Utilisation du midazolam dans l’état de mal épileptique réfractaire de l’enfant

Super-Refractory Status Epilepticus in Children: A Retrospective Cohort Study

OBJECTIVES

To characterize the pediatric super-refractory status epilepticus population by describing treatment variability in super-refractory status epilepticus patients and comparing relevant clinical characteristics, including outcomes, between super-refractory status epilepticus, and nonsuper-refractory status epilepticus patients.

DESIGN

Retrospective cohort study with prospectively collected data between June 2011 and January 2019.

SETTING

Seventeen academic hospitals in the United States.

PATIENTS

We included patients 1 month to 21 years old presenting with convulsive refractory status epilepticus. We defined super-refractory status epilepticus as continuous or intermittent seizures lasting greater than or equal to 24 hours following initiation of continuous infusion and divided the cohort into super-refractory status epilepticus and nonsuper-refractory status epilepticus groups.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified 281 patients (157 males) with a median age of 4.1 years (1.3-9.5 yr), including 31 super-refractory status epilepticus patients. Compared with nonsuper-refractory status epilepticus group, super-refractory status epilepticus patients had delayed initiation of first nonbenzodiazepine-antiseizure medication (149 min [55-491.5 min] vs 62 min [33.3-120.8 min]; p = 0.030) and of continuous infusion (495 min [177.5-1,255 min] vs 150 min [90-318.5 min]; p = 0.003); prolonged seizure duration (120 hr [58-368 hr] vs 3 hr [1.4-5.9 hr]; p < 0.001) and length of ICU stay (17 d [9.5-40 d] vs [1.8-8.8 d]; p < 0.001); more medical complications (18/31 [58.1%] vs 55/250 [22.2%] patients; p < 0.001); lower return to baseline function (7/31 [22.6%] vs 182/250 [73.4%] patients; p < 0.001); and higher mortality (4/31 [12.9%] vs 5/250 [2%]; p = 0.010). Within the super-refractory status epilepticus group, status epilepticus resolution was attained with a single continuous infusion in 15 of 31 patients (48.4%), two in 10 of 31 (32.3%), and three or more in six of 31 (19.4%). Most super-refractory status epilepticus patients (30/31, 96.8%) received midazolam as first choice. About 17 of 31 patients (54.8%) received additional treatments.

CONCLUSIONS

Super-refractory status epilepticus patients had delayed initiation of nonbenzodiazepine antiseizure medication treatment, higher number of medical complications and mortality, and lower return to neurologic baseline than nonsuper-refractory status epilepticus patients, although these associations were not adjusted for potential confounders. Treatment approaches following the first continuous infusion were heterogeneous, reflecting limited information to guide clinical decision-making in super-refractory status epilepticus.

Critical Care in the Pediatric Emergency Department

In caring for critically ill children, recognition and management often begins in the pediatric emergency department. A seamless transition in care is needed to ensure appropriate care to the sickest of children. This review covers the management of critically ill children in the pediatric emergency department beyond the initial stabilization for conditions such as acute respiratory failure and pediatric acute respiratory distress syndrome, traumatic brain injury, status epilepticus, congenital heart disease, and metabolic emergencies.

Quality assurance evaluation of a simple linear protocol for the treatment of impending status epilepticus in a pediatric emergency department 2 years postimplementation

Objective:

To evaluate the efficacy and safety of a simple linear midazolam-based protocol for the management of impending status epilepticus in children up to 18 years of age.

Methods:

This is a descriptive, quality assessment, retrospective chart review of children presenting with the chief complaint of seizure disorder in the emergency department (ED) of a tertiary care pediatric hospital and a triage category of resuscitation or urgent from April 1, 2009, to August 31, 2011. In children with at least one seizure episode in the ED treated according to the linear protocol, three main outcomes were assessed: compliance, effectiveness, and complications.

Results:

Of the 128 children meeting the above study criteria, 68 had at least one seizure episode in the ED, and treatment was required to terminate at least one seizure episode in 46 of 68 patients (67.6%). Fifty-five seizure episodes were treated in the 46 patients: 51 of 55 seizure episodes were treated with midazolam (92.7%) and 4 of 55 with lorazepam or diazepam (7.3%). Of those treated with midazolam, 86.3% (44 of 51) were successfully treated with one or two doses of midazolam. The median seizure duration for all treated patients was 6 minutes. Of the 42 patients treated with midazolam, 7 required either continuous positive airway pressure or intubation, and two patients were treated for hypotension. One patient died of pneumococcal meningitis.

Conclusion:

This simple linear protocol is an effective and safe regimen for the treatment of impending status epilepticus in children.