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Early Neurologic Recovery, Practice Pattern Variation, and the Risk of Endotracheal Intubation Following Established

Eric S Rosenthal1, Jordan J Elm2, James Ingles2

  • 1From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC. erosenthal@mgh.harvard.edu.

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|May 25, 2021
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Summary

Endotracheal intubation rates in established status epilepticus vary significantly by treatment site, independent of patient recovery. This practice variation, not patient outcomes, strongly predicts intubation, suggesting it shouldn't be a sole clinical trial endpoint.

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Area of Science:

  • Neurology
  • Critical Care Medicine
  • Clinical Trials

Background:

  • Established status epilepticus (SE) management involves critical decisions like endotracheal intubation.
  • Understanding factors influencing intubation is crucial for optimizing patient care and trial design.

Purpose of the Study:

  • To investigate the association between early neurologic recovery, practice pattern variation, and endotracheal intubation in patients with established SE.
  • To determine if intubation should be used as a sole clinical trial endpoint in established SE.

Main Methods:

  • Secondary analysis of the Established Status Epilepticus Treatment Trial (ESETT) cohort (N=478).
  • Multivariate regression evaluated factors associated with intubation within 120 minutes of treatment initiation.
  • Analysis included baseline characteristics, acute treatment, and neurologic recovery at 20 and 60 minutes.

Main Results:

  • 24.5% of patients (117/478) required intubation.
  • Intubation rates varied widely across treatment sites (pediatric: 4-32%; adult: 19-39%).
  • Site-specific practice variation was a stronger predictor of intubation than baseline characteristics or early neurologic recovery (aORs ranging from 8.12 to 23.4).

Conclusions:

  • Endotracheal intubation in established SE is significantly linked to site-specific practice patterns, not solely patient recovery.
  • Practice variation, rather than patient outcomes, strongly predicts intubation.
  • Endotracheal intubation should not be used as an isolated clinical trial endpoint for established SE.