Factors associated with treatment delays in pediatric refractory convulsive status epilepticus
I Sánchez Fernández1, M Gaínza-Lein1, N S Abend1
1From the Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (I.S.F., M.G.-L., J.C., M.C.J., K.K., T.L.), and Division of Critical Care, Departments of Neurology, Anesthesiology, and Perioperative and Pain Medicine (R.C.T.), Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universidad de Barcelona, Spain; Facultad de Medicina (M.G.-L.), Universidad Austral de Chile, Valdivia; Divisions of Neurology (N.S.A.) and Critical Care Medicine (A.A.T.), The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Section of Neurology and Developmental Neuroscience (A.E.A., Y.-C.L., A.N., J.J.R.), Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston; Divisions of Neurology (R.A., K.P.) and Pediatric Neurology (T.A.G.), Cincinnati Children's Hospital Medical Center, OH; Department of Neurology and Pediatrics (J.N.B., H.P.G.), University of Virginia Health System, Charlottesville; Center for Neuroscience (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Pediatrics (T.A.G.), University of Cincinnati College of Medicine, OH; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.L.G., M.S.W.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric Neurology (A.R.H., M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Division of Child Neurology (T.L.M.), Department of Neurology, Columbia University Medical Center, Columbia University, New York, NY; Barrow Neurological Institute (A.W., K.W.), Phoenix Children's Hospital, AZ; and Department of Pediatrics (A.W., K.W.), University of Arizona School of Medicine, Phoenix.
Insights
Intermittent seizures and out-of-hospital onset of pediatric convulsive refractory status epilepticus (rSE) are linked to longer treatment delays. Identifying these factors can help reduce time to crucial interventions for pediatric rSE.
Area of Science:
- Pediatric Neurology
- Critical Care Medicine
- Epileptology
Background:
- Refractory status epilepticus (rSE) in children requires prompt treatment to prevent neurological damage.
- Treatment delays in pediatric rSE can be influenced by various clinical factors.
- Understanding these factors is crucial for developing effective treatment protocols.
Purpose of the Study:
- To identify factors associated with treatment delays in pediatric patients diagnosed with convulsive refractory status epilepticus (rSE).
- To analyze the impact of seizure characteristics and onset location on time to medication administration.
- To pinpoint potential targets for intervention to expedite treatment for pediatric rSE.
Main Methods:
- Prospective, observational study conducted from June 2011 to March 2017.
- Inclusion of pediatric patients (1 month to 21 years) with convulsive rSE.
- Utilized a Cox proportional hazards model to evaluate factors associated with treatment delays.
Main Results:
- A total of 219 pediatric patients were studied.
- Intermittent rSE and out-of-hospital onset were independently associated with significant delays in administering the first benzodiazepine (BZD) and first non-BZD antiepileptic drug (AED).
- No studied factors were linked to delays in the administration of continuous infusions.
Conclusions:
- Intermittent rSE and out-of-hospital onset are key factors contributing to delayed treatment in pediatric rSE.
- These findings highlight specific areas for targeted interventions to shorten the time to treatment.
- Reducing treatment delays is essential for improving outcomes in pediatric convulsive rSE.
Objective:
To identify factors associated with treatment delays in pediatric patients with convulsive refractory status epilepticus (rSE).
Methods:
This prospective, observational study was performed from June 2011 to March 2017 on pediatric patients (1 month to 21 years of age) with rSE. We evaluated potential factors associated with increased treatment delays in a Cox proportional hazards model.
Results:
We studied 219 patients (53% males) with a median (25th-75th percentiles [p25-p75]) age of 3.9 (1.2-9.5) years in whom rSE started out of hospital (141 [64.4%]) or in hospital (78 [35.6%]). The median (p25-p75) time from seizure onset to treatment was 16 (5-45) minutes to first benzodiazepine (BZD), 63 (33-146) minutes to first non-BZD antiepileptic drug (AED), and 170 (107-539) minutes to first continuous infusion. Factors associated with more delays to administration of the first BZD were intermittent rSE (hazard ratio [HR] 1.54, 95% confidence interval [CI] 1.14-2.09; p = 0.0467) and out-of-hospital rSE onset (HR 1.5, 95% CI 1.11-2.04; p = 0.0467). Factors associated with more delays to administration of the first non-BZD AED were intermittent rSE (HR 1.78, 95% CI 1.32-2.4; p = 0.001) and out-of-hospital rSE onset (HR 2.25, 95% CI 1.67-3.02; p < 0.0001). None of the studied factors were associated with a delayed administration of continuous infusion.
Conclusion:
Intermittent rSE and out-of-hospital rSE onset are independently associated with longer delays to administration of the first BZD and the first non-BZD AED in pediatric rSE. These factors identify potential targets for intervention to reduce time to treatment.
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