experienced functional neurologic decline, but some survivors achieved good outcomes, highlighting the need for better SE management strategies.
Area of Science:
- Pediatric Neurology
- Critical Care Medicine
- Epileptology
Background:
- Functional neurologic outcomes for pediatric refractory and super-refractory status epilepticus (SE) remain poorly defined.
- Status epilepticus in children necessitates effective treatment strategies with clear outcome assessments.
Purpose of the Study:
- To define the functional neurologic outcome for children (0-17 years) treated with pentobarbital infusion for status epilepticus.
- To evaluate mortality, need for medical technology assistance, and functional neurologic status (Pediatric Cerebral Performance Category - PCPC) at discharge and long-term follow-up.
Main Methods:
- Retrospective chart review of 40 children (0-17 years) who received pentobarbital infusion for status epilepticus between 2003 and 2016.
- Outcomes assessed included mortality, need for new medical technology (tracheostomy, gastrostomy), and functional neurologic outcome using PCPC scores.
- Analysis of patient characteristics (age, sex, ethnicity, etiology, infusion duration) associated with functional neurologic outcome.
Main Results:
- In-hospital mortality was 30% (12/40). Among survivors, 21% (6/28) returned to baseline PCPC, while 50% (14/28) declined by ≥2 PCPC categories.
- 25% of survivors required tracheostomy and 27% required new gastrostomy tubes. New-onset SE patients often had persistent seizures at discharge.
- Etiology, admission PCPC, and new tracheostomy/gastrostomy were associated with worsened PCPC in univariable analysis. Prolonged infusion and hospital stay correlated with neurologic decline.
Conclusions:
- Mortality is high in pediatric patients with refractory SE treated with pentobarbital infusion.
- The majority of pediatric survivors experience functional neurologic disability at hospital discharge.
- Despite prolonged treatment, some children survive with good neurologic outcomes, indicating potential for improved SE management.
Background:
Functional neurologic outcome for children with refractory and super-refractory status epilepticus has not been well defined.
Methods:
Retrospective chart review including children age 0-17 years who received pentobarbital infusion from 2003 to 2016 for status epilepticus. Outcomes were defined in terms of mortality, need for new medical technology assistance at hospital discharge and functional neurologic outcome determined by pediatric cerebral performance category score (PCPC). Potential patient characteristics associated with functional neurologic outcome including age, sex, ethnicity, etiology of the status epilepticus, and duration of pentobarbital infusion were evaluated.
Results:
Forty children met inclusion criteria. In-hospital mortality was 30% (12/40). Of survivors, 21% (6/28) returned to baseline PCPC while half (14/28) declined in function ≥ 2 PCPC categories at hospital discharge. 25% (7/28) of survivors required tracheostomy and 27% (7/26) required new gastrostomy. Seizures persisted at discharge for most patients with new onset status epilepticus while the majority of patients with known epilepsy returned to baseline seizure frequency. Etiology (p = 0.015), PCPC at admission (p = 0.0006), new tracheostomy (p = 0.012), and new gastrostomy tube (p = 0.012) were associated with increase in PCPC score ≥ 2 categories in univariable analysis. Duration of pentobarbital infusion (p = 0.005) and length of hospital stay (p = 0.056) were longer in patients who demonstrated significant decline in neurologic function. None of these variables maintained statistical significance when multiple logistic regression model adjusting for PCPC score at admission was applied. At long-term follow-up, 36% (8/22) of children demonstrated improvement in PCPC compared to discharge and 23% (5/22) showed deterioration including three additional deaths.
Conclusions:
Mortality in this population was high. The majority of children experienced some degree of disability at discharge. Despite prolonged pentobarbital infusion, there were cases of survival with good neurologic outcome.
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