Medical treatment of pediatric status epilepticus

Refractory and super-refractory status epilepticus in children and adolescents: A population-based study

PURPOSE

Refractory (RSE) and super-refractory status epilepticus (SRSE) are serious medical emergencies whose long-term outcomes depend on the timeliness of their management. Population-based clinical and epidemiological data on these conditions are sparse. We aimed to provide a detailed description of the epidemiology and clinical course of RSE and SRSE in children and adolescents and identify potential prognostic biomarkers.

METHODS

In this retrospective population-based study, patients aged one month to 18 years who fulfilled the RSE/SRSE diagnostic criteria and were admitted to the intensive care unit of Haukeland University Hospital from 2012 to 2021 were considered eligible. Detailed clinical and laboratory findings along with information on management and outcomes were systematically analyzed.

RESULTS

Forty-three patients with 52 episodes of RSE/SRSE were identified. The incidence rate was 3.13 per 100,000 per year. The median time from SE onset to the administration of the first rescue drug was 13 min, and from the first rescue drug to second- and third-line treatments, 83 and 66 min, respectively. All patients were alive at discharge.

CONCLUSION

Delays in treatment were observed in various stages of the clinical course of RSE/SRSE. Improvement measures targeting the prompt administration of recuse mediation and subsequent treatment escalation are needed.

Effectiveness of an Educational Intervention on Status Epilepticus Among the Caregivers of Children With Epilepsy: An Interventional Study

Background Status epilepticus (SE) is one of the most common and well-known neurological emergencies in pediatrics, especially among kids under two years of age. Early identification and treatment are crucial in the prevention of neurological complications and morbidities. This study aimed to assess the effectiveness of an educational intervention about SE among caregivers of pediatric patients with epilepsy. Methodology This interventional study was conducted among a convenient sample of 206 caregivers of pediatric patients with epilepsy in King Fahad Medical City, Riyadh, Saudi Arabia, from November 2020 to July 2021. We included patients who were aged 14 years or less and received rescue medication prescriptions in 2020. The educational intervention was applied to caregivers, and knowledge was compared before and after the intervention. A self-administered questionnaire was utilized. Results The mean (±SD) age of children was 7.5 (±3.7) years. The mean (±SD) age of caregivers was 36.4 (±6.1) years. About 51.5% of the children were males. The majority of caregivers were mothers (89.8%). The mean (±SD) score of total knowledge was 12.3/20 (±2.6) before the intervention which increased to 15.7/20 (±3.1) after the intervention, and the difference was found to be statically significant (p = 0.001). This indicates that the educational intervention was effective. Conclusions The educational intervention administered in this study significantly improved the knowledge of caregivers of pediatric patients with epilepsy and can help in providing better care to the patients.

Survey of the perceived treatment gap in status epilepticus care across Sub-Saharan countries from the perspective of healthcare providers

BACKGROUND

Status epilepticus (SE) is a serious condition disproportionately affecting Sub-Saharan African (SSA) countries. Little is known about healthcare provider experiences. This study investigated the healthcare provider perspective of SE care.

METHODS

A pilot questionnaire was developed for healthcare professionals in SSA countries. It was distributed online at a conference concerning epilepsy care and local coordinators distributed the questionnaire in their networks. It was available online between 16th Jan and 1st Feb 2021. The unvalidated questionnaire questioned practitioner demographics, experience, confidence in SE care, common etiologies encountered, anticipated prognosis in their setting, available treatments, and barriers to care. We assessed practitioner perceptions not their knowledge base around SE care. Thematic analysis was used for open-ended questions.

RESULTS

Fifty nine responses were received from 11 countries. Respondents (44% nurses, 46% doctors) reported poor level of adequate SE training (mean self-reported confidence in training 2.9/10 (0/10 very inadequate and 10/10 very adequate training). Delays in arriving at hospital were common with 15 (32%) taking three or more hours and 28 (62%) proposing transport issues and distance were the main reasons for delay. Urban location was significantly associated with clinician confidence. Less than 20% used prehospital benzodiazepine treatment. 46 (78%) stated benzodiazepines were first-line hospital drug management, and 52 (88%) indicated alternative second-line hospital treatments were available.

CONCLUSION

A substantial perceived treatment gap in the management of SE in SSA is identified by staff working in SSA. Key issues are around staff training, patient education, medication access, and compliance.

Treatment Outcomes of Pediatric Status Epilepticus in a Tertiary Pediatric Intensive Care Unit

OBJECTIVE

Status epilepticus is associated with high rates of morbidity and mortality; thus, early diagnosis and proper treatment are crucial. We aimed to study the etiology, clinical features, and treatment among pediatric patients with convulsive status epilepticus.

METHODS

The medical records of 100 patients were retrospectively obtained from pediatric intensive care unit. Etiology, clinical features, and treatment were interpreted by using Fisher exact test, χ2 test, and Spearman ρ correlation coefficient.

RESULTS

Seizures had stopped with the first-, second-, and third-line treatment in 29%, 36%, and 35% of the patients, respectively. Only phenytoin treatment was efficient; it has 32.3% rate in second-line treatment. Whereas mortality rate was 10%, morbidity rate was 14% during the follow-up. Epilepsy, hemiparesis, spastic tetraparesis, and mental retardation developed. Mortality was significantly much more in the patients with refractory seizure and cerebral palsy. Development of mental retardation was much higher in the male sex.

CONCLUSIONS

Phenytoin is still one of the most efficient antiepileptic drugs. If the duration of status epilepticus can be shortened by prompt treatment, neurological complications may be prevented.

A study of critically ill children presenting with seizures regardless of seizure duration admitted in the PICU of a tertiary hospital in India

Our aim was to study the clinical profile, immediate outcome and risk factors associated with poor outcome in critically ill children presenting with seizures requiring PICU admission. As seizures lasting 10 min or more can potentially cause brain damage, we included all children regardless of seizure duration. The records of 157 children aged 1 month to 16 years admitted in the PICU at a tertiary hospital in India with seizures as the presenting symptom during a three-year period were studied retrospectively. Median age of patients was 4 years. 34 (21%) had pre-existing epilepsy and 33 (21%) had previous developmental delay/neuro-deficit. Seizure duration was > 30 min in 75 (47.7%) and 56 (35.6%) required the use of more than 2 antiseizure drugs. 101 (64%) had acute symptomatic seizures, 28 (17%) remote symptomatic and 27 (17.1%) had unknown cause. New onset neurological deficit was seen in 18 (15.6%) and 14 (8.9%) died. Young age, high PEWS score at presentation, prolonged/recurrent seizures, CNS infection, need for multiple antiseizure drugs and ventilation/pressor use were risk factors for poor outcome. Neurological outcome and survival of children in our study were good. Further all-inclusive studies irrespective of seizure duration are needed to obtain a complete picture of critical children presenting with seizures.

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All critical children presenting with seizures were included irrespective of seizure duration

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52.2% patients had seizures lasting for less than 30 min

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28.6% patients had CNS infection as the underlying etiology

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Short-term neurological outcome was comparable to previous reports

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Mortality associated with status epilepticus was lower than that reported by other Indian studies

Management of convulsive status epilepticus in children: an adapted clinical practice guideline for pediatricians in Saudi Arabia

Objective:

To increase the use of evidence-based approaches in the diagnosis, investigations and treatment of Convulsive Status Epilepticus (CSE) in children in relevant care settings.

Method:

A Clinical Practice Guideline (CPG) adaptation group was formulated at a university hospital in Riyadh. The group utilized 2 CPG validated tools including the ADAPTE method and the AGREE II instrument.

Results:

The group adapted 3 main categories of recommendations from one Source CPG. The recommendations cover; (i)first-line treatment of CSE in the community; (ii)treatment of CSE in the hospital; and (iii)refractory CSE. Implementation tools were built to enhance knowledge translation of these recommendations including a clinical algorithm, audit criteria, and a computerized provider order entry.

Conclusion:

A clinical practice guideline for the Saudi healthcare context was formulated using a guideline adaptation process to support relevant clinicians managing CSE in children.

Impact of Obesity on Fosphenytoin Volume of Distribution in Pediatric Patients

The impact of body habitus on fosphenytoin pharmacokinetics is poorly understood in pediatric patients. This retrospective, single-center review examined differences in fosphenytoin volume of distribution (V_D) between children with normal and obese body habitus. From 2013 to 2015, patients 2 to 18 years of age who received a loading dose of fosphenytoin were identified. Thirty-seven patients met inclusion criteria. Mean total serum phenytoin concentration was 25.3 ± 6.5 μg/mL in the nonobese group and 29.5 ± 7.6 μg/mL in the obese group ( P = .09). V_D was not significantly different between obese and nonobese groups, 0.92 ± 0.26 L/kg and 0.97 ± 0.48 L/kg ( P = .76), respectively. In contrast to adult studies, these data suggest that fosphenytoin dose adjustments for obese children may be unnecessary.

High dose phenobarbitone coma in pediatric refractory status epilepticus; a retrospective case record analysis, a proposed protocol and review of literature

BACKGROUND

Ongoing refractory status epilepticus is associated with significant morbidity and mortality. Therapeutic coma induction with midazolam, thiopentone, phenobarbitone or propofol is indicated when conventional antiepileptics fail to abort seizure. Of these, the most extensively studied is midazolam. Amongst the remaining three, phenobarbitone has the most favourable pharmacological profile, but has not been studied adequately, more so in the pediatric age group. The current retrospective case records analysis is an attempt to describe use of phenobarbitone coma in pediatric refractory status epilepticus.

METHODS

Case records of patients, admitted with status epilepticus to the pediatric inpatient services of a tertiary care teaching hospital of North India between January 2014 and December 2016 were reviewed. Those with refractory status epilepticus who failed to respond to midaolam infusion and phenobarbitone coma was used were included for analysis.

RESULTS

Overall, 108 children presented in status, of which 34 developed refractory status epilepticus. Of these 34, 21 responded to midazolam infusion and in 13 high dose phenobarbitone coma following a standardised protocol was used. Amongst these 13 (8 males and 5 females, median age 6 years, IQR: 2.5-9.5), 12 responded and 1 succumbed. The median time to clinical seizure resolution and desired electroencephalographic changes post phenobarbitone initiation were 16 (IQR: 12-25) and 72 h (IQR: 48-120) respectively.

CONCLUSION

High dose phenobarbitone appears to be an effective therapeutic modality in pediatric refractory status epilepticus. The current study provides a protocol for its use which can be validated in future studies with larger sample size.

Convulsive status epilepticus in a quaternary hospital paediatric intensive care unit (PICU) in South Africa: An 8 year review

PURPOSE

Convulsive status epilepticus (CSE) is associated with a high morbidity and mortality. This study aimed to describe the clinical profile, aetiology, neuroimaging and EEG findings as well as outcome of children with CSE in Sub-Saharan Africa.

METHODS

This was a retrospective analysis of electronic records of children with CSE admitted to the Paediatric Intensive Care Unit (PICU) over an 8-year period from January 2007 to December 2014.

RESULTS

Seventy six patients were admitted to the PICU with CSE and 55(72%) had refractory status epilepticus. The median age at presentation was 15 months (IQR 6-37 months). The main aetiologies were meningoencephalitis and gastroenteritis in 33(43%) and 19(25%) patients respectively. The most frequently used antiepileptic drugs for CSE in PICU consisted of infusions of midazolam (96%) and thiopentone (22%). Neuroimaging findings were abnormal in 53(75%) patients with hypoxic changes in 17 patients. On multivariable regression, the predictors of poor outcome included the use of more than 3 antiepileptic drugs in PICU(RR-1.41(1.12-1.78), p=0.003), duration of mechanical ventilation for more than 3days (RR 1.98(1.22-3.20), p=0.005) and abnormal neuroimaging findings (RR 3.21(1.53-6.72), p=0.002). The mortality rate was 24%(n=18). Persistent seizures or a new neurological deficit occurred in 58%(n=44). The main cause of mortality was CSE related diffuse cortical and brainstem injury. Predominant neurological sequelae were cerebral palsy and persistent epilepsy.

CONCLUSION

The high burden of infection related CSE is associated with high morbidity and mortality rates in contrast to the rates in developed countries. This highlights the need for early recognition and treatment of underlying conditions.

Single Center Outcomes of Status Epilepticus at a Paediatric Intensive Care Unit

BACKGROUND

Status epilepticus (SE) is a frequent admission diagnosis to paediatric intensive care units (PICUs) and is associated with variable outcomes. We have audited our experience of patients presenting in SE at a Canadian PICU to determine unfavorable outcome variables.

METHODS

Charts of patients <18 years of age presenting in SE to a tertiary care PICU over a 10-year period were audited. Data were analyzed at three care-points: transport, the emergency department (ED) and the PICU. Patient outcome before PICU discharge was categorized as "favorable" for return to pre-status functioning level or "unfavorable" for new deficit/death. Student's t-test and the Kruskal-Wallis test were used for analysis of normal and skewed continuous variables, respectively, and either Chi-square test or Fisher's exact test for categorical variables.

RESULTS

189 patients (54% males) were identified with a median age of 1.9 years. Idiopathic SE had the highest incidence; infectious/vascular etiologies were associated with more unfavorable outcomes. Progression to refractory SE in the ED had a higher incidence of death (p<0.05). Patients with an unfavorable outcome had a higher incidence of apnea during transport (p=0.01), longer hospital stays (p<0.05), need for therapeutic coma (p=0.01), longer duration of therapeutic coma (p<0.05), need for mechanical ventilation (p<0.05), and recurrent or refractory seizures during inpatient stay (p<0.05). Multivariate analysis of unfavorable outcomes of patients in SE presenting to the PICU included renal failure, cerebral edema, apnea during transport, refractory seizures, and recurrent seizures.

CONCLUSIONS

Refractory seizures in children presenting with SE are associated with worsened outcomes in the PICU.

[Pediatric emergencies in the emergency medical service]

Out-of-hospital pediatric emergencies occur rarely but are feared among medical personnel. The particular characteristics of pediatric cases, especially the unaccustomed anatomy of the child as well as the necessity to adapt the drug doses to the little patient's body weight, produce high cognitive and emotional pressure. In an emergency standardized algorithms can facilitate a structured diagnostic and therapeutic approach. The aim of this article is to provide standardized procedures for the most common pediatric emergencies. In Germany, respiratory problems, seizures and analgesia due to trauma represent the most common emergency responses. This article provides a practical approach concerning the diagnostics and therapy of emergencies involving children.

Exploring carer perceptions of training in out-of-hospital use of buccal midazolam for emergency management of seizures (2008-2012)

AIM

This study aims to explore carer perceptions of training in out-of-hospital use of buccal midazolam for emergency management of seizures.

METHODS

A random sample of 100 families (from n = 198) who underwent training at the Sydney Children's Hospitals Network, Randwick campus (2008-2012) were invited to participate in a telephone questionnaire.

RESULTS

Sixty-three carers participated. Thirty-three children were female, median age at training was 4 years and seizure onset 2.75 years. Seizures were generalised in 26 children and focal in 37. Common reasons for prescription included history of prolonged seizures (38%), recent diagnosis of epilepsy (33%) and overseas travel (11%). Ninety-eight per cent of carers reported that training instructions were clear, and 94% reported the risks of using benzodiazepines were satisfactorily explained. Ninety per cent felt confident to administer the drug following training and 62% completed first aid training as recommended. Suggestions for improvement included follow-up/review and additional demonstration/practice. Twenty-one carers (33%) reported giving buccal midazolam a median five times, 67% reported it was effective in terminating the seizure and 71% called an ambulance as instructed. Problems reported in administration included excessive secretions and difficulties drawing up the solution. One child experienced breathing difficulties requiring oxygen by the paramedics. Four children were admitted to children's intensive care unit with status epilepticus requiring intubation.

CONCLUSIONS

Training for out-of-hospital use of buccal midazolam was considered valuable by carers. Only a third of the sample subsequently used midazolam. Half of these carers reported problems in administration and one reported respiratory difficulty. These results highlight the importance of drug safety and efficacious training programmes.

Status epilepticus and refractory status epilepticus management

Status epilepticus (SE) describes persistent or recurring seizures without a return to baseline mental status and is a common neurologic emergency. SE can occur in the context of epilepsy or may be symptomatic of a wide range of underlying etiologies. The clinician's aim is to rapidly institute care that simultaneously stabilizes the patient medically, identifies and manages any precipitant conditions, and terminates seizures. Seizure management involves "emergent" treatment with benzodiazepines followed by "urgent" therapy with other antiseizure medications. If seizures persist, then refractory SE is diagnosed and management options include additional antiseizure medications or infusions of midazolam or pentobarbital. This article reviews the management of pediatric SE and refractory SE.

Interdisciplinary approach to neurocritical care in the intensive care nursery

Neurocritical care is a multidisciplinary subspecialty that combines expertise in critical care medicine, neurology, and neurosurgery, and has led to improved outcomes in adults who have critical illnesses. Advances in resuscitation and critical care have led to high rates of survival among neonates with life-threatening conditions such as perinatal asphyxia, extreme prematurity, and congenital malformations. The sequelae of neurologic conditions arising in the neonatal period include lifelong disabilities such as cerebral palsy and epilepsy, as well as intellectual and behavioral disabilities. Centers of excellence have adapted the principles of neurocritical care to reflect the needs of the developing newborn brain, including early involvement of a neurologist for recognition and treatment of neurologic conditions, attention to physiology to help prevent secondary brain injury, a protocol-driven approach for common conditions like seizures and hypoxic-ischemic encephalopathy, and education of specialized teams that use brain monitoring and imaging to evaluate the effect of critical illness on brain function and development.

Intramuscular midazolam versus intravenous diazepam for treatment of seizures in the pediatric emergency department: a randomized clinical trial

AIM

To compare the therapeutic efficacy of intramuscular midazolam (MDZ-IM) with that of intravenous diazepam (DZP-IV) for seizures in children.

DESIGN

Randomized clinical trial.

SETTING

Pediatric emergency department.

PATIENTS

Children aged 2 months to 14 years admitted to the study facility with seizures.

INTERVENTION

Patients were randomized to receive DZP-IV or MDZ-IM.

MAIN MEASUREMENTS

Groups were compared with respect to time to treatment start (min), time from drug administration to seizure cessation (min), time to seizure cessation (min), and rate of treatment failure. Treatment was considered successful when seizure cessation was achieved within 5min of drug administration.

RESULTS

Overall, 32 children (16 per group) completed the study. Intravenous access could not be obtained within 5min in four patients (25%) in the DZP-IV group. Time from admission to active treatment and time to seizure cessation was shorter in the MDZ-IM group (2.8 versus 7.4min; p<0.001 and 7.3 versus 10.6min; p=0.006, respectively). In two children per group (12.5%), seizures continued after 10min of treatment, and additional medications were required. There were no between-group differences in physiological parameters or adverse events (p=0.171); one child (6.3%) developed hypotension in the MDZ-IM group and five (31%) developed hyperactivity or vomiting in the DZP-IV group.

CONCLUSION

Given its efficacy and ease and speed of administration, intramuscular midazolam is an excellent option for treatment of childhood seizures, enabling earlier treatment and shortening overall seizure duration. There were no differences in complications when applying MDZ-IM or DZP-IV.

Shake, rattle, and roll: an update on pediatric seizures

Seizure is a common presenting complaint for patients in the pediatric emergency department (PED) setting. In some cases, protocols are in place on how to manage this group of patients, for example, a patient with a simple febrile seizure already back to baseline or a patient with known epilepsy already back to baseline. However, many scenarios present dilemmas for physicians in the PED, specifically patients with status epilepticus (SE). Unfortunately, there is not a national SE protocol, and hospital-specific guidelines may or may not exist. Current practices are constantly changing because new medications arise, and more information is gathered regarding existing medications and guidelines. Here we will review the basics about first-time afebrile seizures presenting to the PED and common treatments specific to seizure types. We will then review SE management basics and medical therapy, including both older and newer agents and their routes of administration for both the prehospital and the hospital setting.

Advances in pediatric neurocritical care

Because pediatric intensive care units (PICUs) improve survival for a range of acute diseases, attention has turned toward ensuring the best possible functional outcomes after critical illness. The neurocritical care of children is of increasing interest. However, the pediatric population encompasses a heterogeneous set of neurologic conditions, with several possible models of how best to address them. This article reviews the special challenges faced by PICUs with regards to diseases, technologies, and skills and the progress that has been made in treatment, monitoring, and prognostication. Recent advances in translational research expected to modify the field in the near-term are described.

Status epilepticus in childhood

Status epilepticus (SE) remains a life-threatening condition that afflicts both adults and children, and may occur at onset of epilepsy, especially in children. Febrile SE is the most common cause in children, while other symptomatic causes are less frequent compared to adults. The aetiological workup that must be undertaken in all cases includes neuroimaging and electroencephalography. The various electroencephalographic patterns seen in patients with SE along with the out-of-hospital treatment for SE in children and treatment strategies in cases that are refractory to first-line medical treatments are discussed. Medically induced coma may be necessary in refractory cases, although the optimal agents to use and degree of electroencephalographic suppression in children remain unclear. Neurosurgery is not a well-known treatment option that could be considered for refractory cases. Although the prognosis has probably improved over the years, it remains a potential life-threatening emergency.

Evaluation of unlicensed and off-label antiepileptic drugs prescribed to children: Brazilian Regulatory Agency versus FDA

BACKGROUND

Epileptic seizures are neurological disorders common in children; 4 to 10% of under 16-year olds have suffered at least one seizure. Antiepileptic drugs represent the basis of treatment for the majority of patients, but many of the drugs prescribed to pediatrics are used unlicensed and off-label.

OBJECTIVE

To analyze the prevalence of use of unlicensed and off-label antiepileptic drugs, by the pediatric population, according to the Food and Drug Administration and the Brazilian National Health Surveillance Agency. Setting General Hospital of the Faculty of Medicine at Ribeirão Preto, Brazil.

METHODS

A cross-sectional, retrospective and observational study was carried out. The daily prescriptions of children up to 12 years of age were collected for the analysis of antiepileptic drug use. Data of the registration number, sex, age, reason hospitalized, unit where hospitalized, drug prescribed, dosage, route and administration frequency were collected.

MAIN OUTCOME MEASURE

Antiepileptic drugs prescribed for children were classified as unlicensed and off-label according to the term of the product's license registered in the Food and Drug Administration and the Brazilian National Health Surveillance Agency.

RESULTS

Of the 6,637 pediatric patients identified during the study period, 583 (9.0%) received at least one antiepileptic drug. The most used antiepileptic drugs were phenobarbital, phenytoin, carbamazepine, valproic acid and clonazepam. As expected, the number of pharmaceutical dosage form classified as unlicensed or off-label was high in both agencies, but distinct between the two. The number of patients (n = 287) using unlicensed drugs was similar in the two agencies, but the use of off-label drugs was higher according to the analysis carried out by the North American agency (40.5%).

CONCLUSIONS

Old-generation antiepileptic drugs are widely prescribed to children. The results found for the use of off-label drugs demonstrate the absence of uniformity in action between the agencies and a lack of integration between the studies carried out. Although legislation on the licensing of drugs aims to protect the patients from drugs that have not been scientifically evaluated, the scarcity of data about the safety of the therapeutic resources obliges the doctors to prescribe unlicensed and off-label antiepileptic drugs to the pediatric population.

Neurocritical care for neonates

OPINION STATEMENT

Neurocritical care is an emerging subspecialty that combines expertise in neurology, critical care medicine, neuroradiology, and neurosurgery. Increasing evidence from the adult literature suggests that specialized neurocritical care can lead to improved outcomes following acute brain injury. Critically ill neonates with neurologic conditions may also benefit from specialized neurocritical care. Adherence to guidelines and managing patients in intensive care nurseries with dedicated, multidisciplinary neurocritical care personnel may optimize outcomes. This goal may be achieved by more quickly recognizing neurologic impairment, preventing secondary brain injury by maintaining basic physiologic functions, and rapidly implementing therapies. Nurseries that care for neonates with suspected acute brain injury should be prepared to adequately support multiorgan involvement, monitor the brain to detect seizures, evaluate for brain injury using MRI, and follow development through school age.

Altered GABA signaling in early life epilepsies

The incidence of seizures is particularly high in the early ages of life. The immaturity of inhibitory systems, such as GABA, during normal brain development and its further dysregulation under pathological conditions that predispose to seizures have been speculated to play a major role in facilitating seizures. Seizures can further impair or disrupt GABA_A signaling by reshuffling the subunit composition of its receptors or causing aberrant reappearance of depolarizing or hyperpolarizing GABA_A receptor currents. Such effects may not result in epileptogenesis as frequently as they do in adults. Given the central role of GABA_A signaling in brain function and development, perturbation of its physiological role may interfere with neuronal morphology, differentiation, and connectivity, manifesting as cognitive or neurodevelopmental deficits. The current GABAergic antiepileptic drugs, while often effective for adults, are not always capable of stopping seizures and preventing their sequelae in neonates. Recent studies have explored the therapeutic potential of chloride cotransporter inhibitors, such as bumetanide, as adjunctive therapies of neonatal seizures. However, more needs to be known so as to develop therapies capable of stopping seizures while preserving the age- and sex-appropriate development of the brain.

Convulsive status epilepticus in children: etiology, treatment protocol and outcome

This study aimed to determine the etiology, treatment protocol and outcome of convulsive status epilepticus (SE) in children. An institutional treatment protocol using benzodiazepines (diazepam and midazolam) was assessed in a retrospective case study. The treatment protocol (Ege Pediatric Status Epilepticus Protocol or EPSEP) was developed based on an operational definition of pediatric SE according to the duration of seizure activity. Pediatric SE is divided into three categories: initial SE (20-30 min), established SE (30-60 min) and refractory SE (>60 min). Eight (30%) of the studied episodes were initial SE, 10 (37%) were established SE, and 9 (33%) were refractory SE. With respect to the etiological spectrum of SE, 11 (40%) children had meningitis or encephalitis. Febrile SE was identified in 7 (26%) patients. Only 2 episodes of initial SE (7.5%) were controlled with first step of the protocol (two concomitant-doses of rectal diazepam). Midazolam bolus and infusions (up to 1.2 μg/kg/min) were used to treat 22 episodes of SE (9 refractory SE, 10 established SE and 3 initial SE). Complete arrest of convulsive SE was achieved in 21 of 22 (95%) episodes with midazolam infusion. We concluded that the combined use of benzodiazepines (diazepam+midazolam) was safe and effective in the treatment of convulsive SE in children.