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Early Use of Antiseizure Medication in Mechanically Ventilated Traumatic Brain Injury Cases: A Retrospective
Kelly D Haque1, Zachary M Grinspan2,3, Elizabeth Mauer2
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY.
Insights
In children with traumatic brain injury (TBI), early levetiracetam use was linked to fewer seizures compared to phenytoin. This study analyzed 3,479 pediatric TBI patients to compare antiseizure medication effectiveness.
Area of Science:
- Pediatric Neurology
- Neurocritical Care
- Trauma Surgery
Background:
- Traumatic brain injury (TBI) is a major cause of child mortality and morbidity.
- Post-traumatic seizures affect 25% of severe pediatric TBI cases, potentially worsening outcomes.
Purpose of the Study:
- To examine the association between early seizure occurrence and antiseizure medication choice in pediatric TBI.
- To compare levetiracetam versus phenytoin for early seizure prevention in mechanically ventilated children with TBI.
Main Methods:
- Retrospective cohort study of 3,479 children (<18 years) with TBI admitted to 51 U.S. children's hospitals (2010-2017).
- Compared patients receiving levetiracetam on day 0 versus phenytoin on day 0.
- Seizure occurrence identified via ICD-9/10-CM codes.
Main Results:
- Levetiracetam was given to 67% and phenytoin to 33% of patients.
- Seizures occurred in 37% of levetiracetam patients vs. 41% of phenytoin patients (p=0.02).
- Multivariable analysis showed phenytoin use was associated with a 1.26-fold increased likelihood of seizures (aOR 1.26; 95% CI, 1.07-1.48; p=0.01).
Conclusions:
- Early levetiracetam administration showed a lower incidence of seizures compared to early phenytoin in pediatric TBI.
- Further research is needed to confirm causality and explore potential confounding factors or selection bias.
Objectives:
Traumatic brain injury is a leading cause of morbidity and mortality in children. Post-traumatic seizures occur in 25% of children with severe traumatic brain injury and may worsen outcomes. Our objective was to use a retrospective cohort study to examine the association between the early seizure occurrence and the choice of early antiseizure medication in children with traumatic brain injury.
Design:
Retrospective cohort study using the Pediatric Health Information Systems database, 2010-2017.
Setting:
Fifty-one U.S. children's hospitals.
Patients:
Children (< 18 yr old at admission) with diagnostic codes for traumatic brain injury who were mechanically ventilated at the time of admission and with hospital length of stay greater than 24 hours.
Interventions:
None.
Measurements And Main Results:
A total of 3,479 children were identified via coding and including in the analysis. Patients receiving antiseizure medication starting day 0 with levetiracetam were compared with those receiving phenytoin. The outcome was seizure occurrence, identified using validated International Classification of Diseases, 9th Revision, Clinical Modification and International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes. The median (interquartile range) age of patients was 4 (1-11) years, and the most common mechanism of injury was motor vehicle accident, occurring in 960 of patients (27%). A total of 2,342 patients (67%) received levetiracetam on day 0 and 1,137 patients (33%) received phenytoin on day 0. Totally 875 patients (37%) receiving levetiracetam on day 0 developed seizures, compared with 471 patients (41%) receiving phenytoin on day 0 (p = 0.02). Upon multivariable analysis adjusting for age, injury by child abuse, subdural hemorrhage, ethnicity, and admission year, children receiving phenytoin on day 0 were 1.26 (95% CI, 1.07-1.48) times more likely to be associated with post-traumatic seizure occurrence, compared with children receiving levetiracetam on day 0 (p = 0.01).
Conclusions:
Early administration of levetiracetam was associated with less-frequent seizure occurrence than early administration of phenytoin in mechanically ventilated children with traumatic brain injury. Additional studies are necessary to determine if the association is causal or due to unmeasured confounders and/or selection bias.
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