Assessment of Seizure Action Plans in Pediatric Convulsive Status Epilepticus: Focus on Benzodiazepine-Responsive and Resistant Cases.

Abstract

Background and objectives: Optimal acute treatment is crucial in pediatric convulsive status epilepticus (CSE). However, data on the benefits of seizure action plans (SAPs) and treatment algorithm implementation in relation to process and outcome measures in CSE are scarce. Our study examines treatment algorithm adherence in benzodiazepine (BZD)-responsive and BZD-resistant groups and specifically focuses on the relationship with personalized SAPs.

Methods: We performed a prospective observational cohort study evaluating patient care processes and outcomes in young patients with CSE lasting ≥5 minutes, requiring admission and an antiseizure medication(s) (ASM) for seizure termination from February 2016 to July 2018. Patients with infantile spasms, invasive EEG monitoring, unclear seizure duration, unclear ASM administration time, or seizure cluster were excluded. We used univariate statistics to analyze the data.

Results: We enrolled 60 patients (median age 3.7 [1.9-7.0] years, 48% female), including 34 BZD-responsive and 26 BZD-resistant patients. Patients who had access to a personalized SAP, even if it was not adhered to, experienced a median (p25-p75) time to first ASM of 6 minutes (5-18; n = 34). By contrast, patients without access to a personalized SAP had a longer median (p25-p75) time to the first ASM of 15 minutes (8-27; n = 24; p < 0.05). The median (p25-p75) time to administer the first ASM was 6 (5-15; n = 33) minutes in BZD-responsive patients vs 15 (6-32; n = 25; p < 0.05) minutes in BZD-resistant patients. Treatment protocol implementation rates were lower in BZD-resistant vs BZD-responsive patients. The median (p25-p75) time to administer the first ASM was 5 minutes (4-5; n = 14) in patients who implemented a personalized SAP compared with 16 minutes (6-31; n = 20; p < 0.001) in patients without SAP implementation. The median (p25-p75) seizure duration in personalized SAP implementation and nonimplementation groups was 9 (6-16; n = 14) and 22 (11-64; n = 20; p < 0.01) minutes, respectively. The intubation rate was 14% for those who implemented the personalized SAP and 53% for those who did not (p < 0.05).

Discussion: Seizure duration was shorter in patients with personalized SAP, and the time to administer ASM was faster. In addition, BZD-resistant patients were less likely to follow treatment protocols, and the time to first-line therapy was slower. SAP and algorithm implementation was associated with a lower intubation rate, indicating potential benefits, including improved process and patient outcome measures.