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First-line medication dosing in pediatric refractory status epilepticus
Alejandra Vasquez1, Marina Gaínza-Lein1, Nicholas S Abend1
1From the Division of Epilepsy and Clinical Neurophysiology (A.V., M.G.-L., M.A.-G., J.C., T.L.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, MA; Division of Child and Adolescent Neurology (A.V., E.T.P.), Department of Neurology, Mayo Clinic, Rochester, MN; Instituto de Pediatría, Facultad de Medicina (M.G.-L.), Universidad Austral de Chile, Valdivia; Servicio de Neuropsiquiatría Infantil (M.G.-L.), Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago; Division of Neurology (N.S.A.), The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Pediatric Neurology Unit (M.A.-G.), Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain; Section of Neurology and Developmental Neuroscience (A.A., J.J.R.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Neurology (R.A., T.G., K.P.), Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, 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.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Department of Neurology (R.F.-M., K.S.), Division of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.L.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric Neurology (R.M.G.), Washington University Medical Center, Washington University School of Medicine, St. Louis, MO; Department of Neurology (K.K.), Boston Children's Hospital, Harvard Medical School, MA; Section of Pediatric Critical Medicine (Y.-C.L.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Child Neurology (T.L.M.), Department of Neurology, Columbia University Medical Center, Columbia University, New York, NY; Division of Pediatric Neurology (T.L.M.), Ann & Robert H. Lurie Children's Hospital of Chicago, IL; Division of Pediatric Neurology (M.A.M., D.T.), Duke University Medical Center, Duke University, Durham, NC; Department of Neurology (L.A.M., E.J.N., M.S.W.), Division of Pediatric Neurology, University of Washington, Seattle; Center for Integrative Brain Research (E.J.N.), Seattle Children's Research Institute, WA; Department of Pediatrics (A.P.O.), Nationwide Children's Hospital, The Ohio State University, Columbus; Department of Pediatrics (J.P.), Division Pediatric Neurology, Neuro-Critical Care Program, Oregon Health and Science University, Portland; Division of Critical Care (R.C.T.), Departments of Neurology, Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, MA; Critical Care and Pediatrics (A.T.), The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine; and Department of Child Health (A.W., K.W.), University of Arizona College of Medicine and Barrow's Neurological Institute at Phoenix Children's Hospital.
Low benzodiazepine (BZD) doses were common in pediatric refractory status epilepticus (RSE). Factors like male sex and delayed treatment were linked to lower BZD doses, reducing seizure cessation success.
Area of Science:
- Neurology
- Pediatric Epilepsy
Background:
- Refractory status epilepticus (RSE) is a neurological emergency requiring prompt and adequate treatment.
- Benzodiazepines (BZDs) are first-line agents for status epilepticus, but optimal dosing in pediatric RSE remains a concern.
Purpose of the Study:
- To identify factors associated with suboptimal benzodiazepine (BZD) dosing in pediatric patients with refractory status epilepticus (RSE).
- To evaluate the impact of BZD treatment variability on achieving seizure cessation in this population.
Main Methods:
- Retrospective analysis of prospectively collected data from 289 pediatric patients with convulsive RSE.
- Evaluation of initial and total BZD doses within 10 minutes of treatment initiation.
- Logistic regression and Cox regression analyses to identify predictors of low dosing and its effect on seizure cessation.
Main Results:
- Over half of patients (57.9%) received a low initial BZD dose, and 37.1% received a low total BZD dose.
- Factors associated with low total BZD dose included male sex, older age, no prior epilepsy diagnosis, and delayed BZD treatment.
- Low total BZD dosing was significantly associated with a decreased likelihood of seizure cessation (HR 0.7).
Conclusions:
- Benzodiazepine doses were frequently lower than recommended in both out-of-hospital and in-hospital settings for pediatric RSE.
- Male sex, older age, lack of prior epilepsy diagnosis, and delayed treatment predict lower total BZD doses.
- Inadequate BZD dosing in pediatric RSE reduces the probability of successful seizure cessation.
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